Living Donor Liver Transplantation with Augmented Venous Outflow and Splenectomy: A Promised Land for Small Left Lobe Grafts. Annals of surgery Fujiki, M., Hashimoto, K., Quintini, C., Aucejo, F., Kwon, C. H., Matsushima, H., Sasaki, K., Campos, L., Eghtesad, B., Diago, T., Iuppa, G., D'amico, G., Kumar, S., Liu, P., Miller, C., Pinna, A. 2022


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