Living Donor Liver Transplantation With Augmented Venous Outflow and Splenectomy

Abstract

Objective: Living donor liver transplantation (LDLT) using small grafts, especially left lobe grafts (H1234-MHV) (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. Methods: Between 2012 and 2020, we performed 130 adult LDLT using 61 (47%) LLG (H1234-MHV) in a single Enterprise. The median graftto-recipient weight ratio was 0.84%, with graft-to-recipient weight ratio <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 (H5678) (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. Results: Graft survival rates at 1, 3, and 5 years were 94%, 90%, and 83%, respectively, with no differences between LLG (H1234-MHV) and RLG (H5678). 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 model for end-stage liver disease score and LLG (H1234-MHV) as independent risk factors for EAD and splenectomy as a protective factor (odds ratio: 0.09; P = 0.03). For LLG (H1234-MHV)-LDLT, patients who underwent prereperfusion splenectomy tended to have better 1-year graft survival than those receiving postreperfusion splenectomy. Conclusions: LLG (H1234-MHV) are feasible in adult LDLT with excellent outcomes comparable to RLG (H5678). Venous outflow augmentation and splenectomy help lower the threshold of using small-forsize grafts without compromising graft survival.

Association between Hepatocellular Carcinoma Recurrence and Graft Size in Living Donor Liver Transplantation: A Systematic Review

“…Intraoperative decision making is based on the portal vein and hepatic artery flow and pressure measurements ( Figure 3 ). Other factors including the level of portal hypertension play an additional role intraoperatively, but also during the planning of the initial strategy in context for the estimated GRWR when donor and recipient are matched before transplantation [ 51 ]. In addition to the best possible inflow modulation, the optimal liver outflow reconstruction includes the creation of large anastomoses to the cava vein directly or through interposition grafts.…”

“…The Cleveland group has recently demonstrated that an augmented graft outflow reconstruction (i.e., all three recipient hepatic veins used for the outflow of LLG-LDLT) together with meticulous PVP/flow measurement and inflow modulation whenever appropriate (before or after graft implantation) can lead to excellent and comparable results after LDLT using small grafts (GRWR < 0.7) [ 51 ].…”

Biliary complications following split liver transplantation in adult recipients: a matched pair analysis on single-center experience

“…Ex vivo splitting makes a raw cut surface, which can miss bile leaks during transplantation. Another possible explanation for lower rates of BCs in our series is that our transplant team has considerable experience performing living donor liver transplantation, [24][25][26] in which similar surgical techniques are required for splitting liver and vascular/biliary reconstruction. Especially when performing SLT using hemiliver grafts, experience with this advanced surgical technique is advantageous.…”

Left Lobe First With Purely Laparoscopic Approach

“…However, the use of LLG is accompanied by increased risks of graft failure associated with small-for-size syndrome (SFSS) 9,11 . To sustain acceptable outcomes for recipients, appropriate preventive measures for SFSS with portal inflow modulation and outflow augmentation have been reported by our group and others 7,12–14 …”

“…Most transplant centers currently perform adult LDLT almost exclusively using right-lobe grafts (RLGs), which reduce risks for recipients but impart more surgical stress to the donors 4–6 . Selected centers, including our group, have implemented a left-lobe graft (LLG) first approach to improve donor safety 7–10 . However, the use of LLG is accompanied by increased risks of graft failure associated with small-for-size syndrome (SFSS) 9,11 .…”