Rammohan Ashwin, Rela Mohamed, Kim Dong-Sik, Soejima Yuji, Kasahara Mureo, Ikegami Toru, Spiro Michael, Aristotle Raptis Dimitri, Humar Abhinav
Institute of Liver Disease & Transplantation, Dr. Rela Institute & Medical Centre, Bharath Institute of Higher Education & Research, Chennai, India.
Department of Surgery, Korea University College of Medicine, Seoul, Korea.
Clin Transplant. 2022 Oct;36(10):e14657. doi: 10.1111/ctr.14657.
Portal inflow modulation (PIM) aimed at reducing portal hyperperfusion is commonly used in living donor liver transplantation (LDLT) to reduce the risk of small-for-size syndrome (SFSS). Many different techniques, both pharmacological and surgical have been used for this purpose. There is, however, little consensus on the best method of PIM, its exact role in preventing SFSS and on early post-LDLT recovery.
To identify whether modifications of portal pressures and flows enhance recovery after LDLT and to provide international expert panel recommendations.
Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central.
Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel.
CRD42021260997.
Five hundred and ninety four articles were identified through databases' search. Of the 24 included for a final review by the working group (WG), there were five randomized control trials, four prospective studies and 15 retrospective series. Six outcome measures which were likely to influence early recovery after LDLT, especially in small-for-size grafts (SFSG) were shortlisted. These included acute kidney injury, SFSS, morbidity including sepsis, length of ICU and hospital stay, morbidity of the PIM technique and overall mortality. The WG noted that PIM in this subset of LDLT recipients had a beneficial effect on all the outcomes measures.
Considering all decision domains, the panel recommends pre- and intraoperative actual graft weight validation, portal pressure/flow measurements, and a comprehensive donor evaluation for the determination of potentially small-for-size/ small-for-flow grafts as mandatory. (Quality of Evidence: Moderate | Grade of Recommendation: Strong) Pharmacological PIM helps improve early renal function in LDLT recipients. (Quality of Evidence: High | Grade of Recommendation: Strong) In selected patients with SFSG, PIM helps reduce SFSS/EAD and sepsis. (Quality of Evidence: Moderate | Grade of Recommendation: Strong) PIM in the form of splenectomy has increased morbidity compared to splenic artery ligation (SAL). (Quality of Evidence: Low | Grade of Recommendation: Strong) In LDLT recipients with SFSG, PIM may help reduce morbidity/mortality. (Quality of Evidence: Low | Grade of Recommendation: Strong) In LDLT recipients with SFSG, modification of portal pressures and flows enhances recovery after LDLT. (Quality of Evidence: Moderate | Grade of Recommendation: Strong).
旨在减少门静脉高灌注的门静脉血流调节（PIM）常用于活体肝移植（LDLT），以降低小肝综合征（SFSS）的风险。为此已采用了许多不同的技术，包括药理学和手术技术。然而，关于PIM的最佳方法、其在预防SFSS中的确切作用以及LDLT术后早期恢复方面，几乎没有共识。
确定门静脉压力和血流的改变是否能促进LDLT术后的恢复，并提供国际专家小组的建议。
Ovid MEDLINE、Embase、Scopus、谷歌学术和Cochrane中心。
按照PRISMA指南进行系统评价，并根据国际专家小组采用的GRADE方法提出建议。
PROSPERO注册号：CRD42021260997。
通过数据库检索共识别出594篇文章。工作组（WG）纳入最终审查的24篇文章中，有5项随机对照试验、4项前瞻性研究和15项回顾性系列研究。筛选出6项可能影响LDLT术后早期恢复的结局指标，尤其是小体积移植物（SFSG）的相关指标，包括急性肾损伤、SFSS、包括脓毒症在内的发病率、重症监护病房（ICU）住院时间和医院住院时间、PIM技术的发病率以及总体死亡率。WG指出，LDLT受者亚组中的PIM对所有结局指标均有有益影响。
综合所有决策领域，专家小组建议术前和术中进行实际移植物重量验证、门静脉压力/血流测量，以及对供体进行全面评估以确定潜在的小体积/小流量移植物，这些为强制性要求。（证据质量：中等 | 推荐等级：强）药理学PIM有助于改善LDLT受者的早期肾功能。（证据质量：高 |推荐等级：强）在选定的SFSG患者中，PIM有助于降低SFSS/早期移植物功能丧失（EAD）和脓毒症的发生率。（证据质量：中等 | 推荐等级：强）与脾动脉结扎术（SAL）相比，脾切除术形式的PIM发病率更高。（证据质量：低 | 推荐等级：强）在SFSG的LDLT受者中，PIM可能有助于降低发病率/死亡率。（证据质量：低 | 推荐等级：强）在SFSG的LDLT受者中，门静脉压力和血流的改变可促进LDLT术后的恢复。（证据质量：中等 | 推荐等级：强）
