Objective: 

Living donor liver transplantation (LDLT) using small grafts, especially left lobe grafts (H1234-MHV) (LLG), continues to be a challenge due to small-for-size syndrome (SFSS). We herein demonstrate that with surgical modifications, outcomes with small grafts can be improved.

Methods: 

Between 2012 and 2020, we performed 130 adult LDLT using 61 (47%) LLG (H1234-MHV) in a single Enterprise. The median graft-to-recipient weight ratio was 0.84%, with graft-to-recipient weight ratio <0.7% accounting for 22%. Splenectomy was performed in 72 (56%) patients for inflow modulation before (n=50) or after (n=22) graft reperfusion. In LLG-LDLT, venous outflow was achieved using all three recipient hepatic veins. In right lobe graft (H5678) (RLG)-LDLT, the augmented graft right hepatic vein was anastomosed to the recipient’s cava with a large cavotomy. Outcome measures include SFSS, early allograft dysfunction (EAD), and survival.

Results: 

Graft survival rates at 1, 3, and 5 years were 94%, 90%, and 83%, respectively, with no differences between LLG (H1234-MHV) and RLG (H5678). Splenectomy significantly reduced portal flow without increasing the complication rate. Despite the aggressive use of small grafts, SFSS and EAD developed in only 1 (0.8%) and 18 (13.8%) patients, respectively. Multivariable logistic regression revealed model for end-stage liver disease score and LLG (H1234-MHV) as independent risk factors for EAD and splenectomy as a protective factor (odds ratio: 0.09; P=0.03). For LLG (H1234-MHV)-LDLT, patients who underwent prereperfusion splenectomy tended to have better 1-year graft survival than those receiving postreperfusion splenectomy.

Conclusions: 

LLG (H1234-MHV) are feasible in adult LDLT with excellent outcomes comparable to RLG (H5678). Venous outflow augmentation and splenectomy help lower the threshold of using small-for-size grafts without compromising graft survival.

中文翻译：

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增加静脉流出和脾切除的活体肝移植：小型左叶移植物的希望之地

 客观的：

由于小尺寸综合征(SFSS)，使用小型移植物，尤其是左叶移植物 (H1234-MHV) (LLG) 的活体肝移植 (LDLT) 仍然是一个挑战。我们在此证明，通过手术修改，可以改善小移植物的结果。

 方法：

2012 年至 2020 年间，我们在单个企业中使用 61 (47%) LLG (H1234-MHV) 进行了 130 例成人 LDLT。移植物与受体重量比中位数为0.84%，移植物与受体重量比<0.7%的占22%。 72 名 (56%) 患者在移植物再灌注之前 (n = 50) 或之后 (n = 22) 进行了脾切除术以调节血流。在 LLG-LDLT 中，使用所有三个受体肝静脉实现静脉流出。在右叶移植物 (H5678) (RLG)-LDLT 中，增强的移植物右肝静脉通过大腔切口与受体静脉吻合。结果指标包括 SFSS、早期同种异体移植功能障碍 (EAD) 和存活率。

 结果：

1 年、3 年和 5 年移植物存活率分别为 94%、90% 和 83%，LLG (H1234-MHV) 和 RLG (H5678) 之间没有差异。脾切除术显着减少了门脉血流量，但没有增加并发症发生率。尽管积极使用小移植物，但仅 1 名 (0.8%) 和 18 名 (13.8%) 患者分别出现 SFSS 和 EAD。多变量逻辑回归显示，终末期肝病评分和 LLG (H1234-MHV) 模型是 EAD 的独立危险因素，而脾切除术是保护因素（比值比：0.09； P = 0.03）。对于 LLG (H1234-MHV)-LDLT，接受再灌注前脾切除术的患者往往比接受再灌注后脾切除术的患者有更好的 1 年移植物存活率。

 结论：

LLG (H1234-MHV) 在成人 LDLT 中是可行的，其结果与 RLG (H5678) 相当。静脉流量增加和脾切除术有助于降低使用小型移植物的门槛，而不影响移植物的存活。