Hepatic regeneration following right lobectomy: Estimation of regenerative capacity

The regenerative capacity of the liver was assessed using a volumetric method on computed tomography in 21 adults: 16 underwent a standard right hepatic lobectomy for hepatocellular carcinoma, there were hepatic metastases in 3 others, and 2 suffered from other diseases. The patients' ages ranged from 33 to 68 years with a mean age of 57.0 years. The regeneration rate was expressed as the rate of the volume increase of the remnant left lobe compared with the preoperative volume of the left lobe. A univariate regression analysis showed that the portal pressure had a highly inverse correlation with the regeneration rate of the liver (r = –0.4753,P = 0.0397), while a multiple regression analysis demonstrated the correlation between the portal pressure, age, and the regeneration rate (multipler = 0.5640). The regeneration rate of the normal liver (97.6 ± 53.5%) was significantly higher than that of the chronic hepatitic (43.0 ± 40.7%), and also tended to be higher than that of the cirrhotic liver (51.5 ± 13.2%). However, there were no differences between chronic hepatitic and cirrhotic livers. The portal pressure before hepatectomy of the normal liver (149 ± 19 mmH₂O) was significantly lower than those of chronic hepatitic (188 ± 38 mmH₂O) and cirrhotic (245 ±78 mmH₂O) livers. We thus conclude that the regenerative capacity of the liver following a right hepatic lobectomy could be estimated on the basis of both portal pressure and age. The regenerative capacity was also influenced by underlying liver diseases.     

Changes in Hepatic Hemodynamics due to Primary Liver Tumours

Data regarding the afferent circulation of the liver in patients with primary hepatocellular carcinoma are controversial, we have carried out measurement of hepatic arterial and portal venous flow intraoperatively by transit time ultrasonic volume flowmetry. In patients with primary hepatocellular carcinoma the hepatic artery flow increased to 0.55±0.211 compared with the control value of 0.37±0.102 1/min. (p<0.01). The portal venous flow decreased from 0.61±0.212 l/min, to 0.47±l/min. p<0.01). Due to the opposite changes in the afferent circulation the total hepatic blood flow did not change significantly, compared with controls.The ratio of hepatic arterial flow to portal vein flow increased to 1.239±0.246 in patients with hepatocellular carcinoma, which is double of the control value (0.66±0.259 l/min). After resection this ratio did not change.The resection did not alter hepatic artery or portal venous flow significantly, although the total hepatic blood flow decreased significantly (p<0.01).On the basis of our early results it is possible that the ratio of the two circulations may be to deel measured with doppler ultrasound and provide diagnostic information.     

Remission of Splenic Volume in the Recipient During the Course of Adult-to-Adult Living Donor Liver Transplantation: Evaluation Using Multislice Computed Tomography and Semiautomatic Software

Aim

The purpose of the study was to examine changes in splenic volume among recipients during the course of adult-to-adult living donor liver transplantation (LDLT) using multislice computed tomography (CT) scanning with a semiautomatic volumetry software.

Materials and Methods

Forty-eight patients, including 33 males and a mean overall age of 54 ± 8 years), underwent liver transplantation for the primary disease of liver cirrhosis with or without hepatocellular carcinoma (n = 31/17, respectively). The mean MELD score was 14 ± 6. The liver graft mass compared with recipient weight was 74% ± 28%. Splenic artery embolization was not performed. Dynamic CT scans splenic volume, and platelet counts (10³/cm³) were obtained pre, ≤50 day and ≥90 days postoperatively.

Results

The total time to generate volumetry and image postprocessing per examination was <10 minutes. One-factor analysis of variance (ANOVA) revealed that the average splenic volume tended to be reduced from pre- to post-LDLT, although not significantly: pre-LDLT, 469 ± 270 mL; ≤day 50, 369 ± 212 mL; and ≥day 90, 378 ± 210 mL (P = .066). One-factor ANOVA revealed that the average platelet count was significantly different in the 3 periods: pre-LDLT, 69 ± 32 × 10³/cm³; ≤day 50, 181 ± 253 × 10³/cm³; and ≥day 90, 126 ± 64 × 10³/cm³ (P < .01). The post hoc Scheffé test revealed the statistical significance of the platelet counts between pre-LDLT and ≤day 50 (P < .01).

Conclusion

Splenic volumetry with multislice CT and semiautomatic software, which is simple and not time consuming, was able to evaluate remission from hypersplenism during the course of LDLT.     

Functional Hepatic Flow Can Predict the Hepatic Reserve Function in Surgical Cirrhotic Patients

Aim: To evaluate hepatic reserve function by monitoring functional hepatic flow in cirrhotic patients admitted for surgical treatments. Methods: Thirty-seven biopsy-proved cirrhotic patients with portal hypertension and 10 healthy volunteers entered the study. Eleven were Child-Pugh class A, 18 class B, and 8 class C. Eight patients undergone Transjugular intrahepatic portosystemic shunt (TIPS), 10 were submitted to the combination of TIPS and portal-azygous disconnection, 10 were treated with surgical portal-azygous disconnection, and 9 were treated with the combination of portal-azygous disconnection and spleno-renal shunt. The functional hepatic flow (FHF) and total hepatic flow (THF) were determined by means of modified hepatic clearance of D-sorbitol combined with duplex Doppler color sonography. Portal pressure was measured directly by portal vein catheterization. Results: Portal blood flow, hepatic artery flow, and THF significantly increased in cirrhotic patients compared to the controls, while FHF was significantly reduced. Both portal pressure and FHF decreased in cirrhotic patients submitted to TIPS, the combination of TIPS and portal-azygous disconnection, or the combination of portal-azygous disconnection and spleno-renal shunt (p <.05). FHF decreased significantly in patients treated with TIPS compared to other patients (p <.01). The portal pressure decreased in patients treated with portal-azygous disconnection while FHF maintained no changes (p >.05). Conclusions: Monitor of FHF in cirrhotic patients is valuable to predict different hepatic reserve function in patients receiving different surgical operations.     

Assessment of hepatic reserve for indication of hepatic resection: how I do it

Background/purpose Hepatic resection may result in liver failure in patients with cirrhotic livers. Preoperative evaluation of liver function in cirrhotic patients, to prevent postoperative liver failure, is very important.Methods Sixteen patients with hepatocellular carcinoma in cirrhotic livers were enrolled in this study. Liver function was determined quantitatively by monoethylglycinexylidide (MEGX) formation from the metabolism of lidocaine. The whole liver volume and tumor volume were measured by computed tomographic volumetry. The volume of resected liver was recorded by water displacement. The relationship between liver function and remnant liver volume was determined.Results A relationship between the percentage remnant liver volume and ratio of MEGX formation after hepatectomy was found. The regression equation was: (postoperative MEGX formation/preoperative MEGX formation) × 100% = (0.688 × percentage remnant liver volume + 0.179) × 100% (r ² = 0.49). A relationship between MEGX formation after hepatectomy and the international ratio (INR) of prothrombin time was also found. The regression equation was INR = 1.99 – 0.01 × MEGX (r ² = 0.30).Conclusions Post-hepatectomy liver function can be estimated for an individual patient by the appropriate regression equations. Prevention of post-hepatectomy liver failure for patients with cirrhotic livers is feasible.     

Changes in Splenic Volume during Liver Regeneration

Little is known about the relation between liver regeneration and splenic size. We monitored serial changes in liver and spleen volumes using computed tomography in 24 patients with biliary cancer who underwent right hepatectomy or more extensive liver resection following portal vein embolization (PVE). Nonembolized hepatic segments increased in volume from 316 ± 97 cm³ (34% ± 8% of total liver volume) before PVE to 410 ± 115 cm³ (44% ± 8%) after PVE. The volume of nonembolized hepatic segments (i.e., remnant liver) increased to 617 ± 111 cm³ (59% ± 10% of total liver volume before PVE) 14 days after hepatectomy and then increased slowly to reach 795 ± 231 cm³ (76% ± 16%) 1 year after hepatectomy. Splenic volume increased from 87 ± 29 cm³ before PVE to 104 ± 38 cm³ (119% ± 17% of original volume) after PVE. Splenic volume increased to 137 ± 65 cm³ (155% ± 40%) by 14 days after hepatectomy and to 155 ± 67 cm³ (179% ± 41%) by 28 days after hepatectomy, with no further change at 1 year after hepatectomy (153 ± 92 cm³; 174% ± 79%). The rate of increase in splenic volume within the first 14 days after hepatectomy was 2.7 ± 3.6 cm³/day, correlating well with increases in remnant liver volume (r = 0.64, p = 0.0006). These data indicate that the spleen is enlarged during liver regeneration, suggesting that the liver and spleen share certain common growth regulatory mechanisms.     

部分性脾栓塞术在肝癌伴脾功能亢进治疗中的应用

目的评价部分性脾栓塞术（PSE）在原发性肝癌伴脾功能亢进介入治疗中的疗效及临床意义。方法原发性肝癌伴脾功能亢进患者12例，男10例，女2例．平均年龄51．1岁；肝功能Child－PughA级3例，B级9例；在行肝动脉插管化疗栓塞术（TACE）的同时行PSE；术后定期复查血常规和肝功能。结果本组脾栓塞面积为50％～60％，无脾脓肿等严重并发症。术后WBC和PLT显著提高（P〈0．05），并长期维持在较高水平，RBC数量和HG量无明显改变（P〉0．05）。TBIL、ALT和AST无明显变化（P〉0．05），TBA下降（P〈0．05）。结论PSE能纠正脾功能亢进，提高血WBC和PLT的数量，使原发性肝癌伴脾功能亢进患者的TACE能顺利进行，是一种安全、有效的治疗方法。     

Evidence that temporary complete occlusion of splenic vessels prevents massive embolization and sudden death associated with intrasplenic hepatocellular transplantation

It has been reported elsewhere that liver cell suspensions injected at several locations retain some proper hepatic functions, significantly improve the survival rate of rats with different models of acute fulminant hepatic injury, correct some congenital enzyme deficiency diseases, and improve liver function in cirrhotic animals. Among several locations, the splenic parenchyma has been shown to be the most suitable place for hepatocellular transplantation. Unfortunately, infusion of cells into the splenic pulp is not without risk. In fact, portal hypertension and hepatic embolizations have been described after intrasplenic transplantation of hepatocytes or pancreatic islets or fragments. In addition, pulmonary hepatocyte embolizations have been observed in rats with spontaneous (unpublished observations) or surgically induced portosystemic shunts. In this work, we evaluate the efficacy of temporary occlusion of splenic vessels to prevent hepatic and pulmonary embolizations after liver cell transplantation into the spleen in portal hypertension cirrhotic rats with portosystemic shunts.     

Saphenous vein endothelium-dependent relaxation in patients with peripheral vascular disease

In vitro vasomotor responses of saphenous veins of 15 patients undergoing peripheral vascular bypass procedures were studied. Vessels were harvested by standard techniques, sectioned into 4 mm rings, and suspended in organ baths under isometric tension. Stimulation with cumulative doses of norepinephrine revealed a –logED₅₀ of 6.85±0.12 M and maximal tension of 8.64±1.77 g. Patient characteristics suggesting high maximal response (by univariate analysis) included male sex (male 11.69±2.49 g versus female 5.08±1.69 g; p=0.058). Intact and denuded rings were additionally tested for endothelium-dependent relaxation following submaximal norepinephrine precontraction. The vessels relaxed in response to acetylcholine (maximal relaxation 31.1±10.7% at 1 × 10^–6 M), calcium ionophore A23187 (85.3±11.8% at 1 × 10^–5 M), and sodium nitroprusside (150.8±15.2% at 1 × 10^–5 M), but only acetylcholine relaxation was completely endothelium-dependent. Calcium ionophore A23187 relaxation was partially dependent on the endothelium while sodium nitroprusside relaxation was entirely endothelium-independent. Negligible relaxation was observed in response to adenosine diphosphate (ADP) (12.1±12.8% at 1 × 10^–5 M) while histamine and serotonin caused additional contraction only. We concluded that, in patients undergoing vascular surgical procedures, the saphenous vein (1) demonstrates variable contractile function which appears to be greater in males following spinal anesthesia, and (2) exhibits moderate endothelium-dependent relaxation in response to acetylcholine and calcium ionophore A23187 but not to ADP, histamine, or serotonin.     

经导管动脉化疗栓塞术联合部分性脾动脉栓塞术治疗原发性肝癌合并脾功能亢进

目的评价TACE联合部分性脾动脉栓塞术（PSE）治疗原发性肝癌（PHC）合并脾功能亢进的临床效果。方法对26例PHC合并脾功能亢进患者行TACE联合PSE治疗。术后采用肝脏CT、超声、肝功能、血常规及甲胎蛋白（AFP）检查,并进行随访。结果对26例患者共进行63次TACE、27次PSE治疗,全部治疗均获成功,无严重并发症。全部患者随访2个月,均生存;23例患者随访6个月,17例生存;13例患者随访12个月,9例生存;8例患者随访24个月,5例生存。结论 TACE联合PSE治疗PHC合并脾功能亢进可取得较好的临床效果。     

Significance of Liver Size in Hepatic Surgery

The purpose of this study was to evaluate the significance of liver volumetry as a parameter for hepatic functional reserve in cirrhotic patients with hepatocellular carcinoma. Liver volume was calculated from preoperative computed tomograms of 44 cirrhotic patients who underwent elective hepatic resections for hepatocellular carcinoma.The liver volume per body weight of non-alcoholic cirrhotics was significantly smaller than that of alcoholic cirrhotics (20.9 vs. 26.7 cc/kg; p=0.03). The values for alcoholic cirrhotics was comparable with normal values. The liver volume per body weight of the cirrhotic patients demonstrated correlation with the preoperative serum albumin (p<0.01) and indocyanine green clearance (p=0.02). We conclude that the determination of hepatic atrophy by volume try can serve as a parameter for the assessment of hepatic reserve but not as a predictor of postoperative complications in elective liver surgery for cirrhotic patients.     

Laparoscopic cholecystectomy for gallbladder lymphangiomas

The case of a patient with hepatocellular carcinoma and thrombocytopenia secondary to liver cirrhosis who underwent successful hand-assisted laparoscopic hepatectomy after partial splenic embolization is described. A 67-year-old man with severe liver cirrhosis was admitted for treatment of hepatocellular carcinoma. His early phase of hepatic angiography showed two hypervascular tumors in segment 6. The patients liver function was poor, with the indocyanine green retention at 15 min of 49.5%, a total serum bilirubin concentration of 2.0 mg/dl, an albumin concentration of 2.8 g/dl, and an hyaluronic acid concentration of 649 ng/ml. The platelet count was 3.0 × 10⁴/µl secondary to hypersplenism. Partial splenic embolization decreased the splenic volume by 50% preoperatively. At 2 months later, the platelet count was 6.0 × 10⁴/µl, and hand-assisted laparoscopic partial hepatectomy was performed uneventfully. The patients postoperative course was unremarkable, and he was discharged on postoperative day 12.     

The immune status of uraemic children/adolescents with chronic renal failure and renal replacement therapy

In adults with chronic renal failure (CRF) and/or renal replacement therapy (RRT) various immunological abnormalities have been described, but few data are available for the paediatric age group. We performed basic in vitro immunological studies in 26 patients 10 months–19 years of age with advanced renal failure, 11 with CRF (creatinine clearance 16.8±5.2 ml/min per 1.73 m²), 15 on RRT with haemodialysis (HD;n=9) and continuous ambulatory peritoneal dialysis (CAPD;n=6) as well as in 16 healthy controls. None had clinical evidence of deranged immune function. No significant differences were found in the percentages of B- and T-cells, T-cell subsets CD3, CD4, CD8 and mitogenic responses to phytohaemagglutinin and concanavalin A (Con A) between RRT patients (HD=CAPD) and control children. Most parameters in CRF patients were also normal, although they had a low percentage of B-cells (12.1±4.1; RRT: 19.7±6.5; controls: 18.5±7.1;P<0.01), relatively low levels of serum immunoglobulin G (948.4±209.4 mg/dl; HD: 1374.7±235.2 mg/dl;P<0.01; CAPD: 966.3±430.2 mg/dl, NS) and a high normal response to Con A (34.3±13.6 cpm ×10^–3; RRT: 34.5±11.3 cpm ×10^–3; controls: 23.4±9.9 cpm ×10^–3,P<0.01). All these values were, however, well within the normal accepted range. These data indicate that children/adolescents with CRF and/or RRT have no significant basic in vitro immunological defects. This study did not test the functional immune status of the young uraemic patients.     

Roles of subarachnoid blood clots and norepinephrine in cerebral vasospasm

Summary The content of norepinephrine (NE) in the ventricular, basal cisternal and lumbar cerebrospinal fluid (CSF) was determined in 19 patients with ruptured cerebral aneurysms. The cisternal CSF in patients with vasospasm contained a significantly higher level of NE (0.246 ± 0.049 ng/ml) compared with those without vasospasm (0.075 ± 0.001 ng/ml) (p < 0.001). However, this increase is not considered to be high enough to constrict cerebral arteries, unless there is an increased NE-sensitivity in subarachnoid haemorrhage. Vascular responses to NE in vivo were then studied after reversing blood-induced prolonged vasospasm of the rabbit's basilar artery through a transclival approach as well as a newly developed basal cisternal irrigation model. However, NE in molar concentrations between 1 × 10^–10 and 10^–2 failed to produce further contraction of the artery. In conclusion, the increase in NE with vasospasm might be only a secondary phenomenon, and not a causative factor of vasospasm. Early removal of subarachnoid blood clots seemed to prevent the development of vasospasm.     

Splanchnic Haemodynamics and Vasoactive Agents in Experimental Cirrhosis

It is well known that portal hypertension is associated with a hyperdynamic systemic circulatory state. This study measures systemic and splanchnic haemodynamics in an experimental rat model of hepatic cirrhosis. It also investigates the association between haemodynamic changes in cirrhotic animals and circulating levels of the vasoactive hormones glucagon and vasoactive intestinal polypeptide (VIP). Splanchnic blood flow was significantly increased in the cirrhotic group (13.2 ± 1.3 vs. 9.2 ± 1.6 ml/min, P < 0.05). Circulating levels of glucagon and VIP were two and five fold increased respectively in cirrhotic animals compared to controls. There was a strong correlation between portal pressure and glucagon levels in the cirrhotic group (r = 0.85). Raised splanchnic blood flow is partly responsible for elevated portal pressure in this model and this rise may be humorally mediated.     

Blood pressure and total peripheral resistance in children with chronic kidney disease

We performed a study to assess cardiac output (CO) and total peripheral resistance (TPR) at rest and during peak exercise with the goal to better define the role of these parameters in the development of hypertension in children with chronic kidney disease (CKD) stage 2–4. Fifty-two pediatric patients with CKD (mean age 12.7±3.7 years) and 28 healthy individuals of comparable age and sex participated in the study. At rest, children with CKD had a significantly higher systolic and diastolic blood pressure (BP) and calculated mean arterial pressure (MAP) than healthy controls. Total peripheral resistance was significantly higher in children with CKD than in controls (1627.7±534.6 vs 1354.6±338.9 dyne×s×cm^–5, p =0.02). There was no significant difference in heart rate or CO between the two groups. Children taking antihypertensive medications had lower TPR than children without BP medications (1514.6±439.6 vs 1788.2±505.4 dyne×s×cm^–5, respectively, p =0.06). At peak exercise, children with CKD had a significant increase in MAP, heart rate and CO and had a significant decrease in TPR (difference between rest and peak exercise: –782.4±375.9 dyne×s×cm^–5, p <0.001). Children taking BP medications had blunted MAP and CO responses when compared to controls ( CO: 6.2±2.8 l/min vs 9.8±4.5 l/min, respectively, p =0.01; MAP: 13.9±10.2 mmHg vs 21.5±11.7 mmHg, respectively, p =0.01). Children without BP medications had a similar to controls response to exercise in respect to CO, MAP and TPR. We conclude that increased TPR is a major contributor to elevated blood pressure in children with CKD and suggest that BP medications decreasing vascular resistance should be used as a first line of antihypertensive therapy in these patients.     

Long-term efficacy of partial splenic embolization in children

Purpose: To elucidate the role of partial splenic embolization (PSE) procedures, long-term outcome was assessed in terms of the recurrence of thrombocytopenia.Methods: A retrospective study was performed after 41 PSE procedures in 36 patients for hypersplenism owing to portal hypertension. The underlying disease was biliary atresia in 32 patients, extrahepatic portal obstruction in 3, and idiopathic cirrhosis in 1.Results: The average volume embolized was 70.1%. The patients were followed up from 20 days to 182 months (average, 70.8 months). Five patients subsequently died, and 6 underwent liver transplantation. The causes of death or the reasons for liver transplantation were not related to hypersplenism. Eleven patients (30.6%) had recurrence of thrombocytopenia (<100,000/mm³). There was no significant difference in the volume embolized or platelet count before PSE between the patients with and without recurrence of thrombocytopenia. The peak value of platelet count after PSE was significantly lower in the patients with recurrence of thrombocytopenia (P = .0091). In 17 of 24 survivors without liver transplantation, platelet counts remained normal throughout the follow-up period.Conclusions: PSE is a safe and effective procedure. Hematologic indices improved in all 36 patients after PSE, and its long-term efficacy was shown in 70% of the survivors.     

In vitro analysis of the effect of hyperbilirubinemia on rabbit ureter and bladder

Spontaneous resolution of intrauterine pelvic dilatations after birth is an expected outcome. In nonobstructive pelvic dilatations, changes in ureteral and bladder physiology may also play a part. We aimed to demonstrate the effect of increased concentrations of bilirubin on ureteral and bladder muscles in vitro. Normal and pathologic concentrations of bilirubin (3.5×10^-7–10^-5M and 10^-4–4×10^-4M, respectively) caused no change in the basal ureter tension (343.9±29.4 mg). Normal concentrations of bilirubin caused no difference in basal bladder tension (430.2±70.2 mg), but pathologic concentrations caused a decrease of 303.8±52.9 mg. Normal and pathologic amounts of bilirubin were cumulatively applied to rabbit ureteral and bladder tissues both after reaching basal tension and when contracted with KCl (80 mM and 120 mM KCl for ureter and bladder, respectively). The cumulative addition of normal bilirubin concentrations to the ureteral tissues precontracted with KCl produced 86.4±7.2% relaxation, while the addition of pathologic bilirubin concentrations produced a relaxation of 133.9±17.4%, which was significantly higher (p=0.04). Similarly, the addition of normal concentrations of bilirubin to the bladder tissues precontracted with KCl produced a maximal relaxation of 35.3±2.2%, while pathologic concentrations produced a maximal relaxation of 53.5±3.5%, which was significantly higher (0.001). Consequently, high concentrations of bilirubin caused a mild relaxation in basal ureteral and bladder tensions, while pathologically increased concentrations led to significant relaxation in both types of precontracted tissues. We suggest that high bilirubin levels may partly but not directly contribute to the spontaneous recovery of hydronephrosis because of the relaxation effect on bladder while probably causing susceptibility to urinary tract infections because of relaxation of both ureteral and bladder tissues.     

Neuropeptide Y levels in central and peripheral cerebrospinal fluid in patients with intracranial disorders

Summary Neuropeptide Y (NPY) was measured in central and peripheral cerebrospinal fluid (CSF) in patients suffering from various intracranial disorders. The central NPY-like immunoreactivity (LI) level showed a concentration of 129±19 pmol·l^–1 and was significantly increased (p<0.05) compared to peripheral CSF (73±9 pmol·l^–1). From five patients with subarachnoid haemorrhage the CSF NPY-LI levels reached 154±47 pmol·l^–1. In five patients peripheral and central CSF was collected at the same occasion and the CSF NPY-LI concentration was 76±17 pmol·l^–1 in peripheral and 142±23 pmol·l^–1 in central CSF (p<0.01), respectively. In a reference group of 9 patients, who were examined by lumbar myelography because of suspected intervertebral herniated discs, the peripheral CSF NPY-LI concentration was 59±5 pmol·l^–1 a value which was also significantly lower compared to NPY-LI levels in central CSF.Thus it is obvious that NPY is present in human CSF with a relatively higher concentration in central than in peripheral CSF at least in patients with disorders of the central nervous system, suggesting a central origin of the NPY.     

Inferior mesenteric venous left renal vein shunting for decompression of excessive portal hypertension in adult living related liver transplantation

In the present study, we investigated the effect of decompression of excessive portal hypertension by inferior mesenteric venous (IMV) left renal vein shunting in 7 cirrhotic patients with esophago-gastric varices and 2 patients who underwent adult living related donor liver transplantation (ALRDLT). The portal pressure remarkably decreased after shunting in all patients with esophago-gastric varices (388 ± 42 mm H₂O vs. 247 ± 57 mm H₂O; P < .05). It also decreased after a shunt operation in patients who had undergone liver transplantation. We report that the excessive shear stress by portal hypertension after small-for-size LRDLT induces a liver injury and the decompression of portal hypertension by splenic arterial ligation or splenectomy prevents postoperative liver injury following massive hepatectomy and small-for-size LRDLT. Our present studies suggested that IMV left renal vein shunting might prevent postoperative liver injury by partial decompression of excessive portal hypertension following small-for-size LRDLT.