Abstract：
Portal inflow modulation (PIM) aimed at reducing portal hyperperfusion is commonly used in living donor liver transplantation (LDLT) to reduce the risk of small-for-size syndrome (SFSS). Many different techniques, both pharmacological and surgical have been used for this purpose. There is, however, little consensus on the best method of PIM, its exact role in preventing SFSS and on early post-LDLT recovery.
To identify whether modifications of portal pressures and flows enhance recovery after LDLT and to provide international expert panel recommendations.
Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central.
Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel.
CRD42021260997.
Five hundred and ninety four articles were identified through databases\' search. Of the 24 included for a final review by the working group (WG), there were five randomized control trials, four prospective studies and 15 retrospective series. Six outcome measures which were likely to influence early recovery after LDLT, especially in small-for-size grafts (SFSG) were shortlisted. These included acute kidney injury, SFSS, morbidity including sepsis, length of ICU and hospital stay, morbidity of the PIM technique and overall mortality. The WG noted that PIM in this subset of LDLT recipients had a beneficial effect on all the outcomes measures.
Considering all decision domains, the panel recommends pre- and intraoperative actual graft weight validation, portal pressure/flow measurements, and a comprehensive donor evaluation for the determination of potentially small-for-size/ small-for-flow grafts as mandatory. (Quality of Evidence: Moderate | Grade of Recommendation: Strong) Pharmacological PIM helps improve early renal function in LDLT recipients. (Quality of Evidence: High | Grade of Recommendation: Strong) In selected patients with SFSG, PIM helps reduce SFSS/EAD and sepsis. (Quality of Evidence: Moderate | Grade of Recommendation: Strong) PIM in the form of splenectomy has increased morbidity compared to splenic artery ligation (SAL). (Quality of Evidence: Low | Grade of Recommendation: Strong) In LDLT recipients with SFSG, PIM may help reduce morbidity/mortality. (Quality of Evidence: Low | Grade of Recommendation: Strong) In LDLT recipients with SFSG, modification of portal pressures and flows enhances recovery after LDLT. (Quality of Evidence: Moderate | Grade of Recommendation: Strong).
To identify whether modifications of portal pressures and flows enhance recovery after LDLT and to provide international expert panel recommendations.
Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central.
Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel.
CRD42021260997.
Five hundred and ninety four articles were identified through databases\' search. Of the 24 included for a final review by the working group (WG), there were five randomized control trials, four prospective studies and 15 retrospective series. Six outcome measures which were likely to influence early recovery after LDLT, especially in small-for-size grafts (SFSG) were shortlisted. These included acute kidney injury, SFSS, morbidity including sepsis, length of ICU and hospital stay, morbidity of the PIM technique and overall mortality. The WG noted that PIM in this subset of LDLT recipients had a beneficial effect on all the outcomes measures.
Considering all decision domains, the panel recommends pre- and intraoperative actual graft weight validation, portal pressure/flow measurements, and a comprehensive donor evaluation for the determination of potentially small-for-size/ small-for-flow grafts as mandatory. (Quality of Evidence: Moderate | Grade of Recommendation: Strong) Pharmacological PIM helps improve early renal function in LDLT recipients. (Quality of Evidence: High | Grade of Recommendation: Strong) In selected patients with SFSG, PIM helps reduce SFSS/EAD and sepsis. (Quality of Evidence: Moderate | Grade of Recommendation: Strong) PIM in the form of splenectomy has increased morbidity compared to splenic artery ligation (SAL). (Quality of Evidence: Low | Grade of Recommendation: Strong) In LDLT recipients with SFSG, PIM may help reduce morbidity/mortality. (Quality of Evidence: Low | Grade of Recommendation: Strong) In LDLT recipients with SFSG, modification of portal pressures and flows enhances recovery after LDLT. (Quality of Evidence: Moderate | Grade of Recommendation: Strong).
摘要：
背景：旨在减少门静脉过度灌注的门静脉流入调节（PIM）通常用于活体肝移植（LDLT），以降低小体积综合征（SFSS）的风险。许多不同的技术，药理学和外科手术均已用于此目的。有,然而,关于PIM的最佳方法几乎没有共识，它在预防SFSS和早期LDLT后恢复中的确切作用。
目的：确定门静脉压力和流量的改变是否能促进LDLT术后恢复，并提供国际专家小组建议。
方法：OvidMEDLINE，Embase,Scopus,谷歌学者，和CochraneCentral.
方法：遵循PRISMA指南和建议，使用来自国际专家小组的GRADE方法进行系统审查。
未经评估：CRD42021260997。
结果：通过数据库搜索确定了五百九十四条文章。在工作组（WG）进行最后审查的24个项目中，有五项随机对照试验，4项前瞻性研究和15项回顾性研究.六项可能影响LDLT后早期恢复的结果指标，特别是小型移植物（SFSG）入围。这些包括急性肾损伤，SFSS,发病率包括败血症，ICU的长度和住院时间，PIM技术的发病率和总死亡率。工作组指出，该LDLT接受者子集的PIM对所有结果指标都有有益的影响。
结论：考虑到所有决策域，小组建议术前和术中实际移植物重量验证，入口压力/流量测量,以及全面的捐助者评估，以确定潜在的小型/小流量移植物为强制性。（证据质量：中等|推荐等级：强）药物PIM有助于改善LDLT受体的早期肾功能。（证据质量：高|推荐等级：强）在选定的SFSG患者中，PIM有助于减少SFSS/EAD和败血症。（证据质量：中度|推荐等级：强）与脾动脉结扎（SAL）相比，脾切除术形式的PIM发病率增加。(证据质量：低|推荐等级：强)在SFSG的LDLT接受者中，PIM可能有助于降低发病率/死亡率。(证据质量：低|推荐等级：强)在SFSG的LDLT接受者中，改变门静脉压力和流量可增强LDLT后的恢复。（证据质量：中等|推荐等级：强）。
目的：确定门静脉压力和流量的改变是否能促进LDLT术后恢复，并提供国际专家小组建议。
方法：OvidMEDLINE，Embase,Scopus,谷歌学者，和CochraneCentral.
方法：遵循PRISMA指南和建议，使用来自国际专家小组的GRADE方法进行系统审查。
未经评估：CRD42021260997。
结果：通过数据库搜索确定了五百九十四条文章。在工作组（WG）进行最后审查的24个项目中，有五项随机对照试验，4项前瞻性研究和15项回顾性研究.六项可能影响LDLT后早期恢复的结果指标，特别是小型移植物（SFSG）入围。这些包括急性肾损伤，SFSS,发病率包括败血症，ICU的长度和住院时间，PIM技术的发病率和总死亡率。工作组指出，该LDLT接受者子集的PIM对所有结果指标都有有益的影响。
结论：考虑到所有决策域，小组建议术前和术中实际移植物重量验证，入口压力/流量测量,以及全面的捐助者评估，以确定潜在的小型/小流量移植物为强制性。（证据质量：中等|推荐等级：强）药物PIM有助于改善LDLT受体的早期肾功能。（证据质量：高|推荐等级：强）在选定的SFSG患者中，PIM有助于减少SFSS/EAD和败血症。（证据质量：中度|推荐等级：强）与脾动脉结扎（SAL）相比，脾切除术形式的PIM发病率增加。(证据质量：低|推荐等级：强)在SFSG的LDLT接受者中，PIM可能有助于降低发病率/死亡率。(证据质量：低|推荐等级：强)在SFSG的LDLT接受者中，改变门静脉压力和流量可增强LDLT后的恢复。（证据质量：中等|推荐等级：强）。
