Strategies in management of small-for-size graft in recipients of right lobe graft in living donor liver transplantation: a retrospective study

Background
Liver transplantation is the only survival option for patients with end-stage liver disease. Therefore, candidates for liver transplant have been rapidly increasing, which in turn, has led to accepting borderline and small-size grafts to accommodate the demand.
Patients and methods
Of 217 right lobe living donor liver transplant recipients, 18 got small-for-size grafts (SFSG) (graft-to-recipient weight ratios <0.8%) in the period between November 2016 and November 2021 in Ain Shams Center for Organ Transplantation. Intraoperatively, glypressin infusion was started empirically in cases with SFSG and portal pressure was measured. Cases were divided into pharmacological group, where glypressin infusion was kept solely according to their portal pressure (<20 mmHg), and surgical group, which had splenic artery ligation (SAL) according to their portal pressure (>20 mmHg). Splenectomy was done in cases with SFSGs with portal pressure more than 20 mmHg accompanied by huge splenomegaly or hypersplenism. The surgical group was further divided into two subgroups: SAL subgroup and splenectomy subgroup.
Results
Six recipients had terlipressin infusion solely as a pharmacological graft inflow modulation, whereas surgical graft inflow modulation was done in addition to terlipressin infusion in 12 recipients (nine with SAL and three with splenectomy). Total bilirubin in the surgical group was significantly lower than that in the pharmacological group in the first and third 5-day intervals (=0.039 and 0.040, respectively). Portal vein flow velocity mean values of the third 5-day interval were significantly lower in the surgical group (=0.011). In surgical subgroups, total bilirubin and international normalized ratio in the splenectomy subgroup were significantly lower than that in the SAL group by the fifth 5-day interval (=0.019 and 0.020, respectively). Mortality in the pharmacological group was extremely higher than that in the surgical group (=0.009).
Conclusion
Surgical inflow modulation in the form of SAL and more importantly splenectomy is more potent in controlling portal flow and carries better outcome in terms of avoiding the development of small-for-size syndrome.