Hypothermic oxygenated machine perfusion may provide a platform for graft manipulation in pediatric liver transplantation. This study presents an innovative strategy—in-situ liver splitting followed by ex-situ left lateral segment (LLS) hyper-reduction during dual hypothermic oxygenated perfusion (DHOPE)—resulting in successful transplantation in a 2.7-kg neonate with fulminant hepatic failure.
Following approximately 40 min of back-table preparation, DHOPE was performed with the PerLife® system using 3L of PumpProtect® solution. From a technical standpoint, DHOPE enabled ultrasound-guided vascular identification to optimize graft vascularization and the safe use of ultrasonic surgical aspiration to prevent parenchymal debris from entering the perfusate, without disrupting the operative steps. The oxygenated perfusion was continuously maintained throughout the entire LLS hyper-reduction procedure, without interfering with the surgical procedure, while preserving optimal graft conditions, preventing ischemic injury and allowing conditions monitoring. Total preservation time—from donor aortic cross-clamp to graft implantation—was 515 min, including 330 min of hypoxic cold ischemic time and 185 min of DHOPE. The hyper-reduced LLS weighed 175 g (GRWR, 6.5%) from an initial mass of 280 g. At 10 months post-transplant, liver function was normal.
This report demonstrates the feasibility of LLS reduction under DHOPE and may safely prolong total preservation time while reducing hypoxic cold ischemic time and enabling the mitochondrial repair effects of DHOPE, suggesting potential advantages of this approach to graft manipulation, unlocking, perspectives for pediatric liver transplantation.