Graft Reduction in Adult Liver Transplantation: Indications, Techniques, and Outcomes

Purpose Graft reduction can be a patients and graft-saving option to avoid large-for-size syndrome. The aim of this article was to summarize the literature on graft reduction in adult liver transplantation and to show the technique of H 6/7 graft hepatectomy. Methods The technique, showed in a didactical video, entails an ex-situ posterior sectionectomy under hypothermic perfusion. The right hepatic vein is identified, and the transection line follows the right hepatic fissure. The Glissonean pedicles are ligated during parenchymal transection. Results A narrative review of the literature yielded seven studies. A total of 15 liver grafts were reduced in adult liver transplantations. Most of the reduction were ex situ (11/15; 73.3%); graft reduction entailed an H6,7 sectionectomy in 10 cases and one H2, 3 in one case. In-situ reduction included one right hepatectomy (H5, 6, 7,8), two H6, 7 sectionectomy, and one H2, 3 left lateral sectionectomy. The duration of ex-situ reduction averaged 56minutes (median 40.5minutes, range 33-130minutes), and the graft weight to recipient weight ratio (GWRW) decreased from 3.57±0.4 to 2.70±0.5% after graft reduction. The average cold ischemia time was 390minutes (range 230-570minutes). There were no liver retransplantations. Conclusion Graft reduction in adult liver transplantation can become necessary to avoid large-for-size syndrome. Ex-situ H6, 7 sectionectomy represents the easiest “graft reduction hepatectomy” and is able to minimize the occurrence of graft compression while leaving enough functional liver parenchyma.