Large-For-Size Syndrome after Deceased Donor Liver Transplantation: A Case Report

( Yu Mi Kim ),( Sung Ha Lee ),( Jun Suh Lee ),( Jung Hyun Kwon ),( Soon Woo Nam ),( Young Chul Yoon ) 대한간학회 2018 춘·추계 학술대회 (KASL) Vol.2018 No.1

Background: Large-for-size (LFS) is a serious problem that can develop during liver transplantation (LT) and is related to morbidities such as insufficient blood supply causing graft dysfunction or impractical closure of the abdominal wall leading to graft compression. LFS is usually discussed in pediatric LT and is often managed by reducing the size of the graft before implantation. In contrast, only a few cases about managing unexpected LFS during adult LT have been reported. Case: The female patient of 44 years of age was admitted to the Incheon St. Mary’s Hospital with drug-induced acute hepatitis and managed conservatively. However, the patient underwent deceased donor liver transplantation (DDLT) due to persistent liver deterioration. Donor was a 51 year old male, weighing 60.0 kg and matched because the patient weighed 58.4 kg. Donor had a history of eating one bottle of Soju daily for 30 years, but the liver biopsy showed no fatty change at 0 %, but the liver size was shown larger than normal. The weight of donor liver was 2040 g, which was much heavier than normal but the liver transplantation was performed uneventfully. However, left lateral sectionectomy was performed because the abdomen was not be closed. On the next day, the liver function was deteriorated and blood pressure was dropped. Immediately, we took computed tomography (CT) scan and were able to observe the narrowing of the inferior vena cava (IVC) by the liver. Venogram showed significant stenosis at IVC suprahepatic portion, so IVC stent placement was performed using 24 x 80 mm Hercules stent graft (MicroPort Scientific Corporation, Shanghai, China). After stenting, blood pressure was stabilized but liver function was deteriorated more and renal replacement therapy was performed because of impaired renal function. However, liver and renal function gradually improved and discharged without any complication. Discussion & Conclusion: LFS can cause serious complication, but can be solved by various treatment modality.

Prevention and Management of Small-for-Size Syndrome of Liver Transplantation

Nam-Joon Yi 이화여자대학교 의과학연구소 2022 EMJ (Ewha medical journal) Vol.45 No.2

Small-for-size syndrome (SFSS) is a critical complication of partial liver transplantation, particularly in adult-to-adult living donor liver transplantation (ALDLT) using a small graft. Minimally required liver graft size for a successful ALDLT is classically 40% of a standard recipient’s liver volume or 0.8% of recipient body weight. Recent progress in perioperative care and technical improvement push the lower limit of safe graft size to 25% of the recipient’s standard liver volume or 0.6% of the graft versus recipient weight ratio although this is an ongoing debate. The clinical manifestations of SFSS include various symptoms and signs related to graft dysfunction and portal hypertension in patients with small grafts. The risk factors for SFSS include poor preoperative patient condition, including portal pressure, surgical techniques to reduce portal pressure, and graft quality and size. Hence, various approaches have been explored to modulate inflow and pressure to a small graft and to decrease the outflow block to alleviate this SFSS as well as the selection of a patient and graft. Additionally, recent research and efforts to prevent and treat SFSS are reviewed.

Anatomical limits in living donor liver transplantation

Kin Pan Au,Kenneth Siu Ho Chok 대한이식학회 2022 Korean Journal of Transplantation Vol.36 No.3

We review the anatomical limits of living donor liver transplantation. Graft size is the fundamental challenge in partial liver transplantation. Insufficient graft size leads to small-for-size syndrome, graft failure, and graft loss. However, smaller grafts can be used safely with surgical techniques to optimize outflow and modulate inflow, thereby minimizing portal hyperperfusion. Meanwhile, anatomical variations are common in the vascular and biliary systems. These variants pose additional challenges for vascular and biliary reconstruction. Recognition and appropriate management of these variants ensure donor safety and reduce recipient morbidity. The ultimate principle of partial liver transplantation is to ensure a sufficient graft volume with unimpeded outflow and reconstructable vascular and biliary systems. On this basis, the anatomical limits of living donor liver transplantation can be safely expanded.

간세포암에서 종양 크기의 임상적 의의

이상명(Sang Myung Lee),김세준(Say June Kim),이경근(Kyung Keun Lee),김동구(Dong Goo Kim) 대한외과학회 2008 Annals of Surgical Treatment and Research(ASRT) Vol.75 No.1

Purpose: The aim of this study is to evaluate the significance of tumor size as a predictor of biological tumor behavior and to get some information to decide on the proper operative modality by assessing the survival rate for HCC patients. Methods: Between January 1995 and September 2006, 278 patients with hepatocellular carcinoma (HCC) underwent liver surgery at our hospital. Of the 278 cases, 176 cases (63.3%) underwent liver resection and 102 cases (36.4%) underwent liver transplantation (LT). All the patients were divided into 4 groups according to their tumor size; <2 ㎝, 2∼5 ㎝, 5∼10 ㎝ and >10 ㎝. We analyzed the pathologic outcomes, survival rates and the outcome of each operative modality, as related to the tumor size. Results: The incidence of vascular invasion increased with the tumor size (<2 ㎝: 4.6%, 2∼5 ㎝: 23.3%, 5∼10 ㎝: 32.6%, >10 ㎝: 50.0%)(P<0.005). For the less than 2 ㎝ sized tumor group, the Edmonson-Steiner (E-S) grade III or IV was present in 40.7% of the patients, as compared with 78.9% in the group of patients with a tumor larger than 10 ㎝ (P=0.005). The patients with a larger tumor showed a poorer survival rate. Liver transplantation showed the longer disease free survival compared to liver resection, though there was no significant benefit in the survival rate. Patients with a small sized tumor showed a better outcome when they underwent liver transplantation and patients with a large sized tumor did better when they underwent liver resection. Conclusion: Tumor size can be used as a preoperative predictor of the pathologic outcome when considering that the larger size of tumor the patients had, the more prevalent was vascular invasion, the tumor cell grade was more advanced and the survival rate was poorer. For patients with small sized HCC, liver transplantation can be considered the appropriate treatment modality.

Pediatric liver transplantation with hyperreduced left lateral segment graft

Jung-Man Namgoong,Shin Hwang,Gi-Won Song,Dae-Yeon Kim,Tae-Yong Ha,Dong-Hwan Jung,Gil-Chun Park,Chul-Soo Ahn,Kyung Mo Kim,Seak Hee Oh,Hyunhee Kwon,Yong Jae Kwon 한국간담췌외과학회 2020 Annals of hepato-biliary-pancreatic surgery Vol.24 No.4

Backgrounds/Aims: To prevent large-for-size graft-related complications in small infant patients, the size of a left lateral segment (LLS) graft can be reduced to be a hyperreduced LLS (HRLLS) graft. Methods: This study was intended to describe the detailed techniques for harvesting and implanting HRLLS grafts developed in a high-volume liver transplantation (LT) center. Results: The mean recipient age was 4.0±1.7 months (range: 3-6) and body weight was 5.3±1.4 kg (range: 4.1-6.9). Primary diagnoses of the recipients were progressive familial intrahepatic cholestasis in 2 and biliary atresia in 1. The types of LT were living donor LT in 1 and split deceased donor LT in 2. Non-anatomical size reduction was performed to the transected LLS grafts. The mean weight of the HRLLS grafts was 191.7±62.1 g (range: 120-230) and graft-recipient weight ratio was 3.75±1.57% (range: 2.45-5.49). Widening venoplasty was applied to the graft left hepatic vein outflow orifice. Vein homograft interposition was used in a case with portal vein hypoplasia. Types of the abdomen wound closure were one case of primary repair, one of two-staged closure with a mesh, and one of three-staged repair with a silo and a mesh. All three patients recovered uneventfully from the LT operation and are doing well to date for more than 6 years after transplantation. Conclusions: Making a HRLLS graft through non-anatomical resection during living donor LT and split deceased donor LT can be a useful option for treating small infant patients.

Influence of Initial Seedling Size and Root Pruning Intensity on Growth of Transplanting Seedling of Quercus acutissma

Na, Sung-Joon,Lee, Do-Hyung,Kim, In-Sik The Plant Resources Society of Korea 2013 한국자원식물학회지 Vol.26 No.6

The objective of this study was to examine the effect of root pruning intensity in combination with different initial seedling size on the growth of transplanting seedlings of Quercus acutissima. One-year-old seedlings were divided into three groups depending on their height, i.e. small (< 15 cm), medium (25-35 cm) and large size (35 cm <). Root of seedlings was pruned by three intensity such as, leaving 5 cm (severe), 10 cm (medium) and 15 cm (light) of taproot from the root-collar. After one year, we investigated survival rate, height and root-collar diameter (RCD) increment and final shoot dry weight. Also we measured characteristics of newly developed lateral roots such as number, total length, dry weight and diameter. Severe root pruning showed the lowest survival rate in all seedling size. Height increment, RCD increment and shoot dry weight were decreased with increasing intensity of root pruning. Seedlings of medium and light root pruning showed similar above-ground growth and dry weight of lateral roots. More large seedlings showed good survival rate, height increment and final shoot dry mass in all root pruning intensity. Therefore, one-year-old seedlings of Q. acutissima should be pruned taproot by 10 cm and transplanted to obtain excellent performance and increase the efficiency of transplanting work. Based on the findings of this study, it is important that applying to different root pruning intensity depending on initial seedling size for producing 2-year-old seedlings with excellent growth and high quality.

Pediatric deceased donor liver transplantation with in situ size reduction for recipient-graft size matching

Jung-Man Namgoong,Shin Hwang,Dae-Yeon Kim,Tae-Yong Ha,Gi-Won Song,Dong-Hwan Jung,Kyung Mo Kim,Seak Hee Oh 한국간담췌외과학회 2021 Annals of hepato-biliary-pancreatic surgery Vol.25 No.3

We present a case of pediatric deceased donor liver transplantation using a reduced whole liver graft in a 25-month-old boy weighing 12.7 kg. After he had undergone Kasai portoenterostomy for biliary atresia, his general condition deteriorated progressively. He was enrolled on the waiting list for liver transplantation with Pediatric End-stage Liver Disease score of 15. The donor was a 51-month-old boy with body weight of 20 kg. The donor-to-recipient body weight ratio was 158%. The liver graft appeared to be larger than the recipient’s abdominal cavity. Thus, we planned to do in situ size reduction. Recipient surgery was performed following standard procedures. We performed graft outflow vein reconstruction using a modified piggyback technique like the double inferior vena cava method. Since the portal vein was hypoplastic, a side-to-side anastomosis technique was used. We also performed intraoperative portogram to embolize venous collaterals. After completing the graft implantation, we found that the liver graft was too large to be accommodated within the abdomen. After in situ resection of the left lateral section parenchyma, we successfully performed primary closure of the abdominal wound. This patient experienced episodes of acute rejection. He has been doing well for four years after the transplantation.

Pediatric split liver transplantation using a hyperreduced left lateral segment graft in an infant weighing 4 kg

Jung-Man Namgoong,Shin Hwang,Dae-Yeon Kim,Gi-Won Song,Chul-Soo Ahn,Kyung Mo Kim,Seak Hee Oh 대한이식학회 2020 Korean Journal of Transplantation Vol.34 No.3

We present a case of successful split liver transplantation (LT) using a hyperreduced left lateral segment (LLS) graft in a 106-day-old female infant patient weighing 4 kg. The patient was diagnosed with progressive familial intrahepatic cholestasis. Her general condition and liver function deteriorated progressively and she was finally allocated for a split LT under status 1. The deceased donor was a 20-year-old female weighing 63.7 kg. We performed in situ liver splitting and in situ size reduction sequentially. The weight of the hyperreduced LLS graft was 225 g, with a graft-recipient weight ratio of 5.5%. We performed recipient hepatectomy and graft implantation according to the standard procedures for pediatric living-donor LT. Since the graft was too large for primary abdomen closure, the abdominal wall was closed in three stages to make a prosthetic silo, temporary closure with a xenograft sheet, and final primary repair over 2 weeks. The patient has been doing well for more than 6 years after transplantation. In conclusion, split LT using a hyperreduced LLS graft can be a useful option for treating small infants. However, large-for-size graft-related problems, particularly in terms of graft thickness, still remain to be solved.

Clinical Implications for Graft Function of a New Equation Model for the Ratio of Living Donor Kidney Volume to Recipient Body Surface Area

이창기,윤영은,최경화,양승철,이중식,주동진,허규하,김유선,한웅규 대한비뇨의학회 2013 Investigative and Clinical Urology Vol.54 No.12

Purpose: We propose an equation that predicts graft function after kidney transplantation by using donated kidney volume and recipient body surface area (BSA). Materials and Methods: Included were 261 cases of living kidney transplantation between 2007 and 2009. Preoperative computed tomography scans were performed and the donated kidney volume was measured by use of a three-dimensional reconstruction program (Ripidia). The estimated glomerular filtration rate (eGFR) was calculated by using the modification of diet in renal disease formula. Donated kidney volume, preoperative renal function, and demographic factors of both donors and recipients were evaluated as predictors. Results: The mean ages of the donors and recipients were 40.8 and 41.6 years, respectively. The mean donated kidney volume and donated kidney volume/recipient BSA ratio were 153.4 mL and 96.9 mL/m2, respectively. Mean preoperative and postoperative 12-month eGFR of recipients were 7.1 and 59.7 mL/min, respectively, and the mean preoperative eGFR of donors was 92.2 mL/min. Donated kidney volume/recipient BSA ratio, donor age, and recipient gender were the significant predictors of eGFR level (p<0.001) and eGFR<45 mL/min at postoperative 12 months (p=0.005, p<0.001, and p=0.006). From the multiple linear regression equation and predicted probability from logistic regression, we could calculate the equation for the ratio of living donor kidney volume to recipient BSA on graft function. Conclusions: Graft kidney volume/recipient BSA ratio, donor age, and recipient gender were predictors of graft function 12 months after kidney transplantation. Although we are concerned only with the preoperative, this equation model could help physicians to counsel patients concerning their postoperative prognosis and to avoid insufficient volume donations.

Human neural stem cells promote proliferation of endogenous neural stem cells and enhance angiogenesis in ischemic rat brain

Ryu, Sun,Lee, Seung-Hoon,Kim, Seung U.,Yoon, Byung-Woo Medknow PublicationsMedia Pvt Ltd 2016 Neural regeneration research Vol.11 No.2

<P>Transplantation of human neural stem cells into the dentate gyrus or ventricle of rodents has been reportedly to enhance neurogenesis. In this study, we examined endogenous stem cell proliferation and angiogenesis in the ischemic rat brain after the transplantation of human neural stem cells. Focal cerebral ischemia in the rat brain was induced by middle cerebral artery occlusion. Human neural stem cells were transplanted into the subventricular zone. The behavioral performance of human neural stem cells-treated ischemic rats was significantly improved and cerebral infarct volumes were reduced compared to those in untreated animals. Numerous transplanted human neural stem cells were alive and preferentially localized to the ipsilateral ischemic hemisphere. Furthermore, 5-bromo-2′-deoxyuridine-labeled endogenous neural stem cells were observed in the subventricular zone and hippocampus, where they differentiated into cells immunoreactive for the neural markers doublecortin, neuronal nuclear antigen NeuN, and astrocyte marker glial fibrillary acidic protein in human neural stem cells-treated rats, but not in the untreated ischemic animals. The number of 5-bromo-2′-deoxyuridine-positive ⁄ anti-von Willebrand factor-positive proliferating endothelial cells was higher in the ischemic boundary zone of human neural stem cells-treated rats than in controls. Finally, transplantation of human neural stem cells in the brains of rats with focal cerebral ischemia promoted the proliferation of endogenous neural stem cells and their differentiation into mature neural-like cells, and enhanced angiogenesis. This study provides valuable insights into the effect of human neural stem cell transplantation on focal cerebral ischemia, which can be applied to the development of an effective therapy for stroke.</P>