title: Ligation of huge spontaneous porto-systemic collaterals to avoid portal inflow steal in adult living donor liver transplantation: A case-report.
abstract: BACKGROUND
  In adult living donor liver transplantation (LDLT), maintenance of adequate portal inflow is essential for the graft regeneration. Portal inflow steal (PFS) may occur due to presence of huge spontaneous porto-systemic collaterals. A surgical procedure to increase the portal inflow is rarely necessary in adult LDLT.
  
  
  METHODS
  A 52 years male patient with end-stage liver disease due to chronic hepatitis C virus infection. Preoperative portography showed marked attenuated portal vein and its two main branches, patent tortuous splenic vein, multiple splenic hilar collaterals, and large lieno-renal collateral. He received a right hemi-liver graft from his nephew. Exploration revealed markedly cirrhotic liver, moderate splenomegaly with multiple collaterals and large lieno-renal collateral. Upon dissection of the hepato-duodenal ligament, a well-developed portal vein could be identified with a small mural thrombus. The recipient portal vein stump was anastomosed, in end to end fashion, to the graft portal vein. Doppler US showed reduced portal vein flow, so ligation of the huge lieno-renal collateral that allows steal of the portal inflow. After ligation of the lieno-renal collateral, improvement of the portal vein flow was observed in Doppler US.
  
  
  CONCLUSIONS
  There is no accepted algorithm for managing spontaneous lieno-renal shunts before, during, or after liver transplantation, and evidence for efficacy of treatments remains limited. We report a case of surgical interruption of spontaneous huge porto-systemic collateral to prevent PFS during adult LDLT.
  
  
  CONCLUSIONS
  Complete interruption of large collateral vessels might be needed as a part of adult LDLT procedure to avoid devastating postoperative PFS.
authors.affiliation: Liver Transplantation Unit, Gatroenterology Surgical Centre, College of Medicine, Mansoura University, Egypt.
authors.forename: Mohamed
authors.initials: M
authors.lastname: Elshobary
authors.affiliation: Liver Transplantation Unit, Gatroenterology Surgical Centre, College of Medicine, Mansoura University, Egypt. Electronic address: ahmedshehta@mans.edu.eg.
authors.forename: Ahmed
authors.initials: A
authors.lastname: Shehta
authors.affiliation: Liver Transplantation Unit, Gatroenterology Surgical Centre, College of Medicine, Mansoura University, Egypt.
authors.forename: Tarek
authors.initials: T
authors.lastname: Salah
authors.affiliation: Liver Transplantation Unit, Gatroenterology Surgical Centre, College of Medicine, Mansoura University, Egypt.
authors.forename: Ahmed Mohamed
authors.initials: AM
authors.lastname: Sultan
authors.affiliation: Radiology department, Gatroenterology Surgical Centre, Mansoura University, Egypt.
authors.forename: Usama
authors.initials: U
authors.lastname: Shiha
authors.affiliation: Liver Transplantation Unit, Gatroenterology Surgical Centre, College of Medicine, Mansoura University, Egypt.
authors.forename: Ahmed Nabieh
authors.initials: AN
authors.lastname: Elghawalby
authors.affiliation: Liver Transplantation Unit, Gatroenterology Surgical Centre, College of Medicine, Mansoura University, Egypt.
authors.forename: Ahmed
authors.initials: A
authors.lastname: Monier
authors.affiliation: Liver Transplantation Unit, Gatroenterology Surgical Centre, College of Medicine, Mansoura University, Egypt.
authors.forename: Mohamed
authors.initials: M
authors.lastname: Elsadany
authors.affiliation: Liver Transplantation Unit, Gatroenterology Surgical Centre, College of Medicine, Mansoura University, Egypt.
authors.lastname: AmrYassen
authors.affiliation: Liver Transplantation Unit, Gatroenterology Surgical Centre, College of Medicine, Mansoura University, Egypt.
authors.forename: Omar
authors.initials: O
authors.lastname: Fathy
authors.affiliation: Liver Transplantation Unit, Gatroenterology Surgical Centre, College of Medicine, Mansoura University, Egypt.
authors.forename: Mohamed Abdel
authors.initials: MA
authors.lastname: Wahab
keywords: Lieno-renal collaterals; Living donor liver transplantation; Portal inflow steal