Intraoperative Monitor and Modulation of Portal Vein Hemodynamics During Living Donor Liver Transplantation to Prevent Small-for-Size-Syndrome _CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

SUN Chao , ZHU Zhijun , JIANG Wentao , WEI Lin , YANG Tao , ZHANG Weiye , GAO Bin.

Transplantation Department of Tianjin First Center Hospital, Tianjin 300192, China;

Corresponding author：

Keywords：

Living donor liver transplantation; Small-for-size syndrome; Hemodynamics; Splenectomy; Splenic artery ligation

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Objective To analyze the effect of monitoring and modulating the portal vein pressure and blood flow during living donor liver transplantation （LDLT） on preventing small-for-size-syndrome (SFSS).
Methods Data of forty-four LDLT recipients between Oct.2007 and Oct.2008 were reviewed. Actual graft-to-recipient weight ratio（GRWR）, portal vein flow and pressure during operation and syndrome of SFSS after operation were recorded. The patients received splenectomy or splenic artery ligation according to actual GRWR, portal vein flow and pressure and WBC. Relationships between patients’ GRWR, portal vein flow, portal vein pressure and occurrence of SFSS were analyzed.
Results Six patients received splenectomy and 7 patients received splenic artery ligation to decrease the portal vein flow and pressure during the operation. The portal vein flow and pressure decreased after splenectomy （P lt;0.05）. The portal vein pressure decreased （P lt;0.05） and the portal vein flow had no significant change after splenic artery ligation （P＞0.05）. No SFSS occurred after operation.
Conclusion Modulation of portal vein flow and pressure by splenectomy or splenic artery ligation during LDLT operation can decrease the portal vein flow and pressure, and which can prevent the incidence of SFSS.

Citation： SUN Chao,ZHU Zhijun,JIANG Wentao,WEI Lin,YANG Tao,ZHANG Weiye,GAO Bin.. Intraoperative Monitor and Modulation of Portal Vein Hemodynamics During Living Donor Liver Transplantation to Prevent Small-for-Size-Syndrome . CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY, 2010, 17(5): 415-419. doi: Copy

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2.	Heaton N. Small-for-size liver syndrome after auxiliary and split liver transplantation: donor selection [J]. Liver Transpl, 2003; 9(9): S26-S28.
3.	Troisi R, Ricciardi S, Smeets P， et al. Effects of hemi-portocaval shunts for inflow modulation on the outcome of small-for-size grafts in living donor liver transplantation [J]. Am J Transplant, 2005; 5(6): 1397-1404.
4.	Boillot O, Delafosse B, Méchet I, et al. Small-for-size partial liver graft in an adult recipient; a new transplant technique [J]. Lancet, 2002; 359(9304): 406-407.
5.	Man K, Fan ST, Lo CM, et al. Graft injury in relation to graft size in right lobe live donor liver transplantation: a study of hepatic sinusoidal injury in correlation with portal hemodynamics and intragraft gene expression [J]. Ann Surg, 2003; 237(2): 256-264.
6.	Ikegami T, Shimada M, Imura S, et al. Current concept of small-for-size grafts in living donor liver transplantation [J]. Surg Today, 2008; 38(11): 971-982.
7.	Sanefuji K, Iguchi T, Ueda S, et al. New prediction factors of small-for-size syndrome in living donor adult liver transplantation for chronic liver disease [DB/OL]. Transpl Int. [Epub ahead of print]. http://www.ncbi.nlm.nih.gov/pubmed/ 19843295. Oct 19, 2009.
8.	Lee SG, Park KM, Hwang S, et al. Adult-to-adult living donor liver transplantation at the Asan Medical Center, Korea [J]. Asian J Surg, 2002; 25(4): 277-284.
9.	Harihara Y, Makuuchi M, Kawarasaki H, et al. Initial experience with 40 cases of living-related donor liver transplantation at the University of Tokyo [J]. Transplant Proc, 1999; 31(7): 2893-2894.
10.	Furukawa H, Kishida A, Omura T, et al. Indication and strategy for adult living related liver transplantation [J]. Transplant Proc, 1999; 31(5): 1952.
11.	Kawasaki S, Makuuchi M, Matsunami H, et al. Living related liver transplantation in adults [J]. Ann Surg, 1998; 227(2): 269-274.
12.	Ben-Haim M, Emre S, Fishbein TM, et al. Critical graft size in adult-to-adult living donor liver transplantation: impact of the recipient’s disease [J]. Liver Transpl, 2001; 7(11): 948-953.
13.	Kiuchi T, Kasahara M, Uryuhara K, et al. Impact of graft size mismatching on graft prognosis in liver transplantation from living donors [J]. Transplantation, 1999; 67(2): 321-327.
14.	Thuluvath PJ, Yoo HY. Graft and patient survival after adult live donor liver transplantation compared to a matched cohort who received a deceased donor transplantation [J]. Liver Transpl, 2004; 10(10): 1263-1268.
15.	Lo CM, Fan ST, Chan JK, et al. Minimum graft volume for successful adult-to-adult living donor liver transplantation for fulminant hepatic failure [J]. Transplantation, 1996; 62(5): 696-698.
16.	Emond JC, Renz JF, Ferrell LD, et al. Functional analysis of grafts from living donors. Implications for the treatment of older recipients [J]. Ann Surg, 1996; 224(4): 544-552; discussion 552-554.
17.	Nakamura T, Tanaka K, Kiuchi T, et al. Anatomical variations and surgical strategies in right lobe living donor liver transplantation: lessons from 120 cases [J]. Transplantation, 2002; 73(12): 1896-1903.
18.	Ghobrial RM, Hsieh CB, Lerner S, et al. Technical challenges of hepatic venous outflow reconstruction in right lobe adult living donor liver transplantation [J]. Liver Transpl, 2001; 7(6): 551-555.
19.	Demetris AJ, Kelly DM, Eghtesad B, et al. Pathophysiologic observations and histopathologic recognition of the portal hyperperfusion or small-for-size syndrome [J]. Am J Surg Pathol, 2006; 30(8): 986-993.
20.	Lo CM, Liu CL, Fan ST. Portal hyperperfusion injury as the cause of primary nonfunction in a small-for-size liver graft-successful treatment with splenic artery ligation [J]. Liver Transpl, 2003; 9(6): 626-628.
21.	Perkins JD. Treatment of small-for-size syndrome [J]. Liver Transpl, 2008; 14(4): 571-572.
22.	严律南. 成人间活体肝移植的外科技术与创新 [J]. 中国普外基础与临床杂志， 2008； 15（3）： 151-154.
23.	Nishizaki T, Ikegami T, Hiroshige S, et al. Small graft for living donor liver transplantation [J]. Ann Surg, 2001; 233(4): 575-580.
24.	Cattral MS, Greig PD, Muradali D, et al. Reconstruction of middle hepatic vein of a living-donor right lobe liver graft with recipient left portal vein [J]. Transplantation, 2001; 71(12): 1864-1866.
25.	Ozden I, Kara M, Pinarbasi B, et al. Somatostatin and propranolol to treat small-for-size syndrome that occurred despite splenic artery ligation [J]. Exp Clin Transplant, 2007; 5(2): 686-689.
26.	Ito T, Kiuchi T, Yamamoto H, et al. Changes in portal venous pressure in the early phase after living donor liver transplantation: pathogenesis and clinical implications [J]. Transplantation, 2003; 75(8): 1313-1317.
27.	Troisi R, de Hemptinne B. Clinical relevance of adapting portal vein flow in living donor liver transplantation in adult patients [J]. Liver Transpl, 2003; 9(9): S36-S41.
28.	肖辉，王建. 脾切除术后再出血的诊断与防治 [J]. 中国普外基础与临床杂志， 2009； 16（12）： 1035-1036, 1041.

1. Tanaka K, Ogura Y. “Small-for-size graft” and “small-for-size syndrome” in living donor liver transplantation [J]. Yonsei Med J, 2004; 45(6): 1089-1094.
2. Heaton N. Small-for-size liver syndrome after auxiliary and split liver transplantation: donor selection [J]. Liver Transpl, 2003; 9(9): S26-S28.
3. Troisi R, Ricciardi S, Smeets P， et al. Effects of hemi-portocaval shunts for inflow modulation on the outcome of small-for-size grafts in living donor liver transplantation [J]. Am J Transplant, 2005; 5(6): 1397-1404.
4. Boillot O, Delafosse B, Méchet I, et al. Small-for-size partial liver graft in an adult recipient; a new transplant technique [J]. Lancet, 2002; 359(9304): 406-407.
5. Man K, Fan ST, Lo CM, et al. Graft injury in relation to graft size in right lobe live donor liver transplantation: a study of hepatic sinusoidal injury in correlation with portal hemodynamics and intragraft gene expression [J]. Ann Surg, 2003; 237(2): 256-264.
6. Ikegami T, Shimada M, Imura S, et al. Current concept of small-for-size grafts in living donor liver transplantation [J]. Surg Today, 2008; 38(11): 971-982.
7. Sanefuji K, Iguchi T, Ueda S, et al. New prediction factors of small-for-size syndrome in living donor adult liver transplantation for chronic liver disease [DB/OL]. Transpl Int. [Epub ahead of print]. http://www.ncbi.nlm.nih.gov/pubmed/ 19843295. Oct 19, 2009.
8. Lee SG, Park KM, Hwang S, et al. Adult-to-adult living donor liver transplantation at the Asan Medical Center, Korea [J]. Asian J Surg, 2002; 25(4): 277-284.
9. Harihara Y, Makuuchi M, Kawarasaki H, et al. Initial experience with 40 cases of living-related donor liver transplantation at the University of Tokyo [J]. Transplant Proc, 1999; 31(7): 2893-2894.
10. Furukawa H, Kishida A, Omura T, et al. Indication and strategy for adult living related liver transplantation [J]. Transplant Proc, 1999; 31(5): 1952.
11. Kawasaki S, Makuuchi M, Matsunami H, et al. Living related liver transplantation in adults [J]. Ann Surg, 1998; 227(2): 269-274.
12. Ben-Haim M, Emre S, Fishbein TM, et al. Critical graft size in adult-to-adult living donor liver transplantation: impact of the recipient’s disease [J]. Liver Transpl, 2001; 7(11): 948-953.
13. Kiuchi T, Kasahara M, Uryuhara K, et al. Impact of graft size mismatching on graft prognosis in liver transplantation from living donors [J]. Transplantation, 1999; 67(2): 321-327.
14. Thuluvath PJ, Yoo HY. Graft and patient survival after adult live donor liver transplantation compared to a matched cohort who received a deceased donor transplantation [J]. Liver Transpl, 2004; 10(10): 1263-1268.
15. Lo CM, Fan ST, Chan JK, et al. Minimum graft volume for successful adult-to-adult living donor liver transplantation for fulminant hepatic failure [J]. Transplantation, 1996; 62(5): 696-698.
16. Emond JC, Renz JF, Ferrell LD, et al. Functional analysis of grafts from living donors. Implications for the treatment of older recipients [J]. Ann Surg, 1996; 224(4): 544-552; discussion 552-554.
17. Nakamura T, Tanaka K, Kiuchi T, et al. Anatomical variations and surgical strategies in right lobe living donor liver transplantation: lessons from 120 cases [J]. Transplantation, 2002; 73(12): 1896-1903.
18. Ghobrial RM, Hsieh CB, Lerner S, et al. Technical challenges of hepatic venous outflow reconstruction in right lobe adult living donor liver transplantation [J]. Liver Transpl, 2001; 7(6): 551-555.
19. Demetris AJ, Kelly DM, Eghtesad B, et al. Pathophysiologic observations and histopathologic recognition of the portal hyperperfusion or small-for-size syndrome [J]. Am J Surg Pathol, 2006; 30(8): 986-993.
20. Lo CM, Liu CL, Fan ST. Portal hyperperfusion injury as the cause of primary nonfunction in a small-for-size liver graft-successful treatment with splenic artery ligation [J]. Liver Transpl, 2003; 9(6): 626-628.
21. Perkins JD. Treatment of small-for-size syndrome [J]. Liver Transpl, 2008; 14(4): 571-572.
22. 严律南. 成人间活体肝移植的外科技术与创新 [J]. 中国普外基础与临床杂志， 2008； 15（3）： 151-154.
23. Nishizaki T, Ikegami T, Hiroshige S, et al. Small graft for living donor liver transplantation [J]. Ann Surg, 2001; 233(4): 575-580.
24. Cattral MS, Greig PD, Muradali D, et al. Reconstruction of middle hepatic vein of a living-donor right lobe liver graft with recipient left portal vein [J]. Transplantation, 2001; 71(12): 1864-1866.
25. Ozden I, Kara M, Pinarbasi B, et al. Somatostatin and propranolol to treat small-for-size syndrome that occurred despite splenic artery ligation [J]. Exp Clin Transplant, 2007; 5(2): 686-689.
26. Ito T, Kiuchi T, Yamamoto H, et al. Changes in portal venous pressure in the early phase after living donor liver transplantation: pathogenesis and clinical implications [J]. Transplantation, 2003; 75(8): 1313-1317.
27. Troisi R, de Hemptinne B. Clinical relevance of adapting portal vein flow in living donor liver transplantation in adult patients [J]. Liver Transpl, 2003; 9(9): S36-S41.
28. 肖辉，王建. 脾切除术后再出血的诊断与防治 [J]. 中国普外基础与临床杂志， 2009； 16（12）： 1035-1036, 1041.

CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Intraoperative Monitor and Modulation of Portal Vein Hemodynamics During Living Donor Liver Transplantation to Prevent Small-for-Size-Syndrome 

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