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TO THE EDITORS:

Auxiliary partial orthotopic liver transplantation (APOLT) is an accepted treatment option for select children with acute liver failure and metabolic liver disorders.[1, 2] In children with acute liver failure, APOLT permits the native liver to regenerate with the option of withdrawing immunosuppression.[1]

Despite its advantages, APOLT is not universally popular because of the complexity of the operation and technical failures (particularly arterial complications).[3-5] In the scenario of living donor APOLT for children, in which the left lateral section of the donor is used to replace the left lobe of the liver in the recipient, there is a significant mismatch between the sizes of the recipient's left hepatic artery and the adult donor's left hepatic artery. We describe an alternative technique for arterial revascularization of a left lateral section auxiliary liver graft in a child who underwent APOLT for acute liver failure. In this way, we were able to overcome a size mismatch problem between donor and recipient arteries.

REPORT

A 3-year-old girl with hepatitis A–related fulminant hepatic failure was transferred to our center on mechanical ventilator support. She satisfied the criteria for liver transplantation for acute liver failure[6] and was offered auxiliary liver transplantation. The child's blood group was A positive, and she weighed 12 kg. Her paternal uncle (whose blood group was A negative) was assessed for living liver donation. The donor had a standard portal vein and type A biliary anatomy[7] and a Michels type I hepatic artery anatomy.[8]

The donor underwent left lateral sectionectomy. The graft weighed 216 g. The recipient underwent left trisectionectomy and caudate lobectomy to create enough space for the larger graft. The graft was placed orthotopically with its cut surface facing the resected surface of the native liver. The left hepatic vein of the graft was anastomosed to the left hepatic vein stump of the child after the extension of the latter's opening into the inferior vena cava. The left portal vein of the graft was anastomosed to the left portal vein of the child with an extension downward into the main portal vein. Reperfusion of the graft was uneventful.

The arterial anastomosis was complicated by a significant disparity between the child's left hepatic artery and the recipient's left hepatic artery. The graft's left hepatic artery was 4 mm in diameter, and the recipient's left hepatic artery was 1.5 mm in diameter.[9] It was, therefore, decided to anastomose the common hepatic artery of the recipient to the left hepatic artery of the graft, both of which were size-matched (Figs. 1 and 2). The hepatic artery was divided proximal to the gastroduodenal artery so that the native liver would continue to receive its arterial blood flow through the gastroduodenal arcade. Test clamping of the recipient's common hepatic artery proximal to the gastroduodenal artery was performed before division to demonstrate pulsatile flow in the recipient's right hepatic artery. The hepatic artery stump thus created was larger (approximately 4 mm in diameter) and was a size match for an accurate anastomosis. The arterial anastomosis between the recipient's common hepatic artery and the donor's left hepatic artery was performed in an interrupted fashion with 8-0 polypropylene sutures under 4.5X magnification in an end-to-end fashion.

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Figure 1. Schematic diagram showing the anatomy of the common hepatic artery and its relationship with the pancreaticoduodenal arcade. (1) The common hepatic artery arises from the celiac trunk. It divides into (2) left and (3) right hepatic arteries after it gives origin to (4) the gastroduodenal artery. The gastroduodenal artery gives origin to the superior pancreaticoduodenal branch, which forms (5) the pancreaticoduodenal arcade by anastomosing with a branch of (6) the inferior pancreaticoduodenal artery. The latter is a branch of (7) the superior mesenteric artery.

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Figure 2. Schematic diagram after reconstruction. The recipient's common hepatic artery is divided proximal to the origin of the gastroduodenal artery. The divided common hepatic artery is anastomosed to (1) the graft's left hepatic artery. (2) The distal CHA stump is securely ligated. The arterial supply to the right native remnant liver is through (3) the pancreaticoduodenal arcade.

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A color Doppler study was performed for the graft and the native liver remnant daily for the first 5 days and then twice weekly. These studies showed pulsatile flow in both right and left hepatic arteries with a resistive index of 0.7 in the graft and resistive index of 0.76 in the native right liver, which indicated well-preserved arterial perfusion to both the graft and the native liver.

Postoperatively, the patient had a steady recovery, and she was off ventilatory support on day 2. She was maintained on standard double immunosuppression with tacrolimus and steroids. The liver function tests showed steady improvement. Steroids were tapered and discontinued once the graft function stabilized. On postoperative day 25, a hepatobiliary iminodiacetic acid scan showed 96% excretion of tracer activity by the graft and 4% excretion by the native liver. During a review at 6 months, she had good liver function. A repeat hepatobiliary iminodiacetic acid scan showed a 30-70 split between the native liver and the recipient liver. A computed tomography scan confirmed good hepatic arterial supply to the graft and the native liver (Fig. 3).

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Figure 3. Computed tomography arterial phase reconstruction of the hepatic arterial system on follow-up imaging. Note the recipient common hepatic artery/donor left hepatic artery anastomosis and the filling of the right hepatic artery from the superior mesenteric artery (RHA indicates the right hepatic artery).

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APOLT exploits the ability of the liver to regenerate after the acute insult has passed, and it can act as a bridge to support the child during this period. King's College data for APOLT in 20 children with acute liver failure showed that 65% of the children became immunosuppression-free by 23 months.[1] The standard technique of arterial reconstruction in deceased donor APOLT uses a cadaveric iliac artery conduit, which brings inflow from the supraceliac aorta, infrarenal aorta, splenic artery, or gastroduodenal artery.[1, 10-12] In the setting of adult living donor APOLT, a direct anastomosis between the donor's right hepatic artery and the recipient's right hepatic artery is feasible. However, in pediatric living donor APOLT, a discrepancy between the donor and recipient arteries is common. Our technique overcomes this difficulty and allows a safe arterial anastomosis. When the native liver fully regenerates and the graft atrophies after the withdrawal of immunosuppression, the native liver arterial supply remains separate from the arterial supply to the graft from the celiac axis. If the graft needs to be removed because of graft necrosis after the withdrawal of immunosuppression, this can be done safely without damage to the arterial supply of the native liver remnant.

  • Mohamed Rela, M.S., F.R.C.S.1,2

  • Anand Bharathan, M.S., D.N.B.1

  • Rajesh Rajalingam, M.S., M.Ch.1

  • Gomathy Narasimhan, M.S.1

  • Mettu Srinivas Reddy, M.S., F.R.C.S., Ph.D1

  • 1Institute of Liver Surgery and Transplantation

  • Global Hospital and Health City

  • Chennai, India

  • 2Institute of Liver Studies

  • King's College Hospital

  • London, United Kingdom

  • Correspondence to

  • Prof Mohamed Rela MS, FRCS

  • Institute of Liver Surgery & Transplantation

  • Global Hospital & Health City

  • Cheran Nagar, Perumbakkam

  • Chennai 600100

  • INDIA

  • Telephone: 0091-900309886

  • Email: mohamed.rela@gmail.com

REFERENCES

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