Background: Large-for-size syndrome (LFSS) is an uncommon but potentially lethal complication following adult liver transplantation (LT). Reduced-size liver transplantation (RSLT) is considered a valuable alternative to delayed fascial closure or mesh closure for preventing LFSS. In this article, we report a successful adult-to-adult RSLT case with in situ right posterior graft sectionectomy using three-dimensional (3D) computer-assisted planning. This case is unique, as it employed preoperative planned in situ right posterior segmental resection (iRPS).
Case description: A short and slim, 69-year-old woman was admitted to Daping Hospital in January, 2023. The patient had previously been diagnosed with hepatitis B virus (HBV)-related hepatocellular carcinoma and acute-on-chronic liver failure. She had received 1 month of hepatoprotective and anti-HBV treatment before being admitted to Daping Hospital, and she had not suffered from any episodes of encephalopathy or upper gastrointestinal bleeding. The physical examination revealed moderate yellow staining of the skin and sclera, abdominal distension, shifting dullness, and pitting edema of the lower limbs. The laboratory test results revealed high serum total bilirubin (TBil) (121.2 µmol/L) and a long prothrombin time (PT) (23.4 s). Computed tomography (CT) showed a 3.4 cm × 2.9 cm nodule in segment V of the liver without macrovascular invasion. Due to the patient's poor liver function, conventional anti-tumor therapies (e.g., surgical resection, transcatheter arterial chemoembolization, and radiofrequency ablation) could not be used, and LT was the only feasible treatment for the patient. The graft volume (GV) of the allocated liver was measured by computed tomography volumetry (CTV). The estimated graft-recipient weight ratio (GRWR) was 3.8%, and the estimated graft weight/right anteroposterior ratio (GW/RAP) was 120.2, which indicated that the donor liver size was severely mismatched with the recipient's abdominal cavity. After meticulous surgical planning using a 3D simulation implanting model, an in situ right posterior graft sectionectomy was performed, and the reduced-size graft was successfully implanted in the recipient. The post-transplant course was uneventful. At the 12-month follow-up, the patient had an excellent quality of life, and no signs of tumor recurrence.
Conclusions: In situ right posterior graft sectionectomy is a feasible and effective strategy for preventing LFSS, especially if there is a size discrepancy between the donor liver anteroposterior dimensions and the recipient's lower right hemithorax. Accurate preoperative surgical planning is the key element in the success of the proposed size-reduction strategies.
Keywords: Posterior sectionectomy; case report; large-for-size syndrome (LFSS); liver transplantation (LT); three-dimensional planning (3D planning).
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