Elshawy Mohamed, Toshima Takeo, Asayama Yoshiki, Kubo Yuichiro, Ikeda Shinichiro, Ikegami Toru, Arakaki Shingo, Yoshizumi Tomoharu, Mori Masaki
Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
Department of General Surgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt.
Surg Case Rep. 2020 Jul 8;6(1):164. doi: 10.1186/s40792-020-00897-8.
To treat small-for-size syndrome (SFSS) after living donor liver transplantation (LDLT), many procedures were described for portal flow modulation before, during, or after transplantation. The selection of the procedure as well as the best timing remains controversial.
A 43-year-old female with end-stage liver disease underwent LDLT with extended left with caudate lobe graft from her donor who was her 41-year-old brother (graft volume/standard liver volume (GV/SLV), 35.7%; graft to recipient weight ratio (GRWR), 0.67%). During the surgery, splenectomy could not be performed owing to severe peri-splenic adhesions to avoid the ruined bleedings. The splenic artery ligation was not also completely done because it was dorsal to the pancreas and difficult to be approached. Finally, adequate portal vein (PV) inflow was confirmed after portal venous thrombectomy. As having post-transplant optional procedures that are accessible for PV flow modulation, any other procedures for PV modulation during LDLT were not done until the postoperative assessment of the graft function and PV flow for possible postoperative modulation of the portal flow accordingly. Postoperative PV flow kept as high as 30 cm/s. By the end of the 1st week, there was a progressive deterioration of the total bilirubin profile (peak as 19.4 mg/dL) and ascitic fluid amount exceeded 1000 mL/day. Therefore, splenic artery embolization was done effectively and safely on the 10th postoperative day (POD) to reverse early allograft dysfunction as PV flow significantly decreased to keep within 20 cm/s and serum total bilirubin levels gradually declined with decreased amounts of ascites below 500 mL on POD 11 and thereafter. The patient was discharged on POD 28 with good condition.
SFSS can be prevented or reversed by the portal inflow modulation, even by post-transplant procedure. This case emphasizes that keeping accessible angiographic treatment options for PV modulation, such as splenic artery embolization, after LDLT is quite feasible.
为治疗活体肝移植（LDLT）后的小体积综合征（SFSS），移植前、移植期间或移植后有多种门静脉血流调节方法。手术方式的选择以及最佳时机仍存在争议。
一名43岁终末期肝病女性接受了LDLT，供体为其41岁的哥哥，供肝为扩大左半肝加尾状叶移植（移植肝体积/标准肝体积（GV/SLV），35.7%；移植肝与受者体重比（GRWR），0.67%）。手术过程中，由于脾周严重粘连，为避免大出血，无法进行脾切除术。脾动脉结扎也未完全完成，因为其位于胰腺后方，难以触及。最后，门静脉血栓切除术后确认门静脉（PV）流入量充足。由于有可用于PV血流调节的移植后可选手术，在术后评估移植肝功能和PV血流之前，LDLT期间未进行任何其他PV调节手术，以便根据可能的术后门静脉血流情况进行相应调节。术后PV血流一直高达30 cm/s。到第1周结束时，总胆红素水平逐渐恶化（峰值为19.4 mg/dL），腹水每天超过1000 mL。因此，在术后第10天（POD）有效且安全地进行了脾动脉栓塞，以逆转早期移植物功能障碍，因为PV血流显著下降至20 cm/s以内，血清总胆红素水平逐渐下降，术后第11天及之后腹水减少至500 mL以下。患者于术后第28天状况良好出院。
门静脉流入量调节可预防或逆转SFSS，即使是通过移植后手术。该病例强调，LDLT后保留可用于PV调节的血管造影治疗选择，如脾动脉栓塞，是非常可行的。
