Sain S, Pahari H, Tripathi S, Singhvi SK, Dhir U. Hyper-reduced grafts in living donor liver transplant: Techniques and outcomes. World J Transplant 2025; 15(4): 107462 [DOI: 10.5500/wjt.v15.i4.107462]
Corresponding Author of This Article
Hirak Pahari, MD, Department of Liver Transplant and Hepatobiliary Surgery, Sir Ganga Ram Hospital, Old Rajinder Nagar, New Delhi 110060, Delhi, India. hirak.pahari@gmail.com
Research Domain of This Article
Transplantation
Article-Type of This Article
Systematic Reviews
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Soumyadip Sain, Shikhar Tripathi, Department of GI Surgery, Sir Ganga Ram Hospital, New Delhi 110060, India
Hirak Pahari, Suresh K Singhvi, Ushast Dhir, Department of Liver Transplant and Hepatobiliary Surgery, Sir Ganga Ram Hospital, New Delhi 110060, Delhi, India
Co-first authors: Soumyadip Sain and Hirak Pahari.
Author contributions: Sain S and Pahari H came up with the concept; Sain S conducted the initial literature search and removed duplicate entries; Pahari H, Tripathi S, Singhvi SK and Dhir U independently screened the remaining articles for eligibility based on the predefined criteria; Sain S, Pahari H, and Tripathi S addressed any discrepancies or conflicts regarding study eligibility until consensus was achieved; Pahari H, Tripathi S and Sain S performed the review and the meta-analysis; Sain S, Singhvi KS, and Dhir U helped in writing the manuscript; Pahari H and Sain S revised the manuscript.
Conflict-of-interest statement: All authors declare that they have no conflict of interest to disclose.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Hirak Pahari, MD, Department of Liver Transplant and Hepatobiliary Surgery, Sir Ganga Ram Hospital, Old Rajinder Nagar, New Delhi 110060, Delhi, India. hirak.pahari@gmail.com
Received: March 24, 2025 Revised: May 14, 2025 Accepted: August 29, 2025 Published online: December 18, 2025 Processing time: 240 Days and 10.7 Hours
Abstract
BACKGROUND
Pediatric liver transplantation (LT) is the definitive treatment for end-stage liver disease and acute liver failure in children. However, graft size mismatch poses significant challenges, particularly in infants weighing less than 10 kg. Large-for-size grafts can lead to severe complications, including vascular thrombosis and impaired graft perfusion. Surgical innovations, such as hyper-reduced left lateral segment (HRLLS) grafts and monosegmental grafts (MSG), offer viable solutions by tailoring graft size without compromising vascular or biliary integrity.
AIM
To analyze the techniques and outcomes of HRLLS and MSG grafts in pediatric liver trabsplantation.
METHODS
Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a comprehensive literature search was conducted across PubMed, Scopus, and Google Scholar, including studies up to February 2025. Eligible studies included case-control, observational, and randomized controlled trials reporting clinical outcomes of HRLLS, MSG, or reduced left lateral segment grafts (RLLS) in pediatric LT. The Joanna Briggs Institute Critical Appraisal Checklist was used for quality assessment. Meta-analysis was performed using MetaXL software to pool survival outcomes and assess complication profiles.
RESULTS
Eighteen studies involving various graft reduction techniques were included. Both HRLLS and MSG demonstrated comparable one-year survival rates exceeding 80%, with some studies reporting rates above 95%. Complications such as hepatic artery thrombosis, portal vein thrombosis, and sepsis were slightly more frequent in HRLLS/RLLS recipients but remained within acceptable limits. Meta-analysis revealed no significant differences in survivability between graft types.
CONCLUSION
HRLLS and MSG techniques enable successful liver transplantation in small pediatric recipients, achieving long-term outcomes comparable to standard approaches. These graft modification strategies expand donor pool utilization and optimize patient survival while mitigating large-for-size complications.
Core Tip: Tailored graft reduction techniques—hyper-reduced, reduced, and monosegmental—effectively address graft size mismatch in pediatric liver transplantation. Optimal outcomes depend on careful donor selection, graft thickness adjustment, and individualized surgical planning. Vigilant attention to graft-to-recipient weight ratio and vascular anatomy minimizes complications. Long-term data confirm these techniques are safe, durable solutions for small pediatric recipients.
