Ligation of huge spontaneous porto-systemic collaterals to avoid portal inflow steal in adult living donor liver transplantation: A case-report. (2017)

• Record Type: Journal Article
• Authors: Elshobary, Mohamed; Shehta, Ahmed; Salah, Tarek; Sultan, Ahmed Mohamed; Shiha, Usama; Elghawalby, Ahmed Nabieh; Monier, Ahmed; Elsadany, Mohamed; AmrYassen, ; Fathy, Omar; Wahab, Mohamed Abdel
• Is Part Of: International journal of surgery case reports. Volume 31(2017)
• Page Start: 214
• Page End: 217
• Publication Date: 2017
• Subjects: LDLT living donor liver transplantation -- PFS portal inflow steal -- DDLT deceased donor liver transplantation -- MELD model for end stage liver disease -- US ultrasonography -- CT computed tomography -- GRWR graft weight to recipient weight ratio -- TIPS transjugular intrahepatic porto-systemic shunt; Living donor liver transplantation -- Portal inflow steal -- Lieno-renal collaterals; Surgery -- Periodicals; Surgical Procedures, Operative -- Periodicals; Surgery; Electronic journals; Periodicals; 617.005
• DOI: 10.1016/j.ijscr.2016.12.020
• Languages: English
• ISSNs: 2210-2612

Abstract

Highlights: Maintenance of adequate portal inflow is essential for the graft regeneration in adult LDLT. Portal inflow steal may occur due to presence of huge spontaneous porto-systemic collaterals. If the portal inflow to the liver graft is inadequate after adult LDLT, post-transplant impairment of the graft regeneration and eventually graft failure would occur. A surgical procedure to increase the portal inflow is rarely necessary in adult LDLT. We report a case of prophylactic surgical interruption of spontaneous huge porto-systemic collateral to prevent PFS during adult LDLT procedure. Abstract: Introduction: In adult living donor liver transplantation (LDLT), maintenance of adequate portal inflow is essential for the graft regeneration. Portal inflow steal (PFS) may occur due to presence of huge spontaneous porto-systemic collaterals. A surgical procedure to increase the portal inflow is rarely necessary in adult LDLT. Presentation: A 52 years male patient with end-stage liver disease due to chronic hepatitis C virus infection. Preoperative portography showed marked attenuated portal vein and its two main branches, patent tortuous splenic vein, multiple splenic hilar collaterals, and large lieno-renal collateral. He received a right hemi-liver graft from his nephew. Exploration revealed markedly cirrhotic liver, moderate splenomegaly with multiple collaterals and large lieno-renal collateral. Upon dissection of the hepato-duodenal ligament, a well-developed portal vein could be identified with a small mural thrombus. The recipient portal vein stump was anastomosed, in end to end fashion, to the graft portal vein. Doppler US showed reduced portal vein flow, so ligation of the huge lieno-renal collateral that allows steal of the portal inflow. After ligation of the lieno-renal collateral, improvement of the portal vein flow was observed in Doppler US. Discussion: There is no accepted algorithm for managing spontaneous lieno-renal shunts before, during, or after liver transplantation, and evidence for efficacy of treatments remains limited. We report a case of surgical interruption of spontaneous huge porto-systemic collateral to prevent PFS during adult LDLT. Conclusion: Complete interruption of large collateral vessels might be needed as a part of adult LDLT procedure to avoid devastating postoperative PFS.