Rossignol Guillaume, Muller Xavier, Dubois Remi, Rode Agnes, Mabrut Jean-Yves, Mohkam Kayvan
Department of Pediatric Surgery and Liver Transplantation, Femme Mere Enfant University Hospital, Lyon, France.
Department of General Surgery and Liver Transplantation, Croix-Rousse University Hospital, Lyon, France.
Pediatr Transplant. 2023 Jun;27(4):e14510. doi: 10.1111/petr.14510. Epub 2023 Mar 15.
Graft-recipient size matching is a major challenge in pediatric liver transplantation, especially for adolescent recipients. Indeed, adolescents have the lowest transplantation rate among pediatric recipients, despite prioritization policies and the use of split grafts. In case of an important graft-recipient size mismatch, ex situ graft reduction with right posterior sectionectomy (RPS) may optimize the available donor pool to benefit adolescent recipients.
We present three cases of liver graft reduction with ex situ RPS for adolescent recipients. The surgical strategy was guided by GRWR (graft/recipient weight ratio), GW/RAP (right anteroposterior distance ratio), and CT-scan volumetric and anthropometric evaluation.
Recipients were 12, 13, and 14-year-old and weighed 32, 47, and 35 kg, respectively. All liver grafts were procured from brain-dead donors with a donor/recipient weight ratio >1.5. RPS was performed ex situ, removing 20% of the total liver volume leading to a decrease of the GRWR <4% and the GW/RAP <100 g/cm in each case. All three reduced grafts were successfully transplanted with a static cold storage time ranging from 390 to 510 min without the need for delayed abdominal closure. We did not observe any primary non-function, vascular complication, or delayed graft function with a median follow-up of 6 months. One biliary anastomotic stenosis occurred which required surgical treatment.
Ex situ liver graft reduction with RPS allowed for successful transplantation in case of anthropometric graft-recipient size mismatch in adolescent liver transplant candidates. Although the use of split grafts remains the gold standard, RPS should be acknowledged as a way to optimize the donor pool, especially for adolescent recipients.
移植物与受者大小匹配是小儿肝移植中的一项重大挑战，对于青少年受者而言尤其如此。事实上，尽管有优先分配政策以及劈裂式移植物的应用，但青少年在小儿受者中的移植率却是最低的。在移植物与受者大小严重不匹配的情况下，采用右后叶切除术（RPS）进行体外移植物减容或许能够优化可用供体库，从而使青少年受者受益。
我们呈现了3例为青少年受者进行体外RPS肝移植物减容的病例。手术策略由移植物/受者重量比（GRWR）、肝门右前后径比（GW/RAP）以及CT扫描容积和人体测量评估来指导。
受者年龄分别为12岁、13岁和14岁，体重分别为32千克、47千克和35千克。所有肝移植物均取自脑死亡供者，供者/受者重量比>1.5。RPS在体外进行，切除了肝脏总体积的20%，使得每例的GRWR降低<4%，GW/RAP降低<100克/厘米。所有3个减容后的移植物均成功移植，静态冷缺血时间为390至510分钟，无需延迟关腹。中位随访6个月时，我们未观察到任何原发性无功能、血管并发症或移植物功能延迟情况。发生了1例胆道吻合口狭窄，需要手术治疗。
对于青少年肝移植候选者，在人体测量显示移植物与受者大小不匹配的情况下，采用RPS进行体外肝移植物减容可实现成功移植。尽管劈裂式移植物的应用仍是金标准，但RPS应被视为优化供体库的一种方式，尤其是对于青少年受者。
