Dear Editor,
The article by Hikaru et al. [1] offers valuable insights into surgical innovation aimed at improving long‐term outcomes in this high‐risk population. The authors demonstrate that an aggressive resection of sclerotic portal vein trunks combined with modifications to anastomosis techniques—such as enlarging the anastomotic orifice and proactive vein graft interposition—significantly reduces postoperative PV complications from 19% to 3%. Furthermore, their approach appears to promote better PV growth, as evidenced by increased diameters and higher platelet counts, which are crucial for sustained graft function and growth in small children. The comprehensive follow‐up period exceeding 10 years adds weight to their findings, making a compelling case for adopting such strategies to optimize long‐term portal flow and vessel development.
Despite these promising results, several important limitations extend beyond those already acknowledged by the authors. Notably, the retrospective single‐center design raises concerns about selection bias and the generalizability of the findings. The improved outcomes observed in the latter cohort may partly reflect the natural evolution of surgical expertise, perioperative care, and institutional experience over time, rather than solely the impact of the new reconstruction strategy. This temporal confounding factor could overestimate the true effect of the intervention. The reliance on imaging at predetermined intervals, without continuous or more frequent assessment, limits the granularity of PV growth dynamics and may overlook early or subtle stenoses.
Another key shortcoming is the lack of detailed hemodynamic assessment of portal flow intraoperatively and postoperatively [2]. While the authors emphasize the importance of adequate PV flow and collateral vessel management, they do not systematically quantify flow parameters or evaluate the functional significance of PV diameter growth. Such data could elucidate whether morphological improvements translate into physiological benefits, which is essential for establishing causality. Moreover, the heterogeneity in vein graft types and the small sample sizes in subgroup analyses limit definitive conclusions about graft selection and long‐term graft patency, especially considering pediatric growth and vessel remodeling [3].
Furthermore, the study does not address long‐term growth of the reconstructed PV beyond the immediate postoperative period, particularly into adolescence, when vessel dilation and remodeling are critical for sustained graft health. The absence of standardized flow measurements or functional imaging limits understanding of how morphological improvements influence actual portal perfusion and liver function over time. Lastly, the influence of intraoperative decision‐making, such as the extent of trunk resection and collateral vessel occlusion, is not thoroughly quantified, leaving uncertainty about the reproducibility of these techniques in different settings [4, 5].
Future prospective, multicenter studies incorporating intraoperative flow assessments, standardized imaging protocols, and long‐term follow‐up into adolescence are necessary to validate these findings. Such research should aim to clarify the relationship between surgical modifications, physiological flow, vessel growth, and clinical outcomes, ultimately guiding evidence‐based best practices for PV reconstruction in pediatric liver transplantation.
Author Contributions
Both authors contributed equally to the literature review, drafting, and critical revision of the manuscript. Both authors have read and approved the final version.
Funding
The authors have nothing to report.
Ethics Statement
The authors have nothing to report.
Consent
The authors have nothing to report.
Conflicts of Interest
The authors declare no conflicts of interest.
Data Availability Statement
Data sharing not applicable to this article as no datasets were generated or analysed during the current study.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data sharing not applicable to this article as no datasets were generated or analysed during the current study.