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      Post-transplant inflow modulation for early allograft dysfunction after living donor liver transplantation

      case-report

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          Abstract

          Background

          To treat small-for-size syndrome (SFSS) after living donor liver transplantation (LDLT), many procedures were described for portal flow modulation before, during, or after transplantation. The selection of the procedure as well as the best timing remains controversial.

          Case presentation

          A 43-year-old female with end-stage liver disease underwent LDLT with extended left with caudate lobe graft from her donor who was her 41-year-old brother (graft volume/standard liver volume (GV/SLV), 35.7%; graft to recipient weight ratio (GRWR), 0.67%). During the surgery, splenectomy could not be performed owing to severe peri-splenic adhesions to avoid the ruined bleedings. The splenic artery ligation was not also completely done because it was dorsal to the pancreas and difficult to be approached. Finally, adequate portal vein (PV) inflow was confirmed after portal venous thrombectomy. As having post-transplant optional procedures that are accessible for PV flow modulation, any other procedures for PV modulation during LDLT were not done until the postoperative assessment of the graft function and PV flow for possible postoperative modulation of the portal flow accordingly. Postoperative PV flow kept as high as 30 cm/s. By the end of the 1st week, there was a progressive deterioration of the total bilirubin profile (peak as 19.4 mg/dL) and ascitic fluid amount exceeded 1000 mL/day. Therefore, splenic artery embolization was done effectively and safely on the 10th postoperative day (POD) to reverse early allograft dysfunction as PV flow significantly decreased to keep within 20 cm/s and serum total bilirubin levels gradually declined with decreased amounts of ascites below 500 mL on POD 11 and thereafter. The patient was discharged on POD 28 with good condition.

          Conclusions

          SFSS can be prevented or reversed by the portal inflow modulation, even by post-transplant procedure. This case emphasizes that keeping accessible angiographic treatment options for PV modulation, such as splenic artery embolization, after LDLT is quite feasible.

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          Most cited references47

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          Small-for-size graft in living donor liver transplantation: how far should we go?

          Takashi Ito, Yasuhiro Fujimoto, Yasuhiro Ogura … (2003)
          With the extensive use of living donor liver grafts in adult patients, controversy over small-for-size syndrome has escalated in recent years. Although several symptoms have been suggested as manifestations of the syndrome, small-for-size syndrome remains difficult to diagnose because these symptoms are neither specific nor inevitable. The occurrence of small-for-size syndrome also seems to depend on a number of recipient and graft factors. Potential pathogenic mechanisms include persistent portal hypertension and portal overperfusion. At present, several techniques are being explored in an attempt to ameliorate the impact of small-for-size syndrome. Recent experience suggests that the occurrence of small-for-size syndrome is multifactorial and that complications relating to small-for-size grafts should be examined in relation to a variety of graft, recipient, and technical factors.
          Article 0 comments Cited 39 times – based on 0 reviews     Review now
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            Partial splenic embolization in the treatment of patients with portal hypertension: a review of the english language literature.

            Harjit Singh, Juliana G. M. Soares, Kristen Gledhill Koconis (2007)
            This article reviews the existing literature on the use of partial splenic embolization in patients with portal hypertension. All articles published in the English language on splenic embolization or partial splenic embolization as a treatment for portal hypertension were identified with a PubMed search from 1973 through 2005. Partial splenic embolization appears to be efficacious in reducing episodes of variceal bleeding, improving hematologic parameters, enhancing hepatic protein synthesis, and reducing the severity of hepatic encephalopathy. Associated morbidity and mortality appear to be acceptable. The literature, however, is limited in quality. Given the potential benefits of partial splenic embolization, further investigation is warranted to allow evidence-based evaluation of its use.
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              The beneficial role of simultaneous splenectomy in living donor liver transplantation in patients with small-for-size graft.

              Toru Ikegami, SHIN-ICHI YAMASHITA, Noboru Harada … (2008)
              Small-for-size (SFS) graft syndrome is one of the major causes of graft loss in living donor liver transplantation (LDLT). We examined whether splenectomy is beneficial for overcoming SFS graft syndrome in LDLT. The patients were classified into two groups: the Sp (-) group (n=69), in which splenectomy was not performed, and the Sp (+) group (n=44), in which it was. The incidence of SFS graft syndrome was investigated. Risk factors of SFS graft syndrome were identified by univariate- and multivariate analysis. To clarify whether splenectomy is beneficial for patients with a SFS graft, subgroup analysis was performed for patients who had a graft weight-to-standard liver weight (GW-SLW) ratio of 40% or less (n=50). Thirty-one of 113 patients developed SFS graft syndrome. A multivariate analysis identified that having a male donor was an independent risk factor of SFS graft syndrome. SFS graft syndrome occurred in 11 of 50 patients with a GW-SLW ratio<40%, and Sp (-) was an independent risk factor for the occurrence of SFS graft syndrome in patients (P=0.014). Simultaneous splenectomy is favorable for overcoming SFS graft syndrome in LDLT patients with a GW-SLW of 40% or less.
              Article 0 comments Cited 21 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                Mohamed Elshawy: drmohamedelemam@med.asu.edu.eg
                Takeo Toshima:
                ORCID: http://orcid.org/0000-0003-4019-8288
                toshima@surg2.med.kyushu-u.ac.jp
                Yoshiki Asayama: asayama@radiol.med.kyushu-u.ac.jp
                Yuichiro Kubo: yukubo@radiol.med.kyushu-u.ac.jp
                Shinichiro Ikeda: shin_i@surg2.med.kyushu-u.ac.jp
                Toru Ikegami: tikesurg@surg2.med.kyushu-u.ac.jp
                Shingo Arakaki: h052010@med.u-ryukyu.ac.jp
                Tomoharu Yoshizumi: tomyoshi@surg2.med.kyushu-u.ac.jp
                Masaki Mori: m_mori@surg2.med.kyushu-u.ac.jp
                Journal
                Journal ID (nlm-ta): Surg Case Rep
                Journal ID (iso-abbrev): Surg Case Rep
                Title: Surgical Case Reports
                Publisher: Springer Berlin Heidelberg (Berlin/Heidelberg )
                ISSN (Electronic): 2198-7793
                Publication date (Electronic): 8 July 2020
                Publication date PMC-release: 8 July 2020
                Publication date Collection: December 2020
                Volume: 6
                Electronic Location Identifier: 164
                Affiliations
                [1 ]GRID grid.177174.3, ISNI 0000 0001 2242 4849, Department of Surgery and Science, Graduate School of Medical Sciences, , Kyushu University, ; 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
                [2 ]GRID grid.7269.a, ISNI 0000 0004 0621 1570, Department of General Surgery, Faculty of Medicine, , Ain Shams University, ; Cairo, Egypt
                [3 ]GRID grid.177174.3, ISNI 0000 0001 2242 4849, Department of Clinical Radiology, Graduate School of Medical Sciences, , Kyushu University, ; Fukuoka, Japan
                [4 ]GRID grid.267625.2, ISNI 0000 0001 0685 5104, Department of Infectious, Respiratory, and Digestive Medicine, Graduate School of Medicine, , University of the Ryukyus, ; Nakagami, Okinawa, Japan
                Author information
                http://orcid.org/0000-0003-4019-8288
                Article
                Publisher ID: 897
                DOI: 10.1186/s40792-020-00897-8
                PMC ID: 7343689
                PubMed ID: 32642985
                SO-VID: f24adfe0-3087-4277-8599-ab97b8c76fc5
                Copyright © © The Author(s) 2020
                License:

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

                History
                Date received : 30 January 2020
                Date accepted : 5 June 2020
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/100009619, Japan Agency for Medical Research and Development;
                Award ID: 18fk0210023h0002
                Award ID: 17fk0210305h0003
                Award Recipient :
                Funded by: FundRef http://dx.doi.org/10.13039/501100001691, Japan Society for the Promotion of Science;
                Award ID: JP-16K10577
                Award Recipient :
                Categories
                Subject: Case Report
                Custom metadata
                issue-copyright-statement © The Author(s) 2020

                Keywords: liver transplantation,portal flow,modulation,graft dysfunction,small-for-size syndrome,splenic artery,embolization
                Data availability:
                Keywords: liver transplantation, portal flow, modulation, graft dysfunction, small-for-size syndrome, splenic artery, embolization

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