Selective splenectomy centered on graft-to-spleen volume ratio is a practical option in living donor liver transplantation to prevent early allograft dysfunction: A Prospective validation study.

Background: While simultaneous splenectomy (SPX) is an option in selected cases of living donor liver transplantation (LDLT) to protect graft function, graft-to-spleen volume ratio (GSVR) may serve as a new determinant of SPX. A prospective validation study was conducted to test our institutional strategy of SPX based mainly on GSVR, which has been employed since 2019.

Methods: This prospective study enrolled 141 LDLT recipients from 2019 to 2024. The indication for SPX was GSVR ≤0.70 and high-risk patients (ABO-incompatibility or donor age ≥45 y) with a final portal venous pressure >15 mmHg. Surgical outcomes related to graft function were evaluated and compared between the group with SPX (n=51), the group without SPX (n=90), and the historical control group without SPX despite GSVR of ≤0.70 (from 2007 to 2018, n=33). The risk factors for early allograft dysfunction (EAD) in the modern era were also investigated.

Results: Low GSVR indicated 88.2% (45 out of 51) of SPX in the prospective cohort. The historical group (no-SPX despite GSVR ≤0.70) showed an increased incidence of EAD with post-transplant thrombocytopenia, cholestasis, coagulopathy, and massive ascites. In contrast, these adverse events decreased significantly after introducing the new selective SPX protocol, with comparable results between the SPX and no-SPX groups in the prospective cohort. The Model for End-stage Liver Disease (MELD) score was the only indicator of EAD in the multivariable analysis after 2019.

Conclusions: Selective SPX centered on GSVR is a feasible and practical option in LDLT to screen out high-risk recipients and improve their graft function for EAD prevention.