Implementation of intraoperative distal splenic artery ligation for portal inflow modulation in adult living donor liver transplantation

In living donor liver transplant, graft hyperperfusion can lead to early allograft dysfunction, graft loss, and even mortality. Portal inflow modulation is advocated to prevent hyperperfusion injury. We implemented intraoperative distal splenic artery ligation (SAL) since January 2021 in recipients with one or more of the indications: graft to recipient weight ratio <0.8, graft to spleen volume ratio ≤1, high post-reperfusion portal venous flow (≥250 mL/min/100 g of graft weight), low hepatic artery peak systolic velocity (≤20 cm/s), and/or high post-reperfusion portal venous pressure (≥15 mm Hg). This group was compared with a retrospective splenic artery ligation-not done (non-SAL) group, during July 2019-December 2020, who met any one or more of the above criteria, but had not undergone SAL. Out of 426 patients who underwent living donor liver transplant during the study period, 90 and 42 right lobe adult recipients were included in the SAL and non-SAL groups, respectively. The SAL group had a significant reduction in post-reperfusion portal flow and pressure and also improved hepatic arterial peak systolic velocity compared to the non-SAL group ( p <0.01). Significant reduction in serum total bilirubin and ascitic fluid was observed on post-operative days 1, 3, 5, 7, and 14 in the SAL group ( p <0.01). There was a significant reduction in the incidence of early allograft dysfunction in the SAL group compared to the non-SAL group (8.8% vs. 26.2%, p <0.01). There was a decreased incidence of small for size syndrome (SFSS) ( p <0.05) with no incidence of grade-C SFSS and lower 90-day mortality in the SAL group ( p <0.01). Intraoperative distal SAL significantly reduces portal hyperperfusion, thereby reducing early allograft dysfunction, small for size syndrome, morbidity, and improving 1-year survival.