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Surgical techniques and innovations in living related liver transplantation
K Tanaka1, S Uemoto, Y Tokunaga
1Second Department of Surgery, Faculty of Medicine, Kyoto University, Japan.
Insights
Living related liver transplantation (LRLT) in children offers a promising solution to the organ shortage. Meticulous surgical management is crucial for successful outcomes in pediatric liver transplants.
Area of Science:
- Pediatric Surgery
- Transplantation Immunology
- Hepatology
Background:
- Pediatric liver transplantation faces challenges due to organ shortages.
- Living related liver transplantation (LRLT) emerged as a potential solution.
- This study details the experience with LRLT in pediatric recipients.
Purpose of the Study:
- To evaluate the feasibility and outcomes of living related liver transplantation in children.
- To identify critical surgical factors for successful pediatric LRLT.
- To assess LRLT as a supplementary option to cadaveric liver donation.
Main Methods:
- Performed 33 LRLTs on children aged 7 months to 15 years.
- Utilized partial liver grafts (left lateral segment, left lobe, or right lobe) from parental donors.
- Employed meticulous surgical techniques, including preservation of the inferior vena cava and microsurgery for arterial reconstruction.
Main Results:
- Achieved a 27/33 recipient survival rate with functioning grafts.
- Reported patient survival rates of 89% in elective and 50% in emergent cases.
- Managed complications such as hepatic vein stenosis and portal vein issues effectively; microsurgery reduced hepatic artery thrombosis.
Conclusions:
- LRLT is a viable and promising option for pediatric liver transplantation.
- Careful management of surgical details is paramount for successful LRLT outcomes.
- LRLT can significantly supplement the limited supply of cadaveric donor organs for children.
Abstract:
The authors successfully performed a series of 33 living related liver transplantations (LRLT) on children (15 males and 18 females, ranging from 7 months to 15 years of age) from June 1990 to May 1992, with the informed consent of their parents and the approval of the Ethics Committee of Kyoto University. Before operation, six of the children required intensive care, another 14 were hospitalized, and 13 were homebound. Donors (12 paternal and 21 maternal) were selected solely from the parents of the recipients on the basis of ABO blood group and graft/recipient size matching determined by computed tomography scanning. Procurement of graft was performed using ultrasonic aspirator and bipolar electrocautery without blood vessel clamping and without graft manipulation. All donors subsequently had normal liver function and returned to normal life. The left lateral segment (16 cases), left lobe (16 cases), or right lobe (one case) were used as grafts. The partial liver graft was transplanted into the recipient who underwent total hepatectomy with preservation of the inferior vena cava using a vascular side clamp. Twenty-seven of 33 recipients are alive and well with the original graft and have normal liver function. The patient survival rate was 89% (24/27) in elective cases and 50% (3/6) in emergent cases. The other six recipients had functioning grafts but died of extrahepatic complications. Complications of the graft were minimal in all cases. Hepatic vein stenosis, which occurred three times in two cases, was successfully treated by balloon dilatation. In cases with sclerotic portal vein, the authors anastomosed the portal vein of the graft to the confluence of the splenic vein and the superior mesenteric vein without a vascular graft, after experiencing a case of vascular graft thrombosis. After hepatic artery thrombosis occurred in one of the initial seven recipients whose arterial anastomosis was done with surgical loupe, microsurgery was introduced for hepatic artery reconstruction. There has been no occurrence of thrombosis since then. The current results with LRLT suggested that the meticulous management of surgical factors at each stage of the LRLT procedure is crucial for successful outcome. Living related liver transplantation is a promising option for resolving the graft shortage in pediatric liver transplantation and may be regarded as an independent modality to supplement cadaver donation.