Liver transplantation with heterotopic reversed position technique in pediatric patients

Aim: In the setting of pediatric living or deceased donor split liver transplantation, there are problems associated with size-mismatched large grafts. These include the inability to accommodate the graft in the small abdominal cavity of the recipient and to provide sufficient blood supply to the liver graft. Aim of this study is to introduce the liver transplantation with heterotopic reversed position technique and toreport results of the patients treated with this procedure.Material and Method: When anteroposterior diameter of the graft, segment 2-3living donor or split liver, is larger than the abdominal cavity of the recipient, we positioned the graft heterotopically in the right subphrenic space after rotating 180o sagitally. Although this maneuver allowed primary closure of the abdomen, this orientation brought the hilar structures into a reversed position. In back-table hilar structures should be checked before anastomoses because anastomoses sequence may change. Eleven patients transplanted with this technique and 10 of them were younger than 5 year-old. Their weight was between 9 ? 20 kg and GRWR was between 1.5 ? 3.4.Results: Of these, nine patients were acute fulminant liver failure. No vascular complications seen during postoperative period but biliary strictures occurred in two patients which were treated succesfully with percutaneous approach. Seven patients are alive for mean of 11.5 months and 4 cases were lost from causes out of the graft failure (continuing encephalopathy after transplantation, hemodinamically instability, GVHD and peptic ulcer perforation).Discussion: In pediatric liver transplantation, especially in patients with acute fulminant failure, problems like failure of primary closure of abdominal cavity due to graft size and, graft and recipient hilar structures avoid facing appropriately, can be overcome with this technique. Follow-up of the long-term results of the transplanted livers after regeneration is necessary for further acceptability of this technique.