Dextroplantation of Left Liver Graft in Infants

Combined liver-kidney transplantation in pediatric patients

Combined liver-kidney transplantation (CLKT) is a surgical procedure that involves transplanting both liver and kidney organs. There are two types of CLKT: simultaneous liver-kidney transplantation (smLKT) and sequential LKT (sqLKT). CLKT accounts for a small percentage of liver transplantations (LTs), particularly in pediatric cases. Nevertheless, the procedure has demonstrated excellent outcomes, with high survival rates and lower rejection rates. The main indications for CLKT in pediatric patients differ somewhat from that in adults, in which end-stage kidney disease after LT is the major indication. In children, congenital diseases are common reason for performing CLKT; the examples of such diseases include autosomal recessive polycystic kidney disease with congenital hepatic fibrosis which equally affects both organs, and primary hyperoxaluria type 1, a primary liver disease leading kidney failure. The decision between smLKT or sqLKT depends on the dominant organ failure, the specific pathophysiology, and available organ sources. However, there remain significant surgical and societal challenges surrounding CLKT. Innovations in pharmacology and genetic engineering have decreased the necessity for CLKT in early-diagnosed cases without portal hypertension or kidney replacement therapy. Nonetheless, these advancements are not universally accessible. Therefore, decision-making algorithms should be crafted, considering region-specific organ allocation systems and prevailing medical environments.

Portal vein reconstruction in pediatric liver transplantation using end-to-side jump graft: A case report

Attenuated portal vein (PV) flow is challenging in pediatric liver transplantation (LT) because it is unsuitable for classic end-to-end jump graft reconstruction from a small superior mesenteric vein (SMV). We thus introduce a novel technique of an end-to-side jump graft from SMV during pediatric LT using an adult partial liver graft. We successfully performed two cases of end-to-side retropancreatic jump graft using an iliac vein graft for PV reconstruction. One patient was a 2-year-old boy with hepatoblastoma and a Yerdel grade 3 PV thrombosis who underwent split LT. Another patient was an 8-month-old girl who had biliary atresia and PV hypoplasia with stenosis on the confluence level of the SMV; she underwent retransplantation because of graft failure related to PV thrombosis. After native PV was resected at the SMV confluence level, an end-to-side reconstruction was done from the proximal SMV to an interposition iliac vein. The interposition vein graft through posterior to the pancreas was obliquely anastomosed to the graft PV. There was no PV related complication during the follow-up period. Using a jump vascular graft in an end-to-side manner to connect the small native SMV and the large graft PV is a feasible treatment option in pediatric recipients with inadequate portal flow due to thrombosis or hypoplasia of the PV.

Dextroplantation of a reduced left lateral section graft in an infant undergoing living donor liver transplantation

Graft size matching is essential for successful liver transplantation in infant recipients. We present our technique of graft dextroplantation used in an infant who underwent living donor liver transplantation (LDLT) using a reduced left lateral section (LLS) graft. The patient was an 11-month-old female infant weighing 7.8 kg with hepatoblastoma. She was partially responsive to systemic chemotherapy. Thus, LDLT was performed to treat the tumor. The living donor was a 34-year-old mother of the patient. After non-anatomical size reduction, the weight of the reduced LLS graft was 235 g, with a graft-to-recipient weight ratio of 3.0%. Recipient hepatectomy was performed according to the standard procedures of pediatric LDLT. At the beginning of graft implantation, the graft was temporarily placed at the abdomen to determine the implantation location. The graft portal vein was anastomosed with an interposed external iliac vein homograft. As the liver graft was not too large and it was partially accommodated in the right subphrenic fossa, thus the abdominal wall wound was primarily closed. The patient recovered uneventfully. An imaging study revealed deep accommodation of the graft within the right subphrenic fossa. The patient has been doing well for six months without any vascular complications. This case suggests that dextroplantation of a reduced LLS graft can be a useful technical option for LDLT in infant patients.