RESUMO
Excessive portal venous inflow has been known as a determining factor for hepatic injury in small-for-size graft in living-donor liver transplantation. Partial diversion of portal inflow to the systemic circulation by portacaval shunt has been reported as a promising treatment modality to prevent patient from small-for-size graft syndrome. In addition, splenectomy itself is not only a method to decrease portal flow, but also a treatment for the gastric fundal variceal bleeding. We performed living-donor liver transplantation with transient portacaval shunt and splenectomy due to small-for-size graft in a 50 year-old male suffering from hepatitis B virus related liver cirrhosis with bleeding gastric fundal varices, not amenable to control endoscopically. The donor was patient's wife and a graft to recipient body weight ratio (GRWR) was 0.64. During surgery, left portal vein was used for temporary portacaval shunt and the right portal vein was anatomosed to the graft portal vein. After all vascular anastomoses completed, an endoloop (OpenLoop(R), SJM, Paju, Korea) was placed around portacaval shunt without tightening, and the knot pusher was brought out through abdominal wall introduced in a silastic drain tube. Concomitant splenectomy was performed. Twenty-four hours after transplantation, the loop placed around portacaval shunt was tightened as a bedside procedure. The recipient had an uneventful postoperative course and was discharged with normal graft function 26 days after transplantation. Living-donor liver transplantation with transient portacaval shunt and splenectomy could be an acceptable surgical treatment strategy for patients with end-stage liver disease with small-for-size graft and bleeding gastric fundal varices.