Splenic devascularization can replace splenectomy during adult living donor liver transplantation – a historical cohort study

Moon, Deok‐Bog; Hwang, Shin; Ahn, Chul‐Soo; Kim, Ki‐Hun; Ha, Tae‐Yong; Song, Gi‐Won; Jung, Dong‐In; Park, Gil‐Chun; Yoon, Young‐In; Cho, Hwui-Dong; Kwon, Jae‐Hyun; Jung, Yong-Kyu; Ha, Su-Min

doi:10.1111/tri.13405

Cited by 24 publications

(20 citation statements)

References 23 publications

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“…Simultaneous splenectomy for the modulation of portal hyperperfusion is actively debated in the LDLT setting, ( 4,9‐12 ) but discussion about the management of SPSS during the LDLT procedure is scarce. Moreover, existing data about the influence of SPSS, its type and size, and its management on early outcomes in LDLT recipients are unclear.…”

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confidence: 99%

Clinical Significance of Spontaneous Portosystemic Shunts in Living Donor Liver Transplantation

et al. 2020

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Earn MOC for this article: www.wileyhealthlearning.com/aasld.aspx Spontaneous portosystemic shunts (SPSS) are commonly observed in patients undergoing living donor liver transplantation (LDLT); however, their impact on the outcome after transplantation is unclear. We aimed to assess the type, size, and the effects of SPSS on outcomes after LDLT. A total of 339 LDLT recipients in a single institution were included. The type and diameter of the SPSS (splenorenal shunt [SRS], oesogastric shunt, and umbilical shunt) were retrospectively analyzed. A large shunt was defined as having a diameter ≤7 mm. No portal flow modulation was attempted over time. Portal complications were defined as stenosis, thrombosis, or hepatofugal flow requiring any treatment after transplantation. There were 202 (59.0%) patients who exhibited at least 1 large SPSS. Neither the size nor type of SPSS was associated with mortality, morbidity, or liver function recovery. However, the incidence of portal complications was significantly higher in patients with a large SRS (8.6% versus 2.9%; P = 0.04). Multivariate analysis of portal complications revealed 2 independent predictors: pre-LT portal vein thrombosis (PVT) and SRS size. The observed risk among recipients with pre-LT PVT was 8.3% when the SRS was ≤7 mm, but increased to 38.5% when the SRS was >15 mm. The present study suggests that large SPSS do not negatively affect the outcomes after LDLT. However, a large SRS is associated with a higher risk of portal complications, particularly in recipients with pre-LT PVT, for whom intraoperative intervention for SRS should be considered. Otherwise, a conservative approach to SPSS during LDLT seems reasonable.

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confidence: 99%

Clinical Significance of Spontaneous Portosystemic Shunts in Living Donor Liver Transplantation

et al. 2020

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“…Since patients who wait for LDLT often have thrombocytopenia and coagulopathy, pseudoaneurysm of the punctured artery or bleeding around the puncture site should be considered and checked when performing this technique. Furthermore, this technique has a substantial risk of pancreatitis and postembolization syndrome [61]. Moon et al recently reported the effects of a splenic devascularization procedure to prevent various complications, including PVT, pancreatic fistula, and bleeding from the splenic stump after splenectomy [61].…”

Section: Splenic Artery Ligationmentioning

confidence: 99%

“…Furthermore, this technique has a substantial risk of pancreatitis and postembolization syndrome [61]. Moon et al recently reported the effects of a splenic devascularization procedure to prevent various complications, including PVT, pancreatic fistula, and bleeding from the splenic stump after splenectomy [61]. They performed not only SAL but also ligation of the right gastroepiploic artery and division of the gastrosplenic ligament including the short gastric arteries as an alternative to splenectomy.…”

Section: Splenic Artery Ligationmentioning

confidence: 99%

“…The portal vein (arrow) was thrombosed. The splenorenal shunt was closed with simultaneous splenectomy collaterals with intraoperative cine-portogram in recipients with large portosystemic shunts, which are a possible route of postoperative portal flow steal [61,66,67]. We ligate large shunts to maintain adequate portal flow and to prevent the steal phenomenon as long as the portal pressure does not exceed 20 mmHg after test clamping [8,21,68].…”

Section: Portocaval Shuntmentioning

confidence: 99%

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Portal flow modulation in living donor liver transplantation: review with a focus on splenectomy

Yoshizumi

Mori

2019

Surg Today

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Small-for-size graft (SFSG) syndrome after living donor liver transplantation (LDLT) is the dysfunction of a small graft, characterized by coagulopathy, cholestasis, ascites, and encephalopathy. It is a serious complication of LDLT and usually triggered by excessive portal flow transmitted to the allograft in the postperfusion setting, resulting in sinusoidal congestion and hemorrhage. Portal overflow injures the liver directly through nutrient excess, endothelial activation, and sinusoidal shear stress, and indirectly through arterial vasoconstriction. These conditions may be attenuated with portal flow modulation. Attempts have been made to control excessive portal flow to the SFSG, including simultaneous splenectomy, splenic artery ligation, hemi-portocaval shunt, and pharmacological manipulation, with positive outcomes. Currently, a donor liver is considered a SFSG when the graft-to-recipient weight ratio is less than 0.8 or the ratio of the graft volume to the standard liver volume is less than 40%. A strategy for transplanting SFSG safely into recipients and avoiding extensive surgery in the living donor could effectively address the donor shortage. We review the literature and assess our current knowledge of and strategies for portal flow modulation in LDLT.

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“…A more aggressive form of SAL in the form of splenic devascularization involving ligation of the splenic artery, right gastroepiploic artery and division of the gastrosplenic ligament including the short gastric arteries has been proposed by Moon et al as a means to reduce portal flow more than a standard SAL (57). The attendant benefits of this procedure are a significant decrease in complications as compared to splenectomy (1.6% vs 11.3%).…”

Section: Splenic Devascularization Splenic Devascularizationmentioning

confidence: 99%

Technical Advancements in Living Donor Liver Transplant

Sarin¹,

Donmez²,

Tokat³

2021

SGO

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Over the past 2 decades, living donor liver transplantation has become a standard and accepted alternative to deceased donor liver transplantation, especially in countries with poor cadaveric donation rates. Numerous innovations in surgical technique along with improved understanding of post-transplant physiology have led to LDLT having comparable and sometimes exceeding outcomes of DDLT. The importance of venous outflow and adequate anterior sectoral drainage to minimize congestion has been central to improving safety and outcomes in LDLT. Portal vein thrombosis, once a contraindication to transplant is now tackled with excellent outcomes with improvement in surgical technique. Understanding of graft hemodynamics and portal flow has significantly increased the graft pool with acceptance of smaller grafts without lowering patient outcomes. Portal flow modulation techniques are routinely being used to minimize graft injury secondary to portal hypertension and the development of small for size syndrome. Innovative techniques for biliary reconstruction have been devised in a bid to minimize biliary complications. Adoption of microsurgical techniques to arterial reconstruction and utilization of extra anatomic arterial inflow has led to significant shrinkage of grafts lost to hepatic arterial dissection and thrombosis. This review highlights a number of technical advancements made in the field of liver transplant surgery made over the past decade; especially focusing on living donor transplantation.

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Splenic devascularization can replace splenectomy during adult living donor liver transplantation – a historical cohort study

Cited by 24 publications

References 23 publications

Clinical Significance of Spontaneous Portosystemic Shunts in Living Donor Liver Transplantation

Clinical Significance of Spontaneous Portosystemic Shunts in Living Donor Liver Transplantation

Portal flow modulation in living donor liver transplantation: review with a focus on splenectomy

Technical Advancements in Living Donor Liver Transplant

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