Surgical Innovations Impacting Pediatric Liver Transplantation

Organ size is of the utmost importance in pediatric transplantation. The shortage of size-matched organs for pediatric candidates is a continuing difficult problem. When a whole liver is transplanted, the donor should be within 15 to 20% of the recipient's size. The shortage of donors for small children led to the development of "technical variant" transplantation.

Reduced-size liver transplantation is the technique in which a donor liver is divided along anatomic segments to provide a hepatic allograft for a smaller recipient. Grafts can routinely be obtained from a donor many times larger than the recipient. Left-lateral lobe grafts are generally used in the situation in which the donor-to-recipient weight ratio exceeds 4, the left lobe graft is used when the ratio is 2:4, and the right lobe is used when the ratio is 1:2.5. Not only has this technique expanded the donor pool for small recipients, it has also provided excellent long-term liver replacements, with survival results equivalent to transplantation using whole livers for grafts.

The techniques of reduced-size liver transplantation have been applied to other technical variant procedures, including orthotopic auxiliary liver transplantation for the treatment of inborn errors of metabolism, "split-liver" transplantation, and transplantation using living related donors. In auxiliary OLT, a reduced-size graft replaces the resected left lobe of the recipient's liver. The most reasonable use of the procedure is in the treatment of inborn errors of metabolism such as Crigler-Najjar syndrome, in which the recipient's liver maintains its basic capacity for life support. Split-liver transplantation is a technique whereby a donor liver is divided to provide grafts for two recipients. Despite its complexity, it is increasingly being used in pediatric centers because of the obvious advantage of doubling the supply of cadaveric hepatic allografts.

Living donor liver transplantation for infants and children has been established and has proved to have several obvious advantages. First, the earlier and more elective transplantation of small infants provides a major advantage, mitigating malnutrition and pretransplantation complications, resulting in improved survival rates, shorter hospitalization, and markedly reduced overall cost of transplantation. The quality of the graft is uniformly outstanding. Patients with living-related donor grafts are less likely to develop steroid-resistant rejection, fewer lose their grafts to chronic rejection, and, overall, in long-term follow-up, these patients appear to need less immunosuppression than recipients of cadaveric grafts. When applied to pediatric transplantation, the donor usually undergoes only a left-lateral segmentectomy, which has proven to be very safe. The donor mortality worldwide is about 0.1%.

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