Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2022 Oct;36(10):e14657.
doi: 10.1111/ctr.14657.

Does modification of portal pressure and flow enhance recovery of the recipient after living donor liver transplantation? A systematic review of literature and expert panel recommendations

Ashwin Rammohan  1 , Mohamed Rela  1 , Dong-Sik Kim  2 , Yuji Soejima  3 , Mureo Kasahara  4 , Toru Ikegami  5 , Michael Spiro  6   7 , Dimitri Aristotle Raptis  7   8 , Abhinav Humar  9 ; ERAS4OLT.org Working Group
Collaborators, Affiliations

Does modification of portal pressure and flow enhance recovery of the recipient after living donor liver transplantation? A systematic review of literature and expert panel recommendations

Ashwin Rammohan et al. Clin Transplant. 2022 Oct.

Abstract

Background: 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.

Objectives: To identify whether modifications of portal pressures and flows enhance recovery after LDLT and to provide international expert panel recommendations.

Data sources: Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central.

Methods: Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel.

Prospero id: CRD42021260997.

Results: 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.

Conclusions: 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).

Keywords: enhanced recovery after surgery; living donor liver transplantation; morbidity; outcomes; portal flow; portal inflow modulation; portal pressure.

PubMed Disclaimer

References

REFERENCES

    1. Ma KW, Wong KHC, Chan ACY, et al.. Impact of small-for-size liver grafts on medium-term and long-term graft survival in living donor liver transplantation: a meta-analysis. World J Gastroenterol. 2019; 25(36): 5559-5568.
    1. Troisi RI, Berardi G, Tomassini F, Sainz-Barriga M. Graft inflow modulation in adult-to-adult living donor liver transplantation: a systematic review. Transplant Rev (Orlando). 2017; 31(2): 127-135.
    1. Masuda Y, Yoshizawa K, Ohno Y, Mita A, Shimizu A, Soejima Y. Small-for-size syndrome in liver transplantation: definition, pathophysiology and management. Hepatobiliary Pancreat Dis Int. 2020; 19(4): 334-341.
    1. Yagi S, Uemoto S. Small-for-size syndrome in living donor liver transplantation. Hepatobiliary Pancreat Dis Int. 2012; 11(6): 570-576.
    1. Kiuchi T, Kasahara M, Uryuhara K, et al.. Impact of graft size mismatching on graft prognosis in liver transplantation from living donors. Transplantation. 1999; 67(2): 321-327.

Publication types

LinkOut - more resources