Challenges and Outcome of Left-lobe Liver Transplants in Adult Living Donor Liver Transplants

Adult-to-adult living donor liver transplant (LDLT) frequently depend on using the right-lobes of the donor for obtaining adequate graft-to-recipient weight ratio (GRWR) of over 0.8% in the recipient. However, left-lobes remain an important option in adults, since the morbidity in the donor is considerably less with left donor hepatectomy when compared with right side liver resection. Further benefits of left-lobes in LDLT include more predictable anatomy of the left hepatic duct and left portal vein, which are usually long and single resulting in easier anastomosis in the recipient. Likewise, left-lobe grafts are easier to implant with an excellent venous outflow through the combined orifice of left and middle hepatic vein, as opposed to the complex hepatic vein reconstruction required in right-lobe grafts. However, left hepatic artery is often multiple unlike the right hepatic artery. The holy grail of left-lobe transplants is avoidance of small for size syndrome (SFSS) in the recipients. The strategies for overcoming SFSS currently depend on circumventing portal hyperperfusion in the graft. Measurement of portal pressure and modulating it if high, by splenic artery ligation, splenectomy, or hemiportocaval shunts are proving successful in avoiding SFSS. The future aim in adult LDLT should be to use the left-lobe as much as possible for the benefit of the donor at the same time avoiding SFSS even at very low GRWR for the benefit of the recipient.