Living Donor Liver Transplantation with Small Left Lobe Grafts: Prospective Validation of Utility of Splenectomy in Selected Recipients

BACKGROUND We previously reported that the Model for End-stage Liver Disease (MELD) score and donor age are risk factors for small-for-size syndrome in adult living donor liver transplantation (LDLT) involving small grafts. Since April 2021, we have performed splenectomy as a portal inflow modulation in LDLT using small grafts according to the presence of risk factors. In this study, we evaluated the validity of our splenectomy strategies for optimizing graft outcomes. MATERIAL AND METHODS We retrospectively reviewed patients who underwent primary LDLT using left lobe grafts with the middle hepatic vein from January 2005 to January 2024 at our institution. We also compared the graft outcomes between recipients who underwent LDLT beginning in April 2021 (current policy group) and those who underwent LDLT in the era when splenectomy as portal modulation was not indicated (previous policy group). RESULTS In total, 173 consecutive LDLTs (current policy group: n=15) involving left lobe grafts were analyzed. Splenectomy was performed in 9 of 15 (60.0%) patients in the current policy group. All 15 patients in the current policy group remained alive for a median follow-up of 20.5 months. The rate of early allograft dysfunction was significantly lower, and the rate of small-for-size syndrome tended to be lower in the current policy group than in the previous policy group (13.3% vs 39.2%, P=0.047 and 20.0% vs 36.1%, P=0.211, respectively). CONCLUSIONS LDLT with splenectomy for high-risk patients may expand the availability of small left lobe grafts and optimize graft outcomes.