Ex-vivo right posterior sectionectomy for large-for-size mismatch in pediatric liver transplant recipients

Abstract Purpose Large-for-size mismatch remains a major challenge in pediatric and small recipient liver transplantation, particularly when full-size deceased-donor grafts are allocated and conventional splitting is not feasible. Methods We performed a single-center retrospective analysis of seven pediatric and adolescent recipients who underwent deceased donor liver transplantation (DDLT) with ex-vivo right posterior sectionectomy (RPS) between 2018 and 2022. Grafts were considered oversized based on an integrated surgical assessment including graft-to-recipient weight ratio (GRWR), recipient abdominal anatomy, graft morphology, and expected graft fit. Results Median GRWR decreased from 4.7% to 2.2%, allowing graft implantation in all cases. Primary abdominal closure was achieved in six recipients, while one required delayed closure for large-for-size syndrome (LFS). No cases of severe LFS with hemodynamic, ventilatory, or graft perfusion compromise were observed. Major complications occurred in three patients, including one biliary complication requiring surgical revision, one primary graft failure requiring retransplantation, and one death unrelated to graft size or transplant surgery. At a median follow-up of 59.5 months among surviving recipients, six of seven patients were alive; five retained their original graft, while one was alive with a functioning second graft after retransplantation. Conclusion Ex-vivo RPS appears to be a technically feasible rescue graft reduction strategy in highly selected pediatric recipients when conventional graft reduction techniques are not feasible. Given the limited cohort size and the occurrence of primary graft failure and mortality, its safety and efficacy require further evaluation.