Management of Major Portosystemic Shunting in Small-for-Size Adult Living-Related Donor Liver Transplantation with a Left-Sided Graft Liver

PURPOSE: We investigated the mechanisms of small-for-size graft syndrome by time-lag ligation, a novel approach to treating major portosystemic shunts in small-for-size adult living-related donor liver transplantation (LRDLT) using left-sided graft liver. METHODS: Five patients with end-stage liver failure and major splenorenal shunting underwent LRDLT using left lobe grafts. The average graft volume to recipient body weight (GV/RBW) ratio was 0.68 +/- 0.14. Two patients underwent time-lag ligation of their splenorenal (SR) shunts on postoperative days (PODs) 8 and 14, respectively. The shunts of the other three patients were untreated. RESULTS: The portal pressures in the first patient who underwent time-lag ligation rose above 300 mmH(2)O and remained there for 2 weeks. Thus, we ligated the SR shunt in the second patient on POD 14, resulting in an increase from 177 mmH(2)O to 258 mmH(2)O, but it decreased again thereafter. In the other three patients, the SR shunt was not ligated because portal blood flow volumes remained sufficient. Total bilirubin levels in the first time-lag ligation patient rose to 16 mg/dl, paralleling the rise in portal pressures. Although they increased after ligation in the second patient, they did not exceed 10 mg/dl. CONCLUSIONS: We recommend time-lag ligation if portal venous blood flow decreases in the early post-transplant period, but not until at least 2 weeks after transplantation. If the portal venous blood flow does not decrease, early postoperative ligation is unnecessary. If there are no major portosystemic shunts, making a portosystemic shunt might decompress excessive portal hypertension. With donor safety priority in LRDLT, novel approaches must be developed to enable the use of smaller donor grafts. We describe a potential means of using left lobe grafts in adult LRDLT.     

Assessment of portosystemic shunt patency and function with magnetic resonance imaging

Magnetic resonance imaging (MRI) was performed in seven patients before and after portosystemic shunting to evaluate venous changes accompanying nonselective and selective shunt construction. The size and number of the intrahepatic portal and hepatic veins, left perirenal veins, and left upper quadrant varices were evaluated at MRI before and after shunt construction. MRI correctly diagnosed patent shunts in all seven patients. A marked decrease in the size of intrahepatic veins after a total or nonselective shunt suggests adequate portal vein and variceal decompression. Dilatation of left perirenal veins in the presence of a patent mesorenal or splenorenal shunt suggests hypertension of the left renal vein and possibly inadequate decompression of esophageal varices.     

Mesorenal shunt using inferior mesenteric vein and left renal vein in a case of LDLT

Adult-to-adult living donor liver transplantation (LDLT) has become an established treatment option around the world. However, small-for-size graft syndrome remains one of the most serious complications affecting transplant outcomes. Excessive portal hypertension and overperfusion have been shown to play a causative role in this graft injury. Recently, portal hypertension per se has been considered detrimental to graft function, and thus to be avoided for successful outcomes after LDLT. We constructed a mesorenal shunt with anastomosis of the inferior mesenteric vein and left renal vein in the case of an LDLT recipient who showed high portal vein pressure after graft reperfusion. The inferior mesenteric vein is close to the left renal vein, and the anastomosis was obtained with relative ease. The shunt was effective in decreasing portal vein pressure, and postoperative graft function was satisfactory. This new method represents an option for attenuating portal hypertension when elevated portal vein pressure is observed in adult LDLT after graft reperfusion.     

Surgical procedures for decompression of excessive shear stress in small-for-size living donor liver transplantation--new hepatic vein reconstruction

We have reported that acute elevation of portal pressure, reflecting wall shear stress of sinusoidal endothelial cells, triggers liver regeneration after partial hepatectomy and that excessive portal hypertension induces liver failure. For prevention of excessive shear stress in small-for-size living donor liver transplantation (LDLT), we developed a new hepatic vein reconstruction to expand the anastomotic site. Fourteen adult patients, who underwent LDLT, were divided into two groups: previous end-to-end hepatic vein reconstruction in nine patients (group P) and the new method in five patients (group N). The outside middle and left hepatic veins of the graft were incised and enlarged to 40 mm. The vena cava was cut 40 mm longitudinally. The graft was positioned a quarter turn counterclockwise with the hepatic vein of the graft anastomosed end-to-side to the vena cava longitudinally. Postoperative portal pressures and serum total bilirubin levels of these two groups showed portal pressure in group N to rapidly decrease below 25 cm H2O following LDLT. No cases showed posttransplanted hyperbilirubinemia above 10 mg/dL in group N; however, all cases were small-for-size grafts. Moreover, serum total bilirubin levels in group N were significantly lower than those in group P. This procedure is simple despite not using a venous patch. If the hepatic vein is narrow or obstructed, such as in Budd-Chiari syndrome, the procedure is applicable. Even in small-for-size grafts, excessive tension did not occurred at the portal vein or hepatic artery anastomoses. Moreover, it is possible to avoid outflow block and posttransplanted hyperbilirubinemia.     

Liver transplantation with renoportal anastomosis after distal splenorenal shunt

BACKGROUND: The distal splenorenal shunt (DSRS) is designed to maintain hepatopetal portal vein flow while decompressing gastroesophageal varices. However, over time, as the underlying liver disease progresses, the DSRS loses its selectivity. The most common method of addressing this issue during orthotopic liver transplantation is shunt ligation with or without splenectomy. Dismantling the shunt increases the complexity of the transplantation, and splenectomy may increase the risk of infection. HYPOTHESIS: Anastomosis of the donor portal vein to the left renal vein without dismantling the shunt is an effective method of portal vein reconstruction for patients with a patent DSRS. DESIGN: Retrospective analysis. SETTING: University-based teaching hospital, Miami, Fla. PATIENTS: Five liver transplant recipients with patent DSRS who received an orthotopic liver transplant between September 1996 and August 1999. INTERVENTIONS: The donor portal vein was anastomosed end-to-end to the left renal vein during liver transplantation. MAIN OUTCOME MEASURES: Perioperatve morbidity, portal vein flow by Doppler study, patient survival, and graft survival. RESULTS: In all patients, the graft liver reperfused promptly via flow through the left renal vein with adequate decompression of the bowel. Normal portal venous flow was demonstrated by intraoperative and postoperative Doppler ultrasound studies. At the mean follow-up of 16 months, 4 patients were alive with well-functioning grafts. CONCLUSIONS: This novel technique has the advantage of decreasing the complexity of the procedure, without requiring splenectomy, while securing adequate portal perfusion. Additionally, it can be applied without modifications in patients with portal vein thrombosis.     

Successful management of portal hypertension following artificial arterioportal shunting: Report of a case

A 63-year-old woman diagnosed as having hepatic hilar cancer underwent an extended left lobectomy of the liver with excision of the right hepatic artery which was involved by the tumor. Because the hepatic artery could not be reconstructed by direct anastomosis, an artificial arterioportal (A–P) shunt was constructed between the common hepatic artery and the portal vein. However, 4 weeks after the operation, portal hypertension with severe esophageal varices developed. Under the diagnosis of portal hypertension caused by excessive blood flow from the A–P shunt, coil embolization of the common hepatic artery was performed using an angiographic technique, following which the esophageal varices completely disappeared. This case demonstrates that portal hypertension after A–P shunting can be effectively treated with coil embolization.     

Hemodynamic interaction between portal vein and hepatic artery flow in small-for-size split liver transplantation

In split-liver transplantation, the entire portal flow is redirected through relatively small-for-size grafts. It has been postulated that excessive portal blood flow leads to graft injury. In order to elucidate the mechanisms of this injury, we studied the hemodynamic interactions between portal vein- and hepatic artery flow in an experimental model in pigs. Six whole pig liver grafts were implanted in Group 1 ( n=6) and six whole liver grafts were split into right and left grafts and transplanted to Groups 2 ( n=6) and 3 ( n=6), respectively. The graft-to-recipient liver volume ratio was 1:1, 2:3 and 1:3 in Groups 1, 2 and 3, respectively. Portal vein- and hepatic artery flows were measured with an ultrasonic flow meter at 60,120 and 180 min after graft reperfusion. Portal vein pressure was also recorded at the same time intervals. Graft function was assessed at 3,6h and 12h, and morphological changes at 12h after reperfusion. Following reperfusion, portal vein flow showed an inverse relationship to graft size, while hepatic artery flow was reduced proportionately to graft size. The difference was significant among the three groups ( P<0.05). Portal vein pressure was significantly higher in group 3, compared to groups 1 and 2 ( P<0.05). Hepatic artery buffer response was significantly higher in Group 3, compared to Groups 1 and 2 in relation to pre-occlusion values ( P<0.05). Split-liver transplantation, when resulting in small-for-size grafts, is associated with portal hypertension, diminished arterial flow, and graft dysfunction. Arterial flow impairment appears to be related to increased portal vein flow.     

The inferior mesenteric vein to the left gonadal vein shunt for gastroesophageal varices and extrahepatic portal vein thrombosis after living donor liver transplantation: a case report

This 59-year-old woman underwent living donor liver transplantation using a left lobe graft as an aid for autoimmune hepatitis in 2003. Splenectomy was also performed because of blood type incompatibility. Follow-up endoscopic and computed tomography examinations showed gastroesophageal varices with extra hepatic portal vein thrombosis in 2007 that increased (esophageal varices [EV]: locus superior [Ls], moderately enlarged, beady varices [F2], Blue varices [Cb], presence of small in number and localized red color sign [RC1] and telangiectasia [TE+], gastric varices [GV]: extension from the cardiac orifice to the fornix [Lg-cf], moderately enlarged, beady varices [F2], white varices [Cw], absence of red color sign [RC−]). Portal venous flow to the gastroesophageal varices was also confirmed from a large right gastric vein. The splenic vein was thrombosed. Blood flow to the liver graft was totally supplied from the hepatic artery. The graft was functioning well. Because these gastroesophageal varices had a high risk of variceal bleeding, we decided to proceed with a portal reconstruction of a surgical portosystemic shunt in 2008. Severe adhesions were observed around the portal vein. It was impossible to perform portal reconstruction. There were relatively fewes adhesious in the left lower side of the abdominal cavity. We decided to create an inferior mesenteric vein to left gonadal vein shunt. The portal vein pressure decreased from 31.0 to 21.5 cm H₂O thereafter. The postoperative course was smooth without any complication. This patient was discharged on the postoperative day 15. Follow-up endoscopic study showed the improvement in the gastroesophageal varices (EV: Ls, F2, Cb, RC(−), GV: Lg-c, F2, Cw, RC−) at 3 months after the operation. We also comfirmed the patency of the shunt by serial computed tomography examinations.     

Successful super-small-for-size graft liver transplantation by decompression of portal hypertension via splenectomy and construction of a mesocaval shunt: a case report

We performed a successful super-small-for-size graft liver transplantation by decompressing portal hypertension via splenectomy and a mesocaval shunt. A 46-year-old woman with Child-Pugh class C liver cirrhosis associated with Wilson's disease underwent a living donor liver transplantation (LDLT). The donor had an anomalous portal vein, hepatic vein, and bile duct, so we had to use the right lateral segment for the graft. Preoperative computed tomographic (CT) volumetry showed the volume of this area to be 433 mL; graft-to-recipient weight ratio (GRWR) was 0.72; and graft-to-standard liver volume (GV/SLV) was 39.0%. However, the real volume of the resected right lateral segment was 281 g; GRWR was 0.47; and GV/SLV was 25.3%--a super-small-for-size graft. After implantation, congestion of the small graft was severe due to excessive portal hypertension. Therefore, we tried decompressing the portal vein. First, we performed splenectomy which reduced the portal pressure which remained excessive. Second, a mesocaval shunt was constructed decreasing the portal pressure from 38 to 30 cm H2O. Additionally, we initiated continuous portal injection of prostaglandin E1. The postoperative course was not smooth, but the general status slowly recovered. Over 25 cm H2O of portal hypertension was observed until postoperative day 21 when it improved. At last, the recipient was discharged on postoperative day 156. Accurate preoperative CT volumetry is important to obtain sufficient graft volume. Our case may be one of the smallest-for-size grafts that was successfully transplanted. Management of excessive portal hypertension is important for LDLT, especially using a small-for-size graft. Splenectomy and construction of a mesocaval shunt may be useful strategies to decompress the portal vein.     

Transjugular intrahepatic portosystemic shunt vs. small-diameter prosthetic H-graft portacaval shunt: Extended follow-up of an expanded randomized prospective trial

We report herein the results of extended follow-up of an expanded randomized clinical trial comparing transjugular intrahepatic portosystemic shunt (TIPS) to 8 mm prosthetic H-graft portacaval shunt as definitive treatment for variceal bleeding due to portal hypertension. Beginning in 1993, through this trial, both shunts were undertaken as definitive therapy, never as a “bridge to transplantation.” All patients had bleeding esophageal/gastric varices and failed or could not undergo sclerotherapy/banding. Patients were excluded from randomization if the portal vein was occluded or if survival was hopeless. Failure of shunting was defined as inability to shunt, irreversible shunt occlusion, major variceal rehemorrhage, hepatic transplantation, or death. Median follow-up after each shunt was 4 years; minimum follow-up was 1 year. Patients undergoing placement of either shunt were very similar in terms of age, sex, cause of cirrhosis, Child’s class, and circumstances of shunting. Both shunts provided partial portal decompression, although the portal vein-inferior vena cava pressure gradient was lower after H-graft portacaval shunt (P<0.01). TIPS could not be placed in two patients. Shunt stenosis/occlusion was more frequent after TIPS. After TIPS, 42 patients failed (64%), whereas after H-graft portacaval shunt 23 failed (35%) (P <0.01). Major variceal rehemorrhage, hepatic transplantation, and late death were significantly more frequent after TIPS (P <0.01). Both TIPS and H-graft portacaval shunt achieve partial portal decompression. TIPS requires more interventions and leads to more major rehemorrhage, irreversible occlusion, transplantation, and death. Despite vigilance in monitoring shunt patency, TIPS provides less optimal outcomes than H-graft portacaval shunt for patients with portal hypertension and variceal bleeding. Presented at the Forty-First Annual Meeting of The Society for Surgery of the Alimentary Tract, San Diego, Calif., May 21–24, 2000.     

肝移植治疗肝硬化门静脉高压症的临床疗效

目的 探讨肝移植治疗肝硬化门静脉高压症的临床疗效.方法 回顾性分析2000年1月至2012年1月北京大学人民医院收治的181例肝硬化门静脉高压症患者的临床资料.肝移植手术适应证为反复发作上消化道大出血,经内、外科和介入治疗无效,或合并肝功能失代偿的门静脉高压症患者.根据患者情况选择行经典原位肝移植或背驼式肝移植.术中于移植肝植入前后分别经胃网膜右血管置入套管针,连接测压管测压.观察手术前后门静脉压力变化情况,术后并发症的发生情况.术后通过肝移植随访中心定期随访,并根据具体指标调整用药,随访时间截至2012年12月,监测患者食管静脉曲张再出血及生存情况.Kaplan-Meier法计算生存率,计量资料采用（x）±s表示,均值比较采用t检验.结果 181例患者中,65例行经典原位肝移植,116例行背驮式肝移植.手术时间为（485±97） min,术中出血量为（4 380±1 993） mL,无肝期时间为（56±24） min.157例患者留置T管,24例患者未留置T管.102例患者术中经胃网膜右静脉测量了肝移植前后的门静脉压力,术前门静脉压力为（32±11）cmH2O（1 cmH2O =0.098 kPa）,术后门静脉压力为（21±6）cmH20,手术前后门静脉压力比较,差异有统计学意义（t=2.412,P＜0.05）.肝移植术后严重感染23例、急性肾衰竭20例、严重腹腔内出血6例、血管相关并发症5例和移植物原发无功能2例.181例患者均获得随访,随访时间为6 ～131个月.138例患者术后1年复查内镜或行上消化道造影检查,112例曲张静脉完全消失,其余26例较术前明显减轻,总改善率为85.71％（138/161）.术后1年内4例患者出现了上消化道再出血,再出血率为3.70％（4/108）,其中3例经止血药物或内镜治疗后得到缓解,1例死于再次出血导致的肝衰竭.随访患者术后1个月、1年及5年生存率分别为86.8％、84.9％、77.4％.23例死亡患者中,15例死于MODS,5例死?     

Attenuation of acute phase shear stress by somatostatin improves small-for-size liver graft survival.

The major concern of living donor liver transplantation is small-for-size graft injury at the early phase after transplantation. Novel therapeutic strategies should be developed. To investigate the protective effect of somatostatin related to hemodynamic stress on small-for-size liver graft injury, we applied a treatment regimen of low-dose somatostatin in a rat orthotopic liver transplantation model using small-for-size grafts (median, 38.7%; range, 35-42%). Somatostatin was given at 5 minutes before total hepatectomy and immediately after reperfusion in the recipient (20 microg/kg). Graft survival, portal hemodynamics, intragraft gene expression and hepatic ultrastructural changes were compared between the rats with or without somatostatin treatment. Seven-day graft survival rates in the somatostatin treatment group were significantly improved compared to the control group (66.7% vs. 16.7%, P = 0.036). In the treatment group, portal pressure and hepatic surface blood flow were significantly decreased within the first 30 minutes after reperfusion, whereas in the control group, transient portal hypertension and excessive hepatic blood flow were observed. Intragraft expression (both messenger RNA and protein) of endothelin-1 was significantly downregulated accompanied with upregulation of heme oxygenase-1 and A20. Better preservation of liver function was found in the treatment group. Hepatic ultrastructure, especially the integrity of sinusoids, was well protected in the treatment group. In conclusion, low-dose somatostatin rescues small-for-size grafts from acute phase injury in liver transplantation by attenuation of acute-phase shear stress that resulted from transient portal hypertension.     

Postshunt encephalopathy in liver transplanted children with portal vein thrombosis

BACKGROUND: Surgical portosystemic shunting has been reported to alleviate successfully portal hypertension in liver transplanted recipients with portal vein thrombosis. METHODS: We report two liver transplanted children with portal vein thrombosis who developed post-shunt acute encephalopathy. In one child, a mesocaval H-type shunt was created surgically because of bleeding related to Roux-en-Y loop varices at 3 months posttransplantation; in the other, a large spontaneous splenorenal shunt was discovered at the time of diagnosis of portal vein thrombosis on day 34 posttransplantation and was preserved. RESULTS: Post-shunt encephalopathy developed 6 months and 2.7 years after transplantation, causing death in one child. CONCLUSIONS: This report illustrates the risk and the possible dismal outcome of post-shunt encephalopathy in liver transplanted children. Therapeutic procedures other than portosystemic shunting that will restore an hepatopetal portal flow to the liver graft should be considered in liver-transplanted children with portal vein thrombosis.     

Long-term follow-up after a distal splenorenal shunt procedure: A clinical and hemodynamic study

Of 26 patients who underwent distal splenorenal shunting 4 or more years ago (1969 to 1978), 10 died 3 to 87 months postoperatively (mean 38.5 months). Six deaths were due to liver failure, two to hemorrhagic peptic ulcer disease (the shunt remained patent in each patient), one to brain hemorrhage, and one to sepsis. Eight of the surviving patients resumed professional activity, one showed transient signs of encephalopathy, one had a single episode of recurrent variceal bleeding that could be managed conservatively, and no patient had ascites. Eight patients were investigated angiographically and endoscopically. Preoperative and postoperative measurements of the portal vein showed a decreased diameter in five patients and no opacification in the other three 29 to 97 months after surgery. At endoscopy four patients had small residual esophageal varices, one patient had none, and the other three had large varicosities with variceal pressures between 30 and 40 cm H₂O in two and above 40 cm H₂O in one. Although the incidence of postoperative encephalopathy and variceal bleeding was low after distal splenorenal shunting, the operation did not prevent a decrease in hepatopetal portal flow and did not always abolish the esophageal varices.     

Hyperdynamic circulation in the left gastric venous area in patients with portal hypertension: angiological assessment

The time of appearance of the left gastric vein on serial celiac arteriograms in patients with portal hypertension and esophageal varices was compared with that of the portal vein to assess regional hemodynamics in the left venous portion of the stomach, an area located in close proximity to the varices. In two thirds of all the patients with cirrhosis or non-cirrhotic idiopathic portal hypertension (IPH), the left gastric vein was visualized earlier or simultaneously than or with the portal vein, while in all but one patient with prehepatic portal obstruction, there was a delayed opacification of the left gastric vein. These results suggest the presence of a hyperdynamic circulatory state which promotes venous hypertension in the left gastric venous area of the stomach of a considerable number of patients with cirrhosis or IPH. In such a hemodynamic state, selective decompression of varices can be achieved by a left gastric venous caval shunt.     

Extrahepatic portal hypertension: a retrospective analysis.

A retrospective analysis of 19 patients with esophagogastric or intestinal varices secondary to extrahepatic portal hypertension was conducted. Nine patients had onset of bleeding during childhood. In six of eight pediatric patients in whom a shunt was performed no major bleeding occurred during the follow-up period. In seven adults with pure extrahepatic portal hypertension the four shunting procedures effected permanent control of bleeding. In two of three adults in whom portal vein thrombosis was associated with liver disease, shunting was successful. An emergency procedure was infrequently required. Multiple recurrences of bleeding episodes prior to decompression was the rule. Postshunt encephalopathy was never seen. In those patients in whom a shunt thrombosed or could not be performed, recurrent bleeding occurred uncommonly, and was readily managed to bedrest and transfusion.     

门静脉高压症辅助式肝移植术后肝脏血流动力学变化规律的研究

目的:研究辅助式肝移植行功能性分流治疗门静脉高压症肝脏血流动力学的变化规律及病理生理学机制。方法:回顾性分析2014年7月至2018年12月在首都医科大学附属北京友谊医院以活体供肝方式的小体积移植物行功能性分流治疗门静脉高压症患者临床资料,共纳入6例患者为研究对象,其中4例男性,2例女性,中位年龄35.5(29.0～5...     

Recurrent Portal Vein Thrombosis In Liver Transplantation With Renoportal Anastomosis Caused by Spontaneous Reno-Caval Shunts: A Case Report

BackgroundOrthotopic liver transplantation (OLT) in patients with cirrhosis complicated by portal hypertension, portosystemic shunts, and chronic portal vein thrombosis (PVT) has long been challenging. Spontaneous spleno-renal shunts (SRS) allow new surgical techniques to restore portal vein patency and hepatopetal flow. Renoportal anastomosis (RPA) has emerged as an accepted method for transplanting these patients, with good long-term patient and graft survival. Orthotopic liver transplantation with RPA is known to be complicated by recurrent PVT, with few details discussed in the literature.Case ReportWe present a case of a 56-year-old woman with decompensated cirrhosis who underwent deceased donor whole graft OLT using RPA with iliac vein conduit. The postoperative course was complicated by occlusive thrombosis in the portal vein and iliac vein conduit. Venography revealed enlarged left gonadal and lumbar vein varices acting as reno-caval shunts with hepatofugal flow. Embolization of the varices re-established durable venous patency that was confirmed on post-transplant day 68 with no other hemodynamic complications.DiscussionThis showcases an interesting mechanism by which recurrent PVT may occur in patients undergoing OLT with RPA. Because durable portal vein patency can be achieved with Interventional Radiology embolization of reno-caval varices, assessing these communications is an important preoperative consideration for planned OLT with RPA.     

Hyperdynamic circulation in the left gastric venous area in patients with portal hypertension: Angiological assessment

The time of appearance of the left gastric vein on serial celiac arteriograms in patients with portal hypertension and esophageal varices was compared with that of the portal vein to assess regional hemodynamics in the left venous portion of the stomach, an area located in close proximity to the varices. In two thirds of all the patients with cirrhosis or non-cirrhotic idiopathic portal hypertension (IPH), the left gastric vein was visualized earlier or simultaneously than or with the portal vein, while in all but one patient with prehepatic portal obstruction, there was a delayed opacification of the left gastric vein. These results suggest the presence of a hyperdynamic circulatory state which promotes venous hypertension in the left gastric venous area of the stomach of a considerable number of patients with cirrhosis or IPH. In such a hemodynamic state, selective decompression of varices can be achieved by a left gastric venous caval shunt.     

Excessive portal flow causes graft nonfunction in small size liver transplantation: an experimental study in pigs

We investigated the effects of portocaval shunt (PCS) on excessive portal flow in producing sinusoidal microcirculatory injury in small-for-size liver transplants in pigs. The posterior segment of a whole liver (25%) was transplanted orthotopically. The pigs were divided two groups: group A, graft with PCS (n = 11), and group B, graft without PCS (n = 11). The PCS was a side-to-side anastomosis of the portal vein and the inferior vena cava. In group A, eight pigs survived for more than 4 days; all pigs except for one died of graft nonfunction within 24 hours in group B. The portal flow after reperfusion decreased in group A, but increased about three times greater in group B than that before the operation (P < .01). In group B, destruction of the sinusoidal lining and bleeding in the periportal areas were observed after reperfusion, findings that were not recognized in group A. These results suggest that graft nonfunction after small-for-size liver transplantation may be attributable to excessive portal flow producing sinusoidal microcirculatory injury.