Partial left lateral segment transplant from a living donor

Abstract

A shortage of liver donors for low-weight transplant recipients has prompted the development of procedures for liver-reduction, split-liver, and living related donor transplantations. For pediatric recipients weighing less than 10 kg, the left lateral segment is often still too large. We describe the procedure of monosegmental transplantation using segment II after segment III was resected in situ from a living related donor. Successful monosegmental transplantation is technically feasible and is a valid alternative to be considered for cases of size discrepancy between the recipient's volume and the donor's left lateral segment. Copyright 2000 by the American Association for the Study of Liver DiseasesT he main obstacle to the development of pediatric liver transplantation is the disparity between available small-sized donors and the exponential growth of waiting lists. This situation is even worse when recipients weigh less than 10 kg. The development of procedures for liver-reduction, split-liver, and living related donor transplantations has partially palliated this situation. There is a group of low-weight pediatric patients who cannot benefit from these procedures, either because the left lateral segment of a cadaver donor is too big for the recipient's abdomen or because this segment taken from a living donor was, until recently, the maximum reduction that could be achieved. Living related donors are frequently ruled out because the sizes of segments II and III exceed the recipient's abdominal capacity. Under these circumstances, implantation of a single segment can save the life of infant patients. This report discusses the use of pediatric monosegmental transplantation using a liver segment resected in situ from a living related donor. Materials and Methods Case PresentationsPatient 1 is an 8-month-old girl, weighing 7.25 kg, with biliary atresia who underwent transplantation from a living related donor in March 1997. The donor mother was 26 years old and weighed 64 kg.Patient 2 is an 11-month-old girl, weighing 7 kg, with a history of Kasai-type portal enterostomy at the age of 3 months caused by biliary atresia who underwent transplantation from a living related donor in April 1998. The donor father was 28 years old and weighed 56 kg. Surgical ProcedureDonor surgery. Abdominal approach by bilateral subcostal incision was used. The falciform and left triangular ligaments were sectioned, as well as the pars flaccida and condensa of the gastrohepatic omentum. After dissecting the portal vascular pedicle and the left hepatic vein, intraoperative ultrasound was used to confirm the distribution of these structures in the left lateral segment. Once the portal structures (hepatic artery, portal vein, and bile duct) and the left hepatic vein were isolated, the liver parenchyma was excised well to the right of the attachment of the falciform ligament (Fig. 1). The portal pedicle was identified with ultrasound guidance within the left lateral segment, and the parenchyma was sectioned caudal to the portal path (F...

Implications for the usage of the left lateral liver graft for infants ≤10 kg, irrespective of a large-for-size situation - are monosegmental grafts redundant?

“…Authors in favor of monosegmental transplants argue that in some small infants, the proposed use of monosegmental liver transplantation could allow for an easier abdominal wall closure and avoid an insufficient blood supply to the graft. Avoiding the use of synthetic mesh and secondary closure could also reduce the chance of abdominal wall infectious complications [6,9].…”

“…To prevent a graft body weight ratio (GBWR) ratio of more than 4%, some centers choose to reduce the graft into a monosegmental or “hyperreduced” graft. The subsequent reduction can be performed in situ , during the donor operation [5–7] or as a back table procedure [8–10], with the utilization of segment II [6,9,10] or III [5,7,8,11] as grafts. Recently a laparoscopic monosegmental living‐related donor operation has been reported.…”

The effect of liver graft-body weight ratio on the core temperature of pediatric patients during liver transplantation

“…11 Because the smallest functional unit of a graft should include the hepatic artery, portal vein, hepatic vein, and bile duct, a left-lateral liver graft should consist of at least segments 2 and 3. Although small, it may still be large for a small infant, which may affect core temperature.…”

“…However, the left lateral segment graft of an adult liver is often large, causing a high GRWR for infant recipients younger than 1 year or with a body weight less than 10 kg. 11 The procured liver graft is usually preserved at 4°C before being implanted in the recipient. The purpose of this study is to compare the effect of GRWR on core temperature changes during LDLT in children with body weights less than and more than 10 kg.…”

Living donor liver transplantation for neonatal hemochromatosis using non-anatomically resected segments II and III: a case report

“…Liver transplantation is the main therapy for infants who fail to respond to medical treatment [1]. Liver transplantation using either mono-segment II or III [2,3] is a technically challenging option that is especially beneficial for small infants in whom a left lateral segment [4] is large-for-size. We report that non-anatomical resection and transplantation of segments II and III may be a simpler, yet effective, surgical option for neonates with liver failure.…”