Management of major portosystemic shunting in small-for-size adult living-related donor liver transplantation with a left-sided graft liver.
OBJECTIVE
We investigated the mechanisms of small-for-size graft syndrome by time-lag ligation, a novel approach to treating major portosystemic shunts in small-for-size adult living-related donor liver transplantation (LRDLT) using left-sided graft liver.


METHODS
Five patients with end-stage liver failure and major splenorenal shunting underwent LRDLT using left lobe grafts. The average graft volume to recipient body weight (GV/RBW) ratio was 0.68 +/- 0.14. Two patients underwent time-lag ligation of their splenorenal (SR) shunts on postoperative days (PODs) 8 and 14, respectively. The shunts of the other three patients were untreated.


RESULTS
The portal pressures in the first patient who underwent time-lag ligation rose above 300 mmH(2)O and remained there for 2 weeks. Thus, we ligated the SR shunt in the second patient on POD 14, resulting in an increase from 177 mmH(2)O to 258 mmH(2)O, but it decreased again thereafter. In the other three patients, the SR shunt was not ligated because portal blood flow volumes remained sufficient. Total bilirubin levels in the first time-lag ligation patient rose to 16 mg/dl, paralleling the rise in portal pressures. Although they increased after ligation in the second patient, they did not exceed 10 mg/dl.


CONCLUSIONS
We recommend time-lag ligation if portal venous blood flow decreases in the early post-transplant period, but not until at least 2 weeks after transplantation. If the portal venous blood flow does not decrease, early postoperative ligation is unnecessary. If there are no major portosystemic shunts, making a portosystemic shunt might decompress excessive portal hypertension. With donor safety priority in LRDLT, novel approaches must be developed to enable the use of smaller donor grafts. We describe a potential means of using left lobe grafts in adult LRDLT.
Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, Japan.
Yoshinobu
Y
Sato
Satoshi
S
Yamamoto
Toshiyuki
T
Takeishi
Kenichiro
K
Hirano
Takashi
T
Kobayashi
Takashi
T
Kato
Yoshiaki
Y
Hara
Takaoki
T
Watanabe
Hidenaka
H
Kokai
Katsuyoshi
K
Hatakeyama
D000367:Age Factors; D000368:Aged; D001663:Bilirubin / Q000032:analysis; D005260:Female; D006801:Humans; D008099:Liver / Q000033:anatomy & histology; D017093:Liver Failure / Q000601:surgery*; D016031:Liver Transplantation / Q000379:methods*; D019520:Living Donors; D008297:Male; D008875:Middle Aged; D009929:Organ Size; D011170:Portasystemic Shunt, Surgical / Q000379:methods*; D011183:Postoperative Complications; D011446:Prospective Studies; D016896:Treatment Outcome
D001663:Bilirubin