Monosegment Liver Allografts for Liver Transplantation in Infants Weighing Less Than 6 kg: An Initial Indian Experience (original) (raw)
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Liver transplantation with monosegments. Technical aspects and outcome: A meta-analysis
Liver Transplantation, 2005
The shortage of organ donors for low-weight liver transplant recipients, especially small children, has led to the development of new surgical techniques to increase the donor pool. Almost all of these techniques use the left lateral segment (Couinaud's segments II and III), but even this graft could be too large for children under 10 kg, and further reduction could be necessary. Few articles address the issue of monosegmental liver transplantation. Available articles are with small sample sizes or even case reports, which makes it difficult to draw conclusions about indication and outcome for monosegmental grafts. A search of the MEDLINE databases using the terms “Liver Transplantation” and “Monosegmental” or “Monosegments” limited to title or abstract with publication in the English language was conducted. The data from each study were selected and analyzed, regarding donor status (living or cadaveric), donor weight, surgical techniques used in left lateral further reduction, recipient indication for liver transplantation, age and recipient weight, graft-to-recipient body weight ratio, segment utilized, type of abdominal closure, postoperative complications, and survival. Seven publications were identified from 1995 to 2004 and fulfilled the criteria. A total of 27 pediatric patients who received a monosegment transplant were identified, median age 211 days (range, 27 to 454 days) and median weight 4.6 kg (range, 2.45 to 7.4 kg). Segment III was utilized in 21 (78%) and segment II in 6 (22%). Patient survival was 85.2%. In conclusion, monosegment liver transplantation appears to be a satisfactory option for infants weighing less than 10 kg who require a liver transplant. (Liver Transpl 2005;11:564–569.)
Liver Transplantation, 2006
Smaller-size infants undergoing living-donor liver transplantation (LDLT) are at increased risks of vascular complications because of their smaller vascular structures in addition to vascular pedicles of insufficient length for reconstruction. Out of 585 child patients transplanted between June 1990 and March 2005, 64 (10%) weighing less than 6 kg underwent 65 LDLTs. Median age and weight were 6.9 months (range: 1-16 months) and 5 kg (range: 2.8-5.9 kg), respectively. Forty-five lateral segment, 12 monosegment, and 8 reduced monosegment grafts were adopted, and median graft-to-recipient weight ratio was 4.4% (range: 2.3-9.7). Outflow obstruction occurred in only 1 patient (1.5%). Portal vein complication occurred in 9 (14%) including 5 with portal vein thrombosis. Hepatic artery thrombosis (HAT) occurred in 5 (7.7%). Patient and graft survivals were 73% and 72% at 1 yr, and 69% and 68% at 5 yr after LDLT, respectively. Thirteen of 22 grafts (58%) lost during the follow-up period occurred within the first 3 months posttransplantation. Overall graft survival in patients with and without portal vein complication was 67% and 65%, respectively (P ϭ 0.54). Overall graft survival in patients with and without HAT was 40% and 67%, respectively. HAT significantly affected graft survival (P ϭ 0.04). In conclusion, our surgical technique for smaller-size recipients resulted in an acceptable rate of vascular complications. Overcoming early posttransplantation complications will further improve outcomes in infantile LDLT.
Liver transplantation with monosegment from a living donor
Pediatric Transplantation, 2004
Abstract: The shortage of organ donors for low-weight liver transplant recipients, especially for small children, has led to the development of new surgical techniques to increase the donor pool. Almost all of these techniques use the left lateral segment (Couinaud's segments II and III), but even this graft could be too large for children under 10 kg. We report here the case of an 8-month-old boy, weighing 6.1 kg, who received a monosegmental graft (segment III) from his grandmother weighing 68 kg. The graft was reduced at the donor surgery, before clamping of the vessels. The donor was discharged on the fourth post-operative day; the recipient had an uneventful post-operative period and was discharged after 22 days.
Liver transplantation in children with hyper-reduced grafts - A single-center experience
Pediatric Transplantation, 2010
In response to the global shortage of pediatric deceased donor livers for transplantation, the use of reduced size, adult left lateral segmental and living-related grafts for pediatric liver transplantation became an established practice (1, 2). In infants and very small children, even these grafts may be too large with risks of inefficient reperfusion and/or an abdominal compartment syndrome. The need to obviate size mismatch spurred further innovation in adapting these grafts for pediatric transplantation. Although monosegment grafts may be used to remedy this (3, 4), they may result in too radical a reduction producing ''small-for-size'' grafts. Non-anatomical reduction with preparation of a graft that is larger than a monosegment, but smaller than Segments 2 and 3 (termed hyper-reduced size), can provide an ideal size graft (5, 6). Currently, the worldwide experience with the use of hyper-reduced size grafts in children is limited although problems with greater ischemia times, technical difficulties, increased incidence of biliary and vascular complications are suspected. Added evaluation of this technique may serve to guide further strategies in pediatric liver transplant.
Use of split-liver allografts does not impair pediatric recipient growth
Liver Transplantation, 2007
The use of split-liver (SL) allografts continues to be an excellent option for many pediatric recipients. Patient and graft survival with this graft type are comparable to patient and graft survival with whole organ grafts. Quality-of-life issues, specifically growth, for SL recipients have not been compared to those of recipients of more conventional whole-organ recipients. Pediatric recipients of SL and whole allografts at 2 institutions were identified. Height, z score, and delta z score were calculated for all recipients for each year after transplant. Between 1995 and 2004, 201 pediatric liver transplants were analyzed. Data were collected on 39 split-graft recipients and 36 whole-size recipients. Only subjects 3 years or younger were included in the study. Growth retardation was present in all recipients at transplant. Height z score post split and whole-size transplant were not statistically different at 1-(P ϭ 0.65), 2-(P ϭ 0.13), and 3-year (P ϭ 0.32) anniversaries, respectively. Catch-up growth was present only in recipients of split grafts. In conclusion, the use of split grafts as opposed to whole-size grafts revealed no significant differences in terms of linear growth. Our report indicates that split-liver transplantation does not impair recipient growth.
Feasibility and Limits of Split Liver Transplantation From Pediatric Donors
Annals of Surgery, 2006
Objective: To report the results of a multicenter experience of split liver transplantation (SLT) with pediatric donors. Summary Background Data: There are no reports in the literature regarding pediatric liver splitting; further; the use of donors weighing Ͻ40 kg for SLT is currently not recommended. Methods: From 1997 to 2004, 43 conventional split liver procedures from donors aged Ͻ15 years were performed. Nineteen donors weighing Յ40 kg and 24 weighing Ͼ40 kg were used. Dimensional matching was based on donor-to-recipient weight ratio (DRWR) for left lateral segment (LLS) and on estimated graft-to-recipient weight ratio (eGRWR) for extended right grafts (ERG). In 3 cases, no recipient was found for an ERG. The celiac trunk was retained with the LLS in all but 1 case. Forty LLSs were transplanted into 39 children, while 39 ERGs were transplanted into 11 children and 28 adults. Results: Two-year patient and graft survival rates were not significantly different between recipients of donors Յ40 kg and Ͼ40 kg, between pediatric and adult recipients, and between recipients of LLSs and ERGs. Vascular complication rates were 12% in the Յ40 kg donor group and 6% in the Ͼ40 kg donor group (P ϭ not significant). There were no differences in the incidence of other complications. Donor ICU stay Ͼ3 days and the use of an interposition arterial graft were associated with an increased risk of graft loss and arterial complications, respectively. Conclusions: Splitting of pediatric liver grafts is an effective strategy to increase organ availability, but a cautious evaluation of the use of donors Յ40 kg is necessary. Prolonged donor ICU stay is associated with poorer outcomes. The maintenance of the celiac trunk with LLS does not seem detrimental for right-sided grafts, whereas the use of interposition grafts for arterial reconstruction should be avoided. BW indicates body weight; WLW, whole liver weight; GW, graft weight; ICU, intensive care unit; GPT, serum glutamic-oxalacetic transaminase level; Na ϩ , serum sodium level.
Liver Transplantation, Including the Concept of Reduced-size Liver Transplants in Children
Ann Surg, 1988
Since the establishment of a clinical program in liver transplantation in 1984, 162 liver transplants have been performed in 131 patients (78 adults, 53 children). The patient mortality rate while waiting for a suitable organ has been 8% for adults and only 4% for children (25-46% reported in the literature). The low pediatric mortality is a result of the use of reduced-size liver transplants. A total of 14 procedures have been performed in recipients whose clinical condition was deteriorating and for whom no full-size graft could be located. Of 14 children, 13 were less than 3 years of age. Patient survival is 50%, comparable to survival of highrisk recipients of full-size livers. Using reduced-size liver grafting in a transplant program can lower mortality for children awaiting a transplant by overcoming size disparity. Reduced-size liver grafting will allow more effective use of donor resources and provide a potential avenue of research for organ splitting and living related donation.
Living donor liver transplantation for children in Brazil weighing less than 10 kilograms
Liver Transplantation, 2007
Infants with end-stage liver disease represent a treatment challenge. Living donor liver transplantation (LDLT) is the only option for timely liver transplantation in many areas of the world, adding to the technical difficulties of the procedure. Factors that affect morbidity and mortality can now be determined, which opens a new era for improvement. We have accumulated an 11-year experience with LDLT for children weighing Ͻ10 kg. From October 1995 to October 2006, a total of 222 LDLT in patients Ͻ18 years of age were performed; 129 primary LDLT and 7 retransplants (4 LDLT and 3 deceased donor grafts) were performed in 129 infants weighing Ͻ10 kg. Forty-seven patients received grafts with graft-to-recipient weight ratio (GRWR) of Ͼ4%. Two patients received monosegmental grafts, and 2 patients underwent delayed abdominal wall closure. Portal vein thrombosis occurred in 5.4% of the patients, hepatic artery thrombosis in 3.1%, and both in 1.5%. Among several variables studied, only the bilirubin level at the time of transplantation was associated with increased risk of death (P ϭ 0.009). Grafts with GRWR Ͼ4% had no negative effect on patient survival. There were 7 retransplants, and 4 patients received a second parental LDLT. Patient survival rates at 1, 3, and 10 years after transplantation were 88.8%, 84.7%, and 82% for all children, and 87.5%, 84.9%, and 84.9% for infants weighing Ͻ10 kg. LDLT has results comparable to other modalities of liver transplantation in infants. Monosegment grafts were rarely required in this series, although they may be necessary in patients with lower body weight.
Liver transplantation in very small infants
Pediatric transplantation, 2007
This study examines the results of liver transplantation (LT) in children 5 kg or less. Reports suggest an increased morbidity and mortality in children weighing 5 kg or less as compared to larger children. However, over half of all children needing LT are <1 year old. Improving outcomes in very small children is a major goal of liver transplantation.