title: Modulation of graft vascular inflow guided by flowmetry and manometry in liver transplantation.
abstract: BACKGROUND
  Survival of the partial graft after living donor liver transplantation owes much to its tremendous regenerative ability. With excellent venous outflow capacity, a graft within a wide range of graft-to-standard-liver-volume ratios can cope with portal hypertension that is common in liver transplant recipients. However, when the ratio range is exceeded, modulation of graft vascular inflow becomes necessary for graft survival. The interplay between graft-to-standard-liver-volume ratio and portal pressure, in the presence of portosystemic shunt or otherwise, requires individualized modulation of graft portal and arterial inflows. Boosting of portal inflow by shunt ligation can be guided by transonic flowmetry, whereas muting of portal inflow by splenic artery ligation can be monitored by portal electronic manometry.
  
  
  METHODS
  We describe four cases to illustrate the above.
  
  
  RESULTS
  One patient had hepatic artery thrombosis resulting from splenic artery steal syndrome which was the sequela of small-for-size syndrome. Emergency splenic artery ligation and re-anastomosis of the hepatic artery successfully muted the portal inflow and boosted the hepatic arterial inflow. Another patient with portal vein thrombosis underwent thrombendvenectomy. Portal inflow was boosted with ligation of portosystemic shunt, which is often present in these patients with portal hypertension. The coexistence of splenic aneurysm and splenorenal shunt required ligation of both in the third patient. The fourth patient, with portal pressure and flow monitoring, avoided ligation of a coronary vein which became a main portal inflow after portal thrombendvenectomy.
  
  
  CONCLUSIONS
  Management of graft inflow modulation guided selectively by transonic flowmetry or portal manometry was described.
authors.affiliation: Department of Surgery, State Key Laboratory for Liver Research, The University of Hong Kong, 102 Pokfulam Road, Hong Kong, China. seechingchan@gmail.com
authors.forename: See Ching
authors.initials: SC
authors.lastname: Chan
authors.forename: Chung Mau
authors.initials: CM
authors.lastname: Lo
authors.forename: Kenneth S H
authors.initials: KS
authors.lastname: Chok
authors.forename: William W
authors.initials: WW
authors.lastname: Sharr
authors.forename: Tan To
authors.initials: TT
authors.lastname: Cheung
authors.forename: Simon H Y
authors.initials: SH
authors.lastname: Tsang
authors.forename: Albert C Y
authors.initials: AC
authors.lastname: Chan
authors.forename: Sheung Tat
authors.initials: ST
authors.lastname: Fan
mesh_terms: D000368:Aged; D002648:Child; D058625:End Stage Liver Disease / Q000601:surgery; D005260:Female; D005500:Follow-Up Studies; D006085:Graft Survival / Q000502:physiology*; D006801:Humans; D008099:Liver / Q000098:blood supply* / Q000502:physiology; D008102:Liver Circulation / Q000502:physiology*; D016031:Liver Transplantation / Q000502:physiology*; D019520:Living Donors; D008297:Male; D008365:Manometry / Q000379:methods; D008875:Middle Aged; D012039:Regional Blood Flow / Q000502:physiology*; D012212:Rheology / Q000379:methods*