Liver transplantation in children with hyper-reduced grafts - a single-center experience

In small infants and babies who receive split or living-related adult left lateral segmental liver grafts, further reduction (hyper-reduction) of the graft may be necessary to optimize the size of the graft for the child. We report our experience with hyper-reduction of adult left lateral segment grafts in nine children. A retrospective review of the medical records of children who received hyper-reduced grafts at the Children's Hospital at Westmead, Australia was performed. Of 215 liver transplants performed on 186 children between 1986 and May 2009, 147 were reduced grafts. Nine grafts were further reduced (hyper-reduced) after an on-table assessment of graft size relative to the available abdominal space was made. Mean graft size reduction was by 30%. The pledgetted technique of resection was used in four patients. All required delayed closure of the abdomen, and in three patients, fascial closure was not possible and a Surgisis patch (Cook Surgical International, West Lafayette, IN, USA) was placed to augment the abdominal capacity. Two children had hepatic artery thrombosis. One was successfully thrombectomized. In the other, technical problems with the donor liver contributed to death 10 days post-transplant. Two bile leaks, one from the cut surface and the other at the anastomotic site, were oversewn at the time of abdominal closure. On follow-up (median 33 months), two developed biliary strictures requiring dilatation. Hyper-reduction of segmental grafts can be safely performed when needed. In view of its versatility, it may be preferable to hyper-reduce a graft rather than use a monosegment graft. Comparable long-term results are possible. The pledgetted technique of resection is easy, quick, and safe. The fact that it can be performed after revascularization with minimal blood loss adds great flexibility to this technically challenging procedure.