3D Planning Cut Post-Op Complications in Kids’ Liver Transplants

Use of advanced preoperative 3D planning for pediatric liver transplant patients receiving larger grafts was associated with lower risk of postoperative complications, a small retrospective study in Taiwan found.

Kids receiving living-donor livers that were large-for-size — graft-to-recipient weight ratio (GRWR) ≥4% — had a significantly lower risk for postoperative complications in the 3D era than those receiving larger grafts in the pre-3D era and a control group of kids receiving better size-matched organs (OR 0.06, 95% CI 0.006-0.700, P=0.025), reported Chinsu Liu, MD, PhD, of the Taipei Veterans General Hospital in Taiwan, and colleagues.

In the study of 30 kids receiving transplants over the last 15 years, there were no significant between-group differences for graft and patient survival at 4 years (89%-100% and 78%-100%, respectively), the group wrote in the Journal of Pediatric Surgery.

3D imaging has become standard in pretransplant planning, and Liu’s group developed “a novel 3D image model to simulate the liver graft in the recipient’s abdominal cavity that mitigated the surgical uncertainty.”

“This is the first 3D model to combine the information of the donor and recipient in one 3D-rendered image that helps the surgeon determine the orientation of portal vein and hepatic vein anastomoses and predict the possibility of abdominal wall closure with or without graft reduction,” the authors wrote.

The main concern for pediatric living donor liver transplantation (PLDLT) patients is the potential for a size-mismatch in the left lateral segment (LLS), which can lead to large-for-size grafts for children who weigh less than 10 kg, Liu’s group noted. Undergoing a meticulous preoperative evaluation using 3D techniques may reduce the possibility of an abdominal compartment, insufficient portal flow to the graft, and graft compression after abdomen closure.

“Our study showed advanced preoperative 3D planning could comprehensively evaluate the recipient’s clinical factors and design the corresponding surgical technique to minimize postoperative complications and increase the safety of large-for-size grafts in PLDLT,” Liu’s group concluded.

Koji Hashimoto, MD, PhD, director of pediatric liver transplantation at the Cleveland Clinic in Ohio, noted that using 3D images allows clinicians to “see the exact size of the graft.”

“The size of the donor liver is the most important factor to make the transplant success, we have to reduce the size — the thickness of the graft, which depends on the recipient,” Hashimoto who was not involved in the study added. “You can’t bring the 3D model in the operating field, and it doesn’t help much.”

For their study, Liu and colleagues examined data on 30 PLDLT patients who weighed under 10 kg, and were enrolled from November 2004 to July 2021, with the 3D era starting in November 2017. Participants were grouped into three categories:

• GRWR ≥4% before the 3D era (conventional group; n=9)
• GRWR ≥4% during the 3D era (3D group; n=8)
• GRWR <4% (controls; n=13)

3D group patients were numerically younger (median age, 6.5 months vs 8-9 months) and also had the lowest median body weight (4.8 kg). All 3D patients received a reduced modified LLS including — a hyper-reduced LLS (n=5), reduced LLS (n=2), or a segment 2 monosegment (n=1).

Of the 16 patients with vascular or biliary complications, only one was in the 3D group, with six in the conventional group and nine in the control group. The most common vascular complications involved portal vein problems, including stenosis (n=4), thrombus (n=1), and delayed thrombus (n=2). One 3D patient had portal vein stenosis and one conventional patient had hepatic stenosis. Additionally, two patients in the control group had delayed hepatic stenosis and one had a hepatic artery thrombus.

Two patients in the conventional group had non-significant bile leaks and five patients in the control group had delayed biliary anastomosis strictures. There were no biliary complications in the 3D group, the authors added.

Within 4 years of follow-up, three patients died — two in the conventional group and one in the 3D group. Only one of those in the conventional group was related to the surgery (hepatic vein stenosis, causing graft failure).

The authors acknowledged limitations to the data. In addition to the 3D preparation, the “era effect” may have played a significant role in lowering postoperative complications. The 3D model was developed in 2019, so certain patients in the 3D group were not evaluated by this model.