Selective Hemi-Portocaval Shunt Based on Portal Vein Pressure for Small-for-Size Graft in Adult Living Donor Liver Transplantation

Abstract

We developed an algorithm of graft selection in which left lobe donation is considered primarily if the graftto-recipient weight ratio (GRWR) is estimated to be greater than 0.6% in preoperative volumetry with utilization of a hemi-portocaval shunt (HPCS) based on portal vein pressure (PVP) more than 20 mmHg at the time of laparotomy. A total of 11 consecutive adult living donor liver transplantations with small-forsize graft according to our graft selection algorithm were performed between December 2005 and August 2007. Ten patients required HPCS using a vein graft all survived without small-for-size syndrome (SFSS) and shunt complications with a median follow-up of 296 days. One patient without HPCS died of chronic vascular rejection. In all cases, PVP were regulated successfully under 20 mmHg by HPCS. Graft volume reached in mean 84.3% of standard liver volume in right lobe grafts and mean 95.4% in left lobe grafts at 3 months after liver transplantation. Actuarial rate of shunt patency at 1, 3, 6 months and 1 year were 80%, 55%, 26% and 20%, respectively. Selective HPCS based on PVP is an effective procedure and results in excellent patient and graft survival with avoidance of SFSS in grafts greater than 0.6% of GRWR.

Pure Laparoscopic Full-Left Living Donor Hepatectomy for Calculated Small-for-Size LDLT in Adults: Proof of Concept

“…In such cases, even grafts with a GRWR <0.6 can be transplanted successfully (11,13,14). In case of portal hypertension, different surgical techniques are available to reduce or eliminate the rate of postoperative complications related to the small-forsize syndrome (SFSS) (12,16). The signs of SFSS observed in our patients with hyperbilirubinemia could obviously be related to a small graft volume.…”

Minimum graft size calculated from preoperative recipient status in living donor liver transplantation

“…Although portal inflow modulation has been reported to prevent SFSS, (33)(34)(35)(36) the role of modulation remains controversial. (37,38) We previously reported that small graft size is associated with high PVP and that high PVP (25 mm Hg) is correlated with posttransplant thrombocytopenia, (39) but we have not performed any portal inflow modulation because there has not been a recipient with high PVP since that study.…”

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“…27 Another study showed excellent graft survival in recipients of left lobe grafts with graft-to-recipient weight ratio between 0.6 and 0.8. 28 The main concern in using small-for-size grafts is the problem of small-for-size syndrome, which can cause graft loss and necessitate revision transplant.…”