Living donor liver transplantation with extra-small graft; inflow modulation using splenectomy and temporary portacaval shunt

In living donor liver transplantation in adults, a strategy to manage unexpected small graft is essential. The patient was a 47-year-old female with end-stage liver disease secondary to hepatitis C with hepatocellular carcinoma, and the donor was a 20-years-old female. Although the estimated left lobe graft volume was 379g and 35.8% of the standard liver volume of the recipient, the actual volume was just 250g, representing only 23% of the standard liver volume. After implantation of this graft, a splenectomy followed by end-to-side portocaval shut was done, both for modulating excessive portal inflow to the small graft. Despite the excellent initial graft function with hepatopetal portal flow and an excellent gold-colored bile from the graft, the graft portal flow decreased with liver regeneration 4 days after transplantation. So the closure of the portacaval shunt was carried out. Since then there was a good postoperative course without any sign of small graft syndrome. She was discharged from the hospital at 21 days after transplantation. This type of inflow modulation may allow us to manage such an extra-small graft. However, careful post-transplant monitoring of the portal flow is essential for gaining an acceptable outcome.