Ann Surg 1991 Oct;214(4):428-37; discussion 437-9

Liver transplantation in children from living related donors. Surgical techniques and results

Broelsch CE, Whitington PF, Emond JC, Heffron TG, Thistlethwaite JR, Stevens L,
Piper J, Whitington SH, Lichtor JL

Abstract
Pediatric liver transplantation with reduced size donor organs (RLT) has evolved
into a standard clinical procedure increasing the choices of recipients for
their treatment. Nevertheless organ availability remains a major problem. The
authors therefore have proposed to study the use of hepatic segments from living
related donors (LRT) in a group of 20 children less than 2 years of age or
weighing less than 15 kg, in whom standard indications for transplantation
existed. Volunteer related donors were selected after medical and psychiatric
evaluations, and the suitability of the donor's liver was established by
functional and radiologic criteria. A two-stage informed consent process assured
appropriate "volunteerism." Nineteen infants received LRT as first grafts and
one as a second graft. Seventeen of the recipients are alive 3 to 18 months
after LRT. Fifteen of 20 patients are currently at home with the original graft
and normal liver function (bilirubin less than 1.5 mg/dl) after a median
hospital stay of 27 days (range, 14-93 days). Four patients underwent
retransplantation, in all cases due to arterial thrombosis. The overall graft
survival for 20 primary LRTs is 75%, with follow-up between 3 and 18 months. A
number of technical problems occurred during our initial trial, the most
aggravating being vascular thrombosis. Refined approaches to vascular
reconstruction should reduce the incidence of thrombosis and improve the rate of
survival in future cases. The donor group for the initial 20 LRT procedures
comprised 12 mothers, 7 fathers, and 1 grandmother. In addition one father and
one uncle, who was an identical twin of the recipient's father, who did not
qualify for anatomic reasons, were used in repeat LRT. All donors survived and
are now in normal health between 3 and 18 months after LRT, having returned to
all activities enjoyed before donation. The median hospital stay was 6 days
(range, 5-14). Complications were minimal, and all were limited to the first
three procedures, in which a full left hepatectomy was performed. After
alteration of the procedure into a left lateral segmentectomy, no complications
were encountered. The left lateral segmentectomy presents minimal surgical
trauma to the liver and should remain the primary approach for obtaining a liver
graft from a living donor. For children, transplantation of a left lateral
segment from a live donor provides a new way of providing a transplant of
appropriate size and with good function. The success of this program has led to
the acceptance of LRT for general clinical application in the authors'
institution