Tailored standardization of portal vein reconstruction for pediatric liver transplantation at Asan Medical Center

Pediatric recipients, especially infants, are vulnerable to vascular complications because recipient vessels are smaller than those in adult liver transplantation (LT). Once portal vein (PV) stenosis occurs, it is often difficult to treat it through radiological angioplasty. Endovascular stenting is regarded as the final life-saving procedure, with a likelihood of needing retransplantation later. We have established standardized customization of surgical techniques for pediatric LT. Here, we present our tailored standardization of PV reconstruction for pediatric LT with the following 5 topics. 1) tadpole vein homograft conduit interposition for hypoplastic PV in infant patients undergoing split or living donor LT; 2) side-to-side anastomosis for hypoplastic PV in infant patients undergoing infant-to-infant whole liver LT; 3) PV branch patch venoplasty for size-matching in pediatric patients undergoing split or living donor liver transplantation; 4) PV conduit interposition in pediatric patients with congenital absence of PV; 5) wedged patch venoplasty for small-sized graft left PV. There are two features in our techniques for PV reconstruction: 1) frequent use of vein homograft; and 2) funneling of the recipient PV to match with the graft PV. In conclusion, secure PV reconstruction is important for successful pediatric LT. Thus, every effort should be made to ensure obtainment of sufficient portal blood inflow. From the viewpoint of hemodynamics principles, a funnel-shaped PV conduit is the most desirable configuration to ensure effective flow from the splanchnic system in infant patients with PV hypoplasia.