Left Gastric Vein Anatomical Variation as a Determinant of Portal Vein Remodeling and Reconstructive Complexity in...

Portal vein (PV) reconstruction in infant living donor liver transplantation (LDLT) for biliary atresia (BA) is technically challenging because of progressive PV hypoplasia and altered hemodynamics. Variations in left gastric vein (LGV) inflow may influence the PV morphology and surgical complexity; however, this relationship has not been systematically evaluated.

This single-center retrospective study included 104 infants (age <12 mo) who underwent LDLT for BA between April 2018 and September 2025. The LGV inflow type was classified intraoperatively as Trunk (termination into the main PV trunk), Confluence (termination at the superior mesenteric vein-splenic vein confluence), and SpV (termination into the splenic vein). Preoperative imaging was used to assess the PV diameter and flow direction.

The PV diameter was significantly larger in the Trunk group, with lower rates of hypoplasia (diameter <4 mm) and hepatofugal flow than in the Confluence and SpV groups ( P  < 0.001). Technically difficult PV reconstruction occurred in 15.4% of the cases and was significantly more frequent in the Confluence and SpV types ( P  < 0.01). LGV inflow type was an independent predictor of technically difficult reconstruction (odds ratio, 14.6; 95% confidence interval, 2.48-86.2; P  = 0.003). Postoperative PV complications occurred in 4 patients, all of whom were successfully treated with 1-y graft and patient survival rates of 100%.

LGV variants reflect PV remodeling associated with portal hypertension in infant BA and provide a practical preoperative framework for anticipating reconstructive complexity. Recognition of LGV inflow patterns may facilitate tailored portal reconstruction strategies and enhance graft safety in infant LDLT.