Delayed splenic artery occlusion for treatment of established small-for-size syndrome after partial liver transplantation

Abstract

We read the article by Humar et al.1 published in the February 2009 issue of Liver Transplantation with great interest. They described delayed splenic artery occlusion as a treatment option for recipients with established small-for-size syndrome after partial liver transplantation. As described, hyperdynamic splanchnic circulation causing portal hyperperfusion in a small-size graft is a major factor. The results reported by Humar et al. are very encouraging and show that splenic artery ligation (SAL) and splenic artery embolization are very effective procedures. Nevertheless, their potential devastating consequences, such as splenic infarction, splenic abscess, and abdominal sepsis, have been overlooked. We reviewed 132 consecutive living donor liver transplants performed at our center between September 2006 and December 2008. We performed SAL in 3 patients at the time of transplantation solely on the basis of a high Model for End-Stage Liver Disease score and a graft-to-recipient weight ratio < 0.8%. We recently reported a 50-year-old male (Model for End-Stage Liver Disease score = 24) who underwent living donor liver transplantation (modified right lobe with segment VIII reconstruction) with a graft-to-recipient weight ratio of 0.7%. After reperfusion, the graft became firm and congested; however, intraoperative Doppler ultrasound confirmed the patency of all vessels. Postoperatively, the patient remained coagulopathic with an international normalized ratio > 2 for the first 3 days, requiring fresh frozen plasma support. He also had recurrent septic episodes with fluctuating total leukocyte counts and serum bilirubin levels for the first 2 weeks. On postoperative day 16, he developed features of subacute intestinal obstruction. Contrast-enhanced computed tomography (abdomen) revealed dilated bowel loops and an enlarged nonenhancing spleen with hypodense attenuation, except for a small patch at the medial aspect. Initially, the patient was managed conservatively with nasogastric aspiration, intravenous antibiotics, antifungals, and minimal immunosuppression; however, he continued to have recurrent episodes of subacute intestinal obstruction. On postoperative day 50, the patient complained of acute abdominal distension associated with abdominal pain and recurrent vomiting. A computed tomography scan of the abdomen revealed small bowel volvulus with multiple dilated ileal loops and a hypodense spleen suggestive of multiple infarcts with perisplenic collection. Emergency celiotomy showed an ileal volvulus with dilated proximal ileal loops, dense small bowel adhesions with a necrotic spleen, and a large perisplenic collection. Adhesiolysis, derotation of the small bowel, and partial splenectomy with copious peritoneal lavage were performed. The volvulus was thought to be due to adhesions to the infracted spleen. Thereafter, the patient improved dramatically and was discharged in stable condition on the 10th day. Despite its potentially devastating consequences, such as splenic abscess and abdominal sepsis, splenic infarction following SAL has received little attention to date.2 Proximal SAL close to the origin may minimize the risk of splenic infarction but may increase the chances of pancreatitis.3 Troisi et al.4 suggested splenectomy in all liver transplant recipients after documentation of splenic infarction to avoid the inevitable development of splenic abscess.4 Balci et al.2 recently reported 2 cases of splenic infarction following SAL, and 1 of these patients developed a splenic abscess necessitating splenectomy. In summary, we believe that SAL is an effective process to prevent or treat small-for-size syndrome during partial liver transplantation; however, it is associated with severe complications that may complicate the postoperative course and increase the posttransplant morbidity and mortality. Patients with splenic infarction must be closely monitored for early detection of the development of any infectious process. Moreover, we recommend consideration for splenectomy or partial splenectomy in patients not improving with conservative management. Ashish Singhal*, Neerav Goyal*, Vivek Vij Subash Gupta*, * Department of Surgical Gastroenterology and Liver Transplantation, Indraprastha Apollo Hospital, New Delhi, India.