Background: Liver transplantation in infants presents significant challenges due to graft-recipient size disproportion, mainly because of the greater anteroposterior (AP) diameter of the left lateral segment (LLS). To address these issues, various graft reduction techniques have been developed to optimize abdominal cavity accommodation, adjust the graft-to-recipient weight ratio (GRWR <4%), and ensure primary abdominal closure while preventing large-for-size syndrome. Our group previously described a safe, non-anatomical anterior resection (AHR) technique for this purpose. This study aims to evaluate the medium-term outcomes of AHR in the LLS in living donor liver transplantation (LDLT).
Methods: We conducted a retrospective analysis of AHR cases between December 2021 and February 2025. Demographic, intraoperative, and postoperative data from donors and recipients were collected. Outcomes assessed included graft survival, vascular complications, biliary complications, and postoperative morbidity.
Results: A total of 32 liver transplantations using the AHR technique were performed. Among the donors, 78% (n = 25) were male, with an average age of 30.6 ± 5.6 years, body weight (BW) of 73.4 ± 10.9 kg, and body mass index (BMI) of 25 ± 2.5 kg/m². The average hospital stay for donors was 4 ± 1.1 days. No donor experienced surgical complications or required blood transfusion. For recipients, the median age at transplantation was 8.6 months (range: 0.6–21.1), with a median body weight of 6.5 kg (range: 3.9–10.2). The recipient-to-donor body weight ratio (RDBW) was <0.1 in all but one case. The mean graft weight reduction following AHR was 34.1% ± 14.4%, with a mean AP diameter reduction of 36.2% ± 7.6%. The average GRWR decreased from 5.2% ± 1.4% preoperatively to 3% ± 0.8% post-resection. Primary abdominal closure was achieved in 87.5% (n = 28) of cases. No hepatic artery thrombosis (HAT) or hepatic venous outflow obstruction (HVOO) was observed. Late portal vein thrombosis (PVT) developed in 6.8% (n = 2) of recipients, though no early PVT cases occurred. Biliary strictures were noted in 9.3% (n = 3) of recipients. One-year patient and graft survival rates were 96.8%. One patient, later diagnosed with STAT3 gain-of-function syndrome, succumbed to sepsis but had no vascular complications. The median follow-up duration was 516 days.
Conclusion: The AHR technique for liver transplantation in infants has proven to be a safe and reproducible procedure. Its major advantage lies in avoiding the need for hilar vascular dissection of segments II/III. Medium-term results demonstrate excellent patient and graft survival rates (96.7%), with a low incidence of vascular complications. Additionally, the absence of surgical complications requirements among donors highlights the safety of this approach. Given these promising outcomes, AHR represents a viable surgical option for very low-weight pediatric liver transplant recipients.