Left lobes in adult to adult LDLT: The importance of surgical modulations in portal craft inflow. A single center experience.

LEFT LOBES IN ADULT TO ADULT LDLT: THE IMPORTANCE OF SURGICAL MODULATIONS IN PORTAL GRAFT INFLOW. A SINGLE CENTER EXPERIENCE. Augusto Lauro1, Teresa Diago Usò2, Alessandro Dazzi1, Antonio Siniscalchi1, Cristiano Quintini2, Fabrizio Di Benedetto2, Michele Masetti2, Nicola Cautero2, Nicola De Ruvo2, Andrea Risaliti2, Giovanni Ramacciato1, Bruno Begliomini2, Charles M. Miller2, Antonio D. Pinna1. 1Liver and Multiorgan Transplant Unit, Policlinico Sant’Orsola-Malpighi, University of Bologna, Bologna, Italy; 2Liver and Multivisceral Transplant Center, Policlinico of Modena,University of Modena and Reggio Emilia, Modena, Italy Background Due to shortage of cadaveric organs, living donor liver transplantation (LDLT) has been recently applied extensively to adults. The use of left lobes should be encouraged because of donor’s safety, but the metabolic requirements of severely cirrhotic patients are superior and a subsequential graft dysfunction as small for size syndrome(SFSS) is often encountered after transplantation. The importance of increased portal inflow to the graft in LDLT using left lobes are still under debate, and so the surgical modulations used to correct them. Aims We report our initial series of adult to adult LDLT using left lobes, underlining the haemodynamic changes encountered during the transplant and the surgical modulations we applied in order to correct them. The clinical outcome of the grafts was analyzed,with 2 years follow-up. Patients Eight adult recipients underwent left lobe liver transplantation from living donor. Methods Portal vein pressure(PVC) and central venous pressure(CVP) were measured before and after surgical modulation by central line and inferior mesenteric vein (IMV) catheterization.The differential pressures between PVC and CVP analyzed before and after the transplant (r Pre and r Post) were reported.The surgical manoeuvres performed during the transplant were represented by splenectomy and vascular shunts. Results We developed 3 cases of small for size syndrome(SFSS). Two patients were retransplanted, three died. One patient underwent a third transplant for HCV recurrence and died in post-operative period. After 2 years follow-up 66% of recipients survived and 80% of them did not require any further surgery. Conclusion Liver volume, and GRWR, is not the only factor in producing a SFSS after adult to adult LDLT using left lobes. Surgical portal inflow modulation should be considered in case of left lobe liver transplantation between adults: recipients with a higher GRWR with severe portal hypertension can beneficiate of surgical modulations to avoid SFSS and obtain graft functionality.