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Transplantation of a small liver into a large patient may cause problems with correct reperfusion of the graft because of torsion of the hepatic pedicle, leading to malfunction of the transplanted organ. We describe the case of a 60-year-old man with alcoholic cirrhosis and hepatitis B virus who received a small-sized liver graft. Owing to the lack of adequate reperfusion of the transplanted organ arising from pedicular kinking caused by disparate sizes, a breast implant was placed behind the graft as a means of support, thereby resolving the problem. The use of prosthetic materials for the correct placement of grafts with size incongruity is also discussed, and the literature is reviewed.Copyright 1999 by the American Association for the Study of Liver Diseases L iver transplantation has become the best alternative treatment for patients with end-stage liver disease because of advances in anesthesiological and surgical techniques, immunosuppression, and postoperative care. However, some technical aspects, such as correct matching of the graft size and recipient, are critical for its success. Discordance in size between the graft and its future cavity may cause disruptions in the position of the vascular structures, with consequent alterations in organ function. Case ReportA 60-year-old man had Child' s class B-7 hepatic cirrhosis of mixed viral (hepatitis B positive) and alcoholic cause. Physical examination showed the patient to be in a good nutritional state. His height was 176 cm; weight, 88 kg; abdominal circumference, 109 cm; and chest circumference, 102 cm.The patient received a full-size orthotopic liver transplant from a female donor weighing 51 kg (ratio of recipient to donor, 1.7). Hepatectomy was performed with preservation of the retrohepatic vena cava (piggyback). Poor reperfusion of the graft was noticed after performing vascular anastomoses despite repeated checks, leading to prolonged hemorrhage caused by alterations in coagulation and fibrinolysis. After observing a posterior kinking of the hepatic pedicle as a result of the difference in size between the graft and the cavity, it was decided to place a saline-filled breast implant behind the graft to correct the hilar angulation. This resulted in rapid, optimal reperfusion of the graft without liver congestion and with appreciable functional improvement. The operation was then finished uneventfully. It is remarkable that a method was not used to fix the prosthesis, because it remained well placed between the liver and the diaphragm.Control computed tomography showed the correct position of the graft resting on the prosthesis and a biloma in the left hepatic lobe (caused by a small traumatic lesion in the donor liver), which was punctured and drained uneventfully (Fig. 1). At present, more than 1 year later, several control computed tomographic abdominal scans have not shown displacement of the prosthesis or other complications caused by the implant. Moreover, both the helical computed tomographic scan and Doppler studies have proven the patency...

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