Extreme Large-for-Size Syndrome After
Adult Liver Transplantation: A Model
for Predicting a Potentially Lethal
TO THE EDITOR:
We read with great interest the study by Allard et al.
Their conclusions are supported scientiﬁcally and echo
intuition. It is apparent that the morphology of the
right upper abdominal cavity differs among individuals
within and across sexes.
Combining both of these
elegantly to develop a measurable score with which to
objectively “match” a donor graft to the intended recip-
ient is well appreciated.
At our center, a 58-year-old male (A positive;
height, 165 cm; weight, 59.8 kg; body mass index,
) received a liver graft from a group-matched
deceased female donor. On examining the graft in the
operating room, it was felt that the size match would
be adequate. However, when the graft was sited in the
orthotopic position, it was a “snug ﬁt.” The explant
and reperfusion were uneventful. The biliary and arte-
rial anastomoses were completed, and Doppler ultra-
sound examination was normal. The operation lasted
710 minutes with a blood loss of 850 mL. The abdo-
men was closed primarily with no increase in airway
pressures. Within a few hours, the recipient developed
severe allograft dysfunction. A further Doppler ultra-
sound established signiﬁcant outﬂow compromise
from the graft, although forward adequate ﬂow was
maintained in the portal vein. The arterial spectral
waveforms were normal. He was returned back to the
operating room at which time pressure necrosis of the
posterior sector and segment 8 due to compression
between the lower ribcage and the vertebral column
was seen (Figs. 1 and 2). The left liver appeared nor-
mal (Fig. 1). Opening the abdomen seemed to
improve hemodynamic compromise. A composite
mesh was sited to close the abdomen. However, there
was no improvement in the outﬂow tract on Doppler
ultrasound. The liver graft did not recover, and the
patient rapidly succumbed. We did not get an oppor-
tunity to relist him for an emergency retransplant.
Pediatric liver transplants are associated with the
challenges of a large graft,
and although temporary
silastic mesh closures have been performed in more
than 25% of all adult liver transplant procedures in
we did not need to do this in our
patient as the decrease in the domain is limited to the
right upper quadrant which is all under the right rib
cage. After this experience, we began following a policy
FIG. 1. The graft liver in the orthotopic position at
Address reprint requests to Rajiv Lochan, M.D., Integrated Liver
Care Group, Aster CMI Hospital, Bangalore, 560092, India.
Telephone: 08043420100; E-mail: firstname.lastname@example.org
Received November 20, 2017; accepted December 4, 2017.
2017 by the American Association for the Study of Liver
View this article online at wileyonlinelibrary.com.
Potential conflict of interest: Nothing to report.
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