Case Report: Splenorenal shunt management after liver transplantation in a recipient with situs inversus totalis

Situs inversus totalis (SIT) alters graft positioning and vascular reconstruction during liver transplantation. A 56-year-old man with SIT, decompensated hepatitis B cirrhosis and hepatocellular carcinoma received a 558-g deceased-donor whole-liver graft, with a graft-to-recipient weight ratio of 0.60%. The graft was implanted in the native left-sided hepatic fossa in a reversed orientation. Postoperative CT showed a large splenorenal shunt and heterogeneous graft enhancement. Portal vein velocity fell from 44.7 cm/s on postoperative day (POD) 1 to 25 cm/s on POD3–4 and was 32 cm/s on POD5. Endovascular occlusion was abandoned on POD5 because venography showed aneurysmal dilatation and the procedural risk was judged excessive. Open ligation of the approximately 3-cm shunt was performed on POD6, preserving the main renal vein. Portal vein velocity was 30 cm/s after ligation, 37 cm/s on POD7 and 42 cm/s on POD9. Total bilirubin decreased from 158.6 μmol/L on POD4 to 70.5 μmol/L on POD13; the international normalized ratio was 1.49 on POD6 and 1.02 on POD14. The patient was discharged on POD27. Imaging showed no tumor recurrence at approximately 19 months, and alpha-fetoprotein was 7.32 ng/mL at approximately 23 months. This case describes surgical treatment of suspected portal steal in an SIT recipient when endovascular shunt occlusion was unsuitable.