Reduced-Right Posterior Sector Salvage Liver Transplantation Using a Moderate Steatotic Graft from an Obese Donor After Cardiac Death
Liver transplantation remains a critical intervention for end-stage liver disease and select hepatic malignancies. However, challenges such as graft-recipient size mismatch, particularly in adult recipients, pose significant risks of complications, including large-for-size syndrome (LFSS) and small-for-size syndrome (SFSS). This article presents a detailed case of adult-to-adult reduced-right posterior sector liver transplantation (RSLT), highlighting surgical strategies to address size discrepancies and graft quality in a high-risk clinical scenario.
Clinical Presentation and Indications
A 56-year-old male (height: 163 cm; weight: 67 kg; BMI: 25.2 kg/m²) with hepatitis B virus (HBV)-associated recurrent hepatocellular carcinoma (HCC) was referred for salvage liver transplantation. His medical history included prior hepatic resection for an 8 cm HCC in segments 6 and 7, followed by tumor recurrence (three nodules, largest 1.7 cm) within eight months post-resection. Imaging confirmed compliance with the Milan criteria, and transarterial chemoembolization was administered as a bridge to transplantation. Preoperative laboratory results demonstrated preserved liver function (Child-Pugh score: 5; MELD score: 6) but elevated alpha-fetoprotein (72.59 ng/mL).
Donor Characteristics and Graft Assessment
The donor was a 43-year-old male (height: 180 cm; weight: 99 kg; BMI: 30.6 kg/m²) with circulatory death due to acute cerebral herniation secondary to brainstem hemorrhage. Donor liver function tests were normal, though a mild elevation in white blood cell count was noted. The graft weighed 2060 g, resulting in a graft-to-recipient weight ratio (GRWR) of 3.07% and a graft weight/right anteroposterior (GW/RAP) ratio of 108.8. Biopsy revealed 37% hepatic steatosis (13% macrosteatosis), underscoring concerns about graft viability and size-related complications.
Rationale for Graft Reduction
GRWR exceeding 2.5% and GW/RAP ratios >100 correlate with elevated LFSS risk, characterized by poor perfusion, compartment syndrome, and graft dysfunction. For this recipient, reducing graft volume to GRWR <2.5% and GW/RAP <100 was imperative. Preoperative volumetry estimated the right posterior sector constituted 26.8% of total liver volume. Excision of this sector reduced graft weight to 1526 g, achieving GRWR 2.28% and GW/RAP 80.6—parameters deemed safe for transplantation.
Surgical Technique and Reduction Process
The ex vivo right posterior sectorctomy was performed on the back table. Key anatomical landmarks included:
- Cutting Plane: Positioned to the right of the right hepatic vein (RHV) at the second porta hepatis, the retrohepatic inferior vena cava (IVC), and the Rouviere sulcus. Preservation of the RHV ensured unimpeded venous drainage of segments V and VIII.
- Hepatic Parenchymal Dissection: A cavitron ultrasonic surgical aspirator (CUSA) facilitated precise transection, with hemostasis achieved via bipolar coagulation, clips, and sutures.
- Vascular Management: The right posterior hepatic pedicle was divided using a linear stapler (Ethicon Endo-Surgery), maintaining safe distance from the right anterior pedicle to avoid ischemic injury to segments V and VIII.
Total reduction time was 40 minutes. The remaining graft retained intact inflow (portal and arterial) and outflow (RHV) systems.
Implantation and Postoperative Course
Recipient hepatectomy was followed by piggyback implantation. Key steps included:
- Anastomosis of the donor suprahepatic IVC to the recipient’s common hepatic vein orifice.
- Portal vein reconstruction with 6-0 Prolene running suture.
- Microscopic arterial anastomosis using 7-0 Prolene.
- Choledochocholedochostomy without stenting.
Postoperatively, peak serum total bilirubin (21.9 mmol/L) and INR (1.59) on postoperative day (POD) 1 resolved rapidly, reflecting satisfactory graft function. Doppler ultrasound confirmed patency of vascular anastomoses. The patient was discharged on POD 9, with normalized liver function, AFP levels, and no HCC recurrence at 10-month follow-up.
Advantages of Right Posterior Sector Reduction
Traditional RSLT strategies, such as left lateral sectionectomy or right hemihepatectomy, risk SFSS or inadequate outflow due to excessive volume reduction. Right posterior sectorctomy offers distinct benefits:
- Volume Optimization: Remnant graft volume (segments V, VIII, and left liver) balances LFSS and SFSS risks, crucial for steatotic grafts prone to ischemia-reperfusion injury.
- Outflow Preservation: RHV retention ensures adequate venous drainage, critical for functional recovery.
- Thoracic Compatibility: Reduced-right posterior sector minimizes rib cage compression, enhancing graft perfusion and reducing mechanical complications.
Clinical Implications and Conclusion
This case exemplifies tailored surgical planning for adult RSLT, particularly when using steatotic grafts from obese donors. Key considerations include precise volumetry, anatomical expertise, and meticulous vascular preservation. The described technique mitigates size-related complications while maintaining physiological inflow and outflow, offering a viable alternative to conventional reduction methods.
doi.org/10.1097/CM9.0000000000001272
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