transplantation of a 2-year-old deceased-donor liver to a 61-year-old male recipient

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Asian Journal of Surgery (2012) xx, 1e4

Available online at www.sciencedirect.com

journal homepage: www.e-asianjournalsurgery.com

CASE REPORT

Transplantation of a 2-year-old deceased-donorliver to a 61-year-old male recipient*

Wing Chiu Dai a, William W. Sharr a, Kenneth S.H. Chok a, Tan To Cheung a,James Y.Y. Fung b,c, Albert C.Y. Chan a, See Ching Chan a,b,*, Chung Mau Lo a,b

aDepartment of Surgery, The University of Hong Kong, Hong Kong, Chinab State Key Laboratory for Liver Research, The University of Hong Kong, Hong Kong, ChinacDepartment of Medicine, The University of Hong Kong, Hong Kong, China

Received 3 July 2012; received in revised form 10 September 2012; accepted 11 September 2012

KEYWORDSdeceased-donor livertransplantation;

graft-weight-to-recipient-weightratio;

pediatric donor

* This study received no financial or* Corresponding author. 102 Pok Fu LE-mail address: seechingchan@gm

Please cite this article in press as: DaAsian Journal of Surgery (2012), http

1015-9584/$36 Copyright ª 2012, Asiahttp://dx.doi.org/10.1016/j.asjsur.20

Summary The suitable size of a graft is a key element in the success of liver transplantation.A small-for-size liver graft is very likely to sustain a significant degree of injury as a result ofischemia, preservation, reperfusion, and rejection. Usually, small-for-size grafts are a concernin living-donor liver transplantation rather than in deceased-donor liver transplantation. Here,we describe the successful transplantation of a liver from a 2-year-old deceased donor to a 61-year-old male recipient who suffered from liver failure related to hepatitis B. No report ofsuccessful deceased-donor liver transplantation with discrepancies between donor and recip-ient age and size to such an extent has been found in the literature. Despite unusually largediscrepancies, with effort in minimizing the ischemic time, revised surgical techniques, andstrong regenerative power of the “young” graft, the old patient’s liver function gradually re-turned to normal. This again proves that the definition of a “suitable graft” evolves with timeand experience.Copyright ª 2012, Asian Surgical Association. Published by Elsevier Taiwan LLC. All rightsreserved.

1. Introduction

The disparity between demand and supply of liver graftshas led the liver transplant community to look beyond the

material support.am Road, Hong Kong, China.ail.com (S.C. Chan).

i WC, et al., Transplantation of a://dx.doi.org/10.1016/j.asjsur.20

n Surgical Association. Published12.09.005

conventional donor pool toward more marginal donorcandidates. Strategies to increase the number of livergrafts include liver splitting, use of steatotic livers andlivers with familial amyloidotic polyneuropathy disease,and accepting donors over 70 years old1 and donations aftercardiac death.2 These strategies are particularly importantin Asian regions, including Hong Kong, where there isa serious shortage of livers from brain-dead donors.3 Here,we describe a case of liver transplantation where a liver

2-year-old deceased-donor liver to a 61-year-old male recipient,12.09.005

by Elsevier Taiwan LLC. All rights reserved.

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http://dx.doi.org/10.1016/j.asjsur.2012.09.005

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2 W.C. Dai et al.

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donated by a 28-month-old brain-dead boy was trans-planted to a 61-year-old man.

2. Case report

2.1. Donor

The donor was a 28-month-old ChineseeJapanese boy witha body weight of 12 kg and a body height of 90 cm. Hesustained severe head injury, resulting in cerebral hemor-rhage. He received craniectomy but finally succumbed tobrain death 4 days afterward. Throughout his 4-day stay inthe pediatric intensive care unit, he was hemodynamicallystable. Right at the time of his death, there was nopediatric liver transplant candidate in the city who wascompatible with the donor.

2.2. Recipient

The recipient was a 61-year-old Chinese man, a hepatitis Bvirus (HBV) carrier with a known history of diabetes melli-tus. He was admitted to the hospital because of acute-on-chronic liver failure related to an acute flare of hepatitis B.His serum total bilirubin level on admission was 373 mmol/Land the international normalized ratio was 2.5. His HBVDNA was 1.5 � 105 copies/mL. His condition deterioratedrapidly, with the model for end-stage liver disease scorerising to 40 despite commencing antiviral therapy. Hedeveloped hepatic encephalopathy and required intubation12 days after admission. Six days later, he received livertransplantation. His body weight was 64.5 kg and bodyheight was 1.53 m at the time of transplantation, giving anestimated standard liver volume of 1264 mL.4

2.3. Operation

In the donor, the celiac trunk and portal vein were isolatedat the beginning of the liver-recovering procedure so as toreduce the cold ischemic time. The liver was then retrievedwith the standard technique with kocherization of theduodenum, isolation of the inferior vena cava (IVC), andcannulation of the aorta and inferior mesenteric vein. Cross-clamping and perfusion with Viaspan were not performeduntil the recipient was almost ready for implantation. Theliver weighed 360 g. The graft-weight-to-recipient-weightratio was 0.56% and the graft-weight-to-standard-liver-volume ratio was 28.4%. The graft was trimmed at the backtable and the infrahepatic IVC was closed with a TycoAutosuture TA30 linear stapler.

In the recipient, the native liver was cirrhotic withmoderate splenomegaly. Total hepatectomy was performedwith preservation of the IVC. Venovenous bypass was notused. The right hepatic vein and the common trunk of themiddle and left hepatic veins were closed with an EthiconEndopath ATW35 articulating linear cutter. A separateopening was made in the IVC below the hepatic vein orificeto allow caudal shifting of the graft so as to facilitate portalvein and bile duct anastomosis. The piggyback techniquewas adopted because of the discrepancy between the sizeof the donor IVC and that of the recipient IVC. Implantation

Please cite this article in press as: Dai WC, et al., Transplantation of aAsian Journal of Surgery (2012), http://dx.doi.org/10.1016/j.asjsur.20

of graft was started with an end-to-side anastomosis of thegraft suprahepatic IVC to the recipient IVC with a 5/0 Pro-lene suture. After portal vein reconstruction, hepaticartery anastomosis was performed under an operationmicroscope with a 9/0 nylon interrupted suture, and duct-to-duct anastomosis was performed with a 6/0 poly-dioxanone continuous suture for the posterior layer and aninterrupted suture for the anterior layer. At the end of theoperation, Doppler ultrasound study confirmed that allvessels were patent. Portal pressure measured afterimplantation was 16 mmHg and portal flow 333 mL/100 g/min. The cold ischemic time was 214 minutes and warmischemic time 43 minutes.

2.4. Postoperative course

A computed tomography scan 1 week after the operationshowed hypertrophy of the liver graft (Fig. 1). Pathology ofhis excised liver confirmed chronic hepatitis B withcirrhosis. His serum total bilirubin level went down from582 to 392 mmol/L after the operation and reached a peaklevel of 550 mmol/L 9 days after the operation. The levelgradually returned to normal in 2 months’ time. His inter-national normalized ratio returned to normal 11 days afterthe operation. Daily abdominal drain output was around500e1000 mL in the early postoperative period, whichgradually reduced to an insignificant amount 50 days afterthe operation. He underwent re-laparotomy for intra-abdominal collection, with peritoneal fluid growing Cit-robacter freundii, and gradually recovered. At the time ofwriting of this article, he has remained alive for 16 monthsafter transplantation.

3. Discussion

The expanding request for liver transplantation, coupledwith the serious shortage of liver grafts, has increased theuse of extended-criteria donors worldwide. There arereports on cases of deceased-donor liver transplantation(DDLT) using previously forbidden livers such as those withlarge cavernous hemangioma,5,6 polycystic livers,7 andlivers from donors positive of hepatitis B surface antigen.8

Livers from pediatric donors are ideally used for pedi-atric recipients. However, there are occasions where sucha liver is allocated to an adult recipient, e.g., if the pedi-atric donor and an adult patient are within the same bodyweight range. However, no report of successful DDLT withdiscrepancies between donor and recipient age and size toan extent as described herein has been found in the liter-ature. At the time of this transplantation, no pediatric livertransplant candidate in the city was compatible with thedonor. On the other hand, for this patient with a disease ofUNOS status 1A, liver transplantation was the only curativeoption. We therefore decided to go ahead with the trans-plantation, and all details regarding the donor and thesituation of the patient were discussed with the patient’sfamily before the transplantation could proceed.

Emre et al9 reviewed their experience of using pediatricdonor livers in adult liver transplantations and found thatthe incidence of hepatic artery thrombosis was significantlyhigher in the pediatric donor group (12.9%) when compared


Figure 1 Computed tomography scan 1 week after the operation showed hypertrophy of the liver graft: (A) small graft hepaticvein, (B) inferior vena cava, (C) small graft portal vein, and (D) normal recipient portal vein.

Liver transplantation with pediatric donor 3

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with the adult donor group (3.8%; pZ 0.0003). Adam et al10

reviewed their use of small donor livers for adult recipientsand found that risk factors for complications were graftweight below 600 g, graft-weight-to-recipient-weight ratiobelow 0.5, and preservation time exceeding 12 hours.

The suitable size of a graft is a key element in thesuccess of adult-to-adult living-donor liver transplantation(LDLT). A small-for-size graft is very likely to sustaina significant degree of injury as a result of ischemia, pres-ervation, reperfusion, and rejection. Early graft dysfunc-tion predisposes the patient to complications such as sepsisand intracranial hemorrhage. In our early experience,a graft-weight-to-standard-liver-volume ratio of >40%correlated with a patient survival rate of 95%, and a <40%ratio correlated with a 40% survival rate only.11 On reachingthe first 100 cases of right-liver LDLT, we reckoned thata graft larger than 35% of the standard liver volume maysuffice.12 Through accumulation of experience, small-for-size grafts have become less important as a factor inhospital mortality at our center.13 Similarly, Nishizakiet al14 have suggested that a small graft with a graft-weight-to-standard-liver volume ratio of 26e29% can beused for LDLT.

In the literature, most of the studies on small-for-sizeliver graft have their focus on LDLT, as the minimum graftsize for DDLT is expected to be higher because of variousadverse events on brain-dead donors as well as the longerischemic time. The DDLT described herein is quite unusual,with a graft-weight-to-recipient-weight ratio of only 0.56%and a graft-weight-to-standard-liver-volume ratio of only28.4%. Nonetheless, with revised techniques such as caudal


shifting of graft, piggyback technique for implantation,effort in minimizing the ischemic time, and the strongerregenerative power of the “young” graft,15 the oldpatient’s liver function gradually returned to normal. Thisagain proves that the definition of a “suitable graft”evolves with time and experience.

References

1. Kim DY, Cauduro SP, Bohorquez HE, Ishitani MB, Nyberg SL,Rosen CB. Routine use of livers from deceased donors olderthan 70: is it justified? Transplant Int. 2005;18:73e77.

2. Bernat JL, D’Alessandro AM, Port FK, et al. Report of a nationalconference on donation after cardiac death. Am J Transplant.2006;6:281e91.

3. Lo CM. Liver transplantation in Asiadchallenges and opportu-nities. Asian J Surg. 2002;25:270.

4. Chan SC, Liu CL, Lo CM, et al. Estimating liver weight of adultsby body weight and gender. World J Gastroenterol. 2006;12:2217e2222.

5. Aucejo FN, Ortiz WA, Kelly D, et al. Expanding the donor pool:safe transplantation of a cadaveric liver allograft with a 10 cmcavernous hemangiomada case report. Liver Transpl. 2006;12:687e689.

6. Nikeghbalian S, Kazemi K, Salahi H, et al. Transplantation ofa cadaveric liver allograft with right lobe cavernous heman-gioma, without back-table resection: a case report. TransplantProc. 2007;39:1691e1692.

7. Stewart ZA, Kozlowski T, Segev DL, Montgomery RA, Klein AS.Successful transplantation of cadaveric polycystic liver: casereport and review of the literature. Transplantation. 2006;81:284e286.


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8. Ho JK, Harrigan PR, Sherlock CH, et al. Utilization of a liverallograft from a hepatitis B surface antigen positive donor.Transplantation. 2006;81:129e131.

9. Emre S, Soejima Y, Altaca G, et al. Safety and risk of usingpediatric donor livers in adult liver transplantation. LiverTranspl. 2001;7:41e47.

10. Adam R, Castaing D, Bismuth H. Transplantation of smalldonor livers in adult recipients. Transplant Proc. 1993;25:1105e1106.

11. Lo CM, Fan ST, Liu CL, et al. Minimum graft size for successfulliving donor liver transplantation. Transplantation. 1999;68:1112e1116.


12. Fan ST, Lo CM, Liu CL, Yong BH, Wong J. Determinants ofhospital mortality of adult recipients of right lobe live donorliver transplantation. Ann Surg. 2003;238:864e869.

13. Chan SC, Lo CM, Ng KKC, Fan ST. Alleviating the burden ofsmall-for-size graft in right liver living donor liver trans-plantation through accumulation of experience. Am J Trans-plant. 2010;10:859e867.

14. Nishizaki T, Ikegami T, Hiroshige S, et al. Small graft for livingdonor liver transplantation. Ann Surg. 2001;233:575e580.

15. Yokoi H, Isaji S, Yamagiwa K, et al. Donor outcome and liverregeneration after right-lobe graft donation. Transplant Int.2005;18:915e922.


transplantation of a 2-year-old deceased-donor liver to a 61-year-old male recipient

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