Do Natural Portosystemic Shunts Need to Be Compulsorily Ligated in Living Donor Liver Transplantation?

Abstract

Background: Natural portosystemic shunt ligation practices in liver transplant vary widely across transplant centres and are frequently undertaken to prevent the serious consequence of portal steal phenomenon. No concrete indications have so far been convincingly identified for their management in living donor liver transplant. Methods: We retrospectively studied the outcome of 89 cirrhotic patients who either did (n = 63) or did not (n = 25) undergo shunt ligation during living donor liver transplantation between 2017 and 2020. Results: The incidence of early allograft dysfunction/nonfunction (P = 1.0) and portal venous complications (P = 0.555) were similar between the two groups. Although overall complications, biliary complications, and the composite of Grade III and IV complications were significantly higher in the nonligated group (P = 0.015, 0.052 and 0.035), 1year graft and patient survival were comparable between them (P = 0.524). Conclusion: We conclude that shunt ligation in living donor liver transplantation may not always be necessary if adequate portal flow, good vascular reconstruction, and good graft quality have been ensured. ( J CLIN EXP HEPATOL xxxx;xxx:xxx)

Early allograft dysfunction after living donor liver transplantation—current concepts and future directions

“…The authors concluded that a technically pristine inflow and outflow in a good-quality graft allows regeneration and growth of graft capacitance, making shunt ligation unnecessary. [46] Model for end-stage liver disease (MELD) score Pretransplantation MELD score is a critical determinant of post-LDLT graft outcome. In the current era of organ shortage, partial grafts are often transplanted into sicker individuals with high MELD scores to prevent waitlist mortality.…”

“…[11] Later, Okamura et al validated Olthof's definition in 260 LDLT patients, of whom 84 (32.3%) fulfilled the original Olthoff criteria. About 22.7% (59) and 17.7% (46) patients had TB ≥ 10 mg/dL and INR ≥ 1.6 on POD 7, respectively, and 8.5% ( 22) fulfilled both criteria. They observed that a new model combining TB ≥ 10 mg/dL and INR ≥ 1.6 on POD 7 was associated with early graft loss in 59.1% (relative risk [RR], 6.9) and 68.2% (RR, 5.8) at 90 days and 180 days, respectively.…”

“…A retrospective study analyzed the outcome of 63 of 89 patients with cirrhosis who underwent shunt ligation during LDLT and found that the incidence of EAD was similar to that of the non-ligated group. The authors concluded that a technically pristine inflow and outflow in a good-quality graft allows regeneration and growth of graft capacitance, making shunt ligation unnecessary 46 …”

Preventing Small-for-size Syndrome in Living Donor Liver Transplantation: Guidelines From the ILTS-iLDLT-LTSI Consensus Conference

“…After reperfusion, SPSS may divert blood away from the portal system and reduce the hyperperfusion of the graft, thereby reducing the risk of SFSS. 118,177 SPSS are present in about 20%-35% of transplant candidates, with a recent review on the intraoperative management of SPSS concluding that there was heterogenous management of SPSS during LT, with very little consensus. 178,179 The pathophysiology of the development of SFSS is postulated to be related to the increased portal flow and associated shear stress it causes on a small graft.…”