Living donor liver transplantation (LDLT) using small grafts, especially left-lobe grafts (LLG), continues to be a challenge due to small-for-size syndrome (SFSS). We herein demonstrate that with surgical modifications, outcomes with small grafts can be improved.Between 2012 and 2020, we performed 130 adult LDLT using 61 (47%) LLG in a single Enterprise. The median graft-to-recipient weight ratio (GRWR) was 0.84%, with GRWR <0.7% accounting for 22%. Splenectomy was performed in 72 (56%) patients for inflow modulation before (n=50) or after (n=22) graft reperfusion. In LLG-LDLT, venous outflow was achieved using all three recipient hepatic veins. In right-lobe graft (RLG)-LDLT, the augmented graft right hepatic vein was anastomosed to the recipient's cava with a large cavotomy. Outcome measures include SFSS, early allograft dysfunction (EAD), and survival.Graft survival rates at 1, 3, and 5 years were 94%, 90% and 83%, respectively, with no differences between LLG and RLG. Splenectomy significantly reduced portal flow without increasing the complication rate. Despite the aggressive use of small grafts, SFSS and EAD developed in only 1 (0.8%) and 18 (13.8%) patients, respectively. Multivariable logistic regression revealed MELD score and LLG as independent risk factors for EAD and splenectomy as a protective factor (OR 0.09; P=0.03). For LLG-LDLT, patients who underwent pre-reperfusion splenectomy tended to have better 1-year graft survival than those receiving post-reperfusion splenectomy.LLG are feasible in adult LDLT with excellent outcomes comparable to RLG. Venous outflow augmentation and splenectomy help lower the threshold of using small-for-size grafts without compromising graft survival.
View details for DOI 10.1097/SLA.0000000000005630
View details for PubMedID 35894443