Early graft function after intraoperative assessment-guided selective ligation of segment 5/8 veins in adult right lobe living donor liver transplantation: a retrospective cohort study.

Abstract

Background: Reconstruction of segment 5 and/or segment 8 anterior sector veins ≥ 5 mm is widely recommended in adult right lobe living donor liver transplantation (LDLT) to prevent venous congestion. Whether this approach is universally required, or whether selective ligation guided by intraoperative findings is acceptable in lower-risk recipients, remains unresolved.

Methods: This single-centre retrospective cohort study included adult recipients who underwent right lobe LDLT without inclusion of the middle hepatic vein at a high-volume transplant centre (approximately 150 adult LDLTs per year) between November 2021 and May 2025. Eligible patients had intraoperatively measured segment 5 and/or segment 8 veins ≥ 5 mm. Venous management was determined intraoperatively and was not randomized: reconstruction was preferred in recipients judged at higher risk of congestion, and all recipients with graft-to-recipient weight ratio (GRWR) < 0.8 were managed in the reconstruction group. The primary endpoints were postoperative day 7 (POD7) international normalized ratio (INR), total bilirubin, and ascites volume. Multivariable adjustment was prespecified for postoperative ascites only, adjusting for ligation status, MELD score, and GRWR. Prespecified sensitivity analysis restricted to GRWR ≥ 0.8 was performed. Partial Olthoff early allograft dysfunction (EAD) and approximate ILTS-iLDLT small-for-size syndrome (SFSS) were assessed as secondary analyses.

Results: A total of 170 recipients were included (16 selective ligation; 154 reconstruction). Baseline variables did not differ statistically, but all 20 recipients with GRWR < 0.8 were in the reconstruction group. POD7 outcomes were comparable: INR 1.24 vs. 1.27 (p = 0.80), bilirubin 1.46 vs. 1.70 mg/dL (p = 0.35), ascites 1100 vs. 1250 mL (p = 0.89). In multivariable analysis (n = 91), selective ligation was not independently associated with ascites (β = 0.202; 95% CI - 0.359 to + 0.764; p = 0.476); MELD was the only significant predictor (p = 0.024). The GRWR ≥ 0.8 sensitivity analysis confirmed these findings. Partial Olthoff EAD was 25.0% vs. 15.7% (p = 0.42); approximate SFSS was 27.3% vs. 24.7% (p = 1.00). Post-hoc power for the ascites comparison was 80% only for Cohen's d ≥ 0.90, far larger than the observed d = 0.02.

Conclusions: In carefully selected recipients with adequate graft volume and favourable intraoperative findings, selective ligation of segment 5 and/or 8 veins ≥ 5 mm was not associated with worse early graft function in this cohort. Given the small ligation group, non-randomized allocation, and substantial missing data, these preliminary results are consistent with the feasibility of selective ligation in a selected lower-risk subgroup but cannot establish its safety, clinical applicability, or equivalence to reconstruction. Prospective, adequately powered, multicentre validation is required before any change in current clinical practice can be considered.

Clinical trial number: not applicable.