Adult living-donor liver transplantation without simultaneous splenectomy

The need for intraoperative inflow modulation, especially simultaneous splenectomy and shunt ligation, to improve graft survival and avoid small-for-size syndrome (SFSS), is debated. These two procedures, performed during living-donor liver transplantation (LDLT) in some centers, have conflicting effects on portal hemodynamics, and the advantages are unclear. We investigated the impact of graft size on recipient outcomes without simultaneous splenectomy and to identify factors associated with graft survival.

Adult LDLT recipients (n=234) without simultaneous splenectomy at our center were investigated with reference to graft size. The cutoff graft-to-recipient weight ratio (GRWR) for small grafts was set at 0.7%.

Recipient outcomes did not differ significantly between the small-sized graft and the non-small-sized graft groups; In patients with GRWR ≥0.7%, the 1-, 3-, and 5-year graft survival rates were 93%, 91%, and 91%, respectively, while the patient survival rates were 92%, 91%, and 87%, respectively. In patients with GRWR <0.7%, the 1-, 3-, and 5-year graft survival rates were 92%, 92%, and 89%, respectively, and the patient survival rates were 87%, 85%, and 81%, respectively. No significant differences were observed between the two groups in graft survival (P=0.79) or patient survival (P=0.45). The platelet count and graft volume increased significantly and the portal venous flow and shunt/spleen size decreased significantly after LDLT, irrespective of graft size. Older donors (>45 years old) and size disproportion between the graft and spleen (<70%) were independent risk factors for graft failure. Recipients with both factors had significantly worse graft survival (P<0.001).

The present results demonstrated that adult LDLT can be successfully performed without simultaneous splenectomy, however, splenectomy could be considered for cases with spleen-graft size disproportion and older donors.