Do Natural Portosystemic Shunts Need to Be Compulsorily Ligated in Living Donor Liver Transplantation?

Abstract

Background: Natural portosystemic shunt ligation practices in liver transplant vary widely across transplant centres and are frequently undertaken to prevent the serious consequence of portal steal phenomenon. No concrete indications have so far been convincingly identified for their management in living donor liver transplant.

Methods: We retrospectively studied the outcome of 89 cirrhotic patients who either did (n = 63) or did not (n = 25) undergo shunt ligation during living donor liver transplantation between 2017 and 2020.

Results: The incidence of early allograft dysfunction/nonfunction (P = 1.0) and portal venous complications (P = 0.555) were similar between the two groups. Although overall complications, biliary complications, and the composite of Grade III and IV complications were significantly higher in the nonligated group (P = 0.015, 0.052 and 0.035), 1- year graft and patient survival were comparable between them (P = 0.524).

Conclusion: We conclude that shunt ligation in living donor liver transplantation may not always be necessary if adequate portal flow, good vascular reconstruction, and good graft quality have been ensured.

Keywords: AKI, Acute Kidney Injury; BCS, Budd Chiari Syndrome; BMI, Body mass index; C, Caudate; CIT, Cold ischemia time; EAD, Early Allograft Dysfunction; FLR, Future Liver Remnant; GRWR, Graft Recipient Weight Ratio; HAT, Hepatic Artery Thrombosis; HBV, Hepatitis B virus infection; HCV, Hepatitis C virus infection; HE, Hepatic encephalopathy; HRS, Hepatorenal syndrome; HVOTO, Hepatic venous outflow obstruction; IHV, Inferior hepatic vein; IVC, Infrahepatic Vena Cava; LAI, Liver Attenuation Index; LDLT, Living Donor Liver Transplant; LL, Left lobe; MELD, Model for End-stage Liver Disease; MHV, Middle Hepatic Vein; MRL, Modified Right lobe; NASH, Nonalcoholic steatohepatitis; PVT, Portal Vein Thrombosis; RHV, Right Hepatic Vein; SFSS, Small For Size Syndrome; SMV, Superior mesenteric vein; SRL, Standard right lobe; WIT, Warm Ischemia Time; living donor liver transplant; natural portosystemic collateral; shunt ligation.

Figure 1

Showing 1- year patient survival in patients who did (1) or did not (0) undergo shunt ligation during transplant. (P = 0.524).

Figure 2

(a) Showing venogram showing thrombosis and streak of flow in portal vein with significant “steel” of the portal blood flow through a large coronary shuntin a case of right lobe LDLT. (b) showing coil embolisation of the coronary shunt with flow restoration in the portal venous system.