Early Graft Function After Intraoperative Assessment–Guided Selective Ligation of Segment 5/8 Veins in Adult Right Lobe Living Donor Liver Transplantation

Early Graft Function After Intraoperative Assessment–Guided Selective Ligation of Segment 5/8 Veins in Adult Right Lobe Living Donor Liver Transplantation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Early Graft Function After Intraoperative Assessment–Guided Selective Ligation of Segment 5/8 Veins in Adult Right Lobe Living Donor Liver Transplantation Feyza Sonmez Topcu, Emrah Sahin This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9042712/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 21 You are reading this latest preprint version Abstract Background Reconstruction of segment 5 and/or segment 8 anterior sector veins ≥5 mm is commonly recommended in adult right lobe living donor liver transplantation to prevent venous congestion. However, the necessity of routine reconstruction remains controversial. Methods In this retrospective cohort study, adult recipients who underwent right lobe living donor liver transplantation without inclusion of the middle hepatic vein at a high-volume transplant center between November 2021 and May 2025 were analyzed. Patients with intraoperatively measured segment 5 and/or segment 8 veins ≥5 mm were included. Venous management was determined intraoperatively and was not randomized. Patients underwent either venous reconstruction or selective ligation based on functional graft assessment. Early graft function on postoperative day 7 was evaluated using international normalized ratio, total bilirubin, and ascites volume. Multivariable linear regression analysis was performed to adjust for potential confounders, including graft-to-recipient weight ratio (GRWR) and Model for End-Stage Liver Disease (MELD) score. Results A total of 175 recipients were included (16 in the selective ligation group and 159 in the reconstruction group). Baseline demographic and clinical characteristics were comparable between groups. Early graft function parameters on postoperative day 7 did not differ significantly between groups for international normalized ratio (1.24 vs 1.27; p = 0.83), total bilirubin (1.46 vs 1.71 mg/dL; p = 0.30), or ascites volume (1100 vs 1245 mL; p = 0.88). In multivariable analysis adjusting for GRWR and MELD score, selective ligation was not independently associated with increased postoperative ascites (β = 0.214; 95% CI −0.334 to 0.762; p = 0.445). In a sensitivity analysis restricted to recipients with GRWR ≥0.8, results remained consistent (β = 0.242; p = 0.407). Conclusions Selective ligation of segment 5 and/or segment 8 veins ≥5 mm, when guided by intraoperative functional assessment, was not associated with impaired early graft function. Routine reconstruction of all anterior sector veins ≥5 mm may not be mandatory in carefully selected recipients with adequate graft volume and satisfactory perfusion. Clinical trial number: not applicable. living donor liver transplantation right lobe graft middle hepatic vein venous outflow segment veins selective ligation graft function Background Living donor liver transplantation (LDLT) has become an essential strategy in regions with limited availability of deceased donor organs. In adult recipients, right lobe grafts are frequently preferred to meet metabolic demands and to reduce the risk of small-for-size syndrome [ 1 , 2 ]. However, adult right lobe LDLT remains technically demanding and requires meticulous management of venous outflow to ensure adequate graft perfusion and early functional recovery. When the middle hepatic vein (MHV) is preserved in the donor, venous drainage of the anterior sector (segments 5 and 8) becomes a critical determinant of graft hemodynamics. Inadequate drainage of this sector has been associated with graft congestion, impaired regeneration, and early graft dysfunction [ 3 – 5 ]. Consequently, reconstruction of segment 5 and 8 veins ≥ 5 mm has been widely adopted in many transplant centers as a preventive strategy [ 3 , 6 ]. Nevertheless, venous reconstruction increases operative complexity and duration and may not always guarantee long-term patency [ 7 , 8 ]. Emerging clinical evidence suggests that the functional relevance of anterior sector veins depends not only on anatomical diameter but also on graft volume, portal inflow, intrahepatic collateral circulation, and intraoperative hemodynamic conditions [ 9 – 11 ]. In a large retrospective study of 253 recipients, Akamatsu et al. [ 7 ] demonstrated that impaired anterior sector regeneration following MHV deprivation was compensated by posterior sector hypertrophy and did not adversely affect functional recovery or long-term outcomes. These considerations raise the question of whether rigid diameter-based reconstruction criteria are universally necessary. The present study aimed to evaluate whether an intraoperative assessment–guided selective ligation strategy for segment 5 and/or 8 veins ≥ 5 mm affects early graft function in adult right lobe LDLT recipients. Methods Study Design and Patient Selection This retrospective cohort study included adult recipients who underwent right lobe living donor liver transplantation without inclusion of the middle hepatic vein between November 2021 and May 2025 at a high-volume transplant center. Patients were eligible if intraoperatively measured segment 5 and/or segment 8 anterior sector drainage veins were ≥ 5 mm in diameter. Exclusion criteria were anterior sector veins < 5 mm, dominant drainage through a distinct inferior right hepatic vein, left lobe grafts, pediatric recipients, and incomplete perioperative data. Surgical Strategy and Intraoperative Assessment Patients were classified into two groups according to intraoperative venous management. In the Reconstruction Group, V5 and/or V8 veins were reconstructed using direct anastomosis or an interposition graft. In the Selective Ligation Group, V5 and/or V8 veins were ligated based on intraoperative functional assessment. One patient who had one anterior sector vein reconstructed and another ligated was assigned to the Selective Ligation Group, as the primary analytical interest was the safety of ligating at least one ≥ 5 mm tributary. The decision to reconstruct or ligate was not randomized. Reconstruction was preferentially performed in recipients considered at higher risk for venous congestion, including those with marginal graft-to-recipient weight ratio (GRWR) or unfavorable intraoperative perfusion findings. Notably, all recipients with a GRWR < 0.8 were managed in the Reconstruction Group, reflecting a deliberate risk-averse strategy. Selective ligation was applied in recipients with adequate graft volume and satisfactory perfusion characteristics. Intraoperative assessment consisted of macroscopic evaluation of graft color and congestion, venous backflow from anterior sector tributaries, Doppler ultrasonography findings, and portal venous flow characteristics. Donor hepatectomy with preservation of the middle hepatic vein was performed as previously described [ 3 ]. Data Collection and Outcomes Recipient demographic characteristics, preoperative clinical variables, and operative data were retrospectively collected. Graft-to-recipient weight ratio was calculated using standard methodology. The primary endpoints were early graft function parameters on postoperative day 7, including international normalized ratio (INR), total bilirubin level, and ascites volume. Secondary endpoints included operative time, intraoperative blood loss, early postoperative complications, clinically significant ascites (≥ 1000 mL), and early graft dysfunction (INR > 1.6). Due to incomplete intraoperative documentation in some cases, operative variables were analyzed only in patients with complete operative data. Postoperative day 7 laboratory and ascites measurements were analyzed only in patients with available follow-up data. Statistical Analysis Continuous variables were expressed as mean ± standard deviation or median (interquartile range), as appropriate, and compared using the Mann–Whitney U test. Categorical variables were compared using Fisher’s exact test. Given the nonrandomized surgical strategy, GRWR was considered a potential confounder. Multivariable linear regression analysis was performed to identify independent predictors of postoperative ascites using logarithmically transformed ascites volume [log(ascites + 1)]. The model included ligation status, MELD score, and GRWR as covariates. A prespecified sensitivity analysis was conducted by restricting the cohort to recipients with GRWR ≥ 0.8 to control for potential allocation bias related to graft volume. Statistical analyses were performed using SPSS software (version 26.0; IBM Corp., Armonk, NY, USA). A p value < 0.05 was considered statistically significant. Results Patient Characteristics A total of 175 patients were included in the analysis, of whom 159 were assigned to the Reconstruction Group and 16 to the Selective Ligation Group. Baseline demographic and clinical characteristics were comparable between groups, including age, sex distribution, body mass index, MELD score, graft-to-recipient weight ratio, and graft weight (Table 1 ). All recipients with a GRWR < 0.8 (n = 20) were managed in the Reconstruction Group. Table 1 Baseline Demographic and Clinical Characteristics of the Study Groups Variable Selective Ligation Group (n = 16) Reconstruction Group (n = 159) P value Age (years), mean ± SD 53.4 ± 11.7 51.2 ± 14.1 0.69 Male sex, n (%) 12 (75.0) 96 (60.4) 0.29 MELD score, median (IQR) 15 (11–24) 16 (10–20) 0.48 BMI (kg/m 2 ), mean ± SD 27.5 ± 3.7 (n = 6) 27.8 ± 5.8 (n = 126) 0.93 Graft weight (g), mean ± SD 793 ± 104 796 ± 167 0.95 GRWR, median (IQR) 1.04 (0.94–1.22) 1.02 (0.89–1.23) 0.69 GRWR < 0.8, n (%) 0 (0) 20 (12.6) — Continuous variables are presented as mean ± standard deviation or median (interquartile range). Comparisons were performed using the Mann–Whitney U test for continuous variables and Fisher’s exact test for categorical variables. Abbreviations: BMI, body mass index; GRWR, graft-to-recipient weight ratio; IQR, interquartile range; MELD, Model for End-Stage Liver Disease; SD, standard deviation. Operative Outcomes Operative data were available in a subset of patients (Selective Ligation Group, n = 5; Reconstruction Group, n = 109). Median operative time was numerically lower in the Selective Ligation Group (240 vs 270 minutes; p = 0.37), although this difference did not reach statistical significance (Table 2 ). Intraoperative blood loss was also numerically lower in the Selective Ligation Group (median 40 vs 60 mL; p = 0.12). Statistical comparison of operative variables was limited by the small number of patients with complete intraoperative documentation in the ligation group (5 of 16; 31.3%). Table 2 Intraoperative Findings (Subset Analysis: Patients With Complete Operative Data) Variable Selective Ligation Group (n = 5) Reconstruction Group (n = 109) P value Operative time (min), mean ± SD 277.6 ± 100.5 284.0 ± 70.2 0.37 Operative time (min), median (IQR) 240 (230–263) 270 (242–320) Blood loss (mL), median (IQR) 40 (40–40) 60 (50–350) 0.12 Intraoperative variables were analyzed only in patients with complete operative documentation. Data are presented as mean ± standard deviation or median (interquartile range). Comparisons were performed using the Mann–Whitney U test. Abbreviations: IQR, interquartile range; SD, standard deviation. Early Graft Function Postoperative day 7 data were available in 12 patients in the Selective Ligation Group and 119 patients in the Reconstruction Group for laboratory parameters, and in 11 and 84 patients, respectively, for ascites measurements. Postoperative day 7 graft function parameters are summarized in Table 3 . There were no statistically significant differences between groups in INR (1.24 vs 1.27; p = 0.83), total bilirubin (1.46 vs 1.71 mg/dL; p = 0.30), or ascites volume (1100 vs 1245 mL; p = 0.88). Table 3 Early Postoperative Outcomes on Postoperative Day 7 Variable Selective Ligation Group Reconstruction Group P value INR, median (IQR) 1.24 (1.21–1.43) (n = 12) 1.27 (1.17–1.42) (n = 119) 0.83 Total bilirubin (mg/dL), median (IQR) 1.46 (0.79–2.46) (n = 12) 1.71 (1.20–3.30) (n = 119) 0.30 Ascites volume (mL), median (IQR) 1100 (970–1465) (n = 11) 1245 (590–2000) (n = 84) 0.88 Clinically significant ascites (≥ 1000 mL), n (%) 7/11 (63.6) 50/84 (59.5) 1.00 Early graft dysfunction (INR > 1.6), n (%) 2/12 (16.7) 15/119 (12.6) 0.66 Any early complication, n (%) 2/16 (12.5) 28/159 (17.6) 1.00 Data are presented as median (interquartile range) or n/N (%). Continuous variables were compared using the Mann–Whitney U test. Categorical variables were compared using Fisher’s exact test. Sample sizes vary according to data availability. Abbreviations: INR, international normalized ratio; IQR, interquartile range. The incidence of clinically significant ascites (≥ 1000 mL) did not differ between the Selective Ligation and Reconstruction groups (63.6% vs 59.5%; p = 1.00). Similarly, early graft dysfunction (INR > 1.6) was comparable between groups (16.7% vs 12.6%; p = 0.66). The overall rate of early postoperative complications was 12.5% in the Selective Ligation Group and 17.6% in the Reconstruction Group (p = 1.00). Multivariable Analysis Multivariable linear regression analysis using log-transformed postoperative day 7 ascites volume [log(ascites + 1)] was performed with ligation status, MELD score, and GRWR as covariates (Table 4 ). Ligation of an anterior sector vein ≥ 5 mm was not independently associated with postoperative ascites volume (β = 0.214, 95% CI − 0.334 to 0.762; p = 0.445). MELD score was a significant independent predictor of postoperative ascites (β = 0.029, 95% CI 0.007 to 0.052; p = 0.012). GRWR was not independently associated with ascites in this model (β = −0.381, 95% CI − 1.052 to 0.291; p = 0.269). Table 4 Multivariable Linear Regression Analysis for Postoperative Day 7 Ascites (Log-Transformed) Variable β Coefficient 95% CI P value Ligation of ≥ 5 mm anterior sector vein (yes vs no) 0.214 −0.334 to 0.762 0.445 MELD score 0.029 0.007 to 0.052 0.012 GRWR −0.381 −1.052 to 0.291 0.269 Dependent variable: log-transformed postoperative day 7 ascites volume [log(ascites + 1)]. Values represent unstandardized β coefficients derived from multivariable linear regression analysis (n = 94). Abbreviations: CI, confidence interval; GRWR, graft-to-recipient weight ratio; MELD, Model for End-Stage Liver Disease. Sensitivity Analysis: Recipients With GRWR ≥ 0.8 To address potential allocation bias arising from the exclusive assignment of all GRWR < 0.8 recipients to the Reconstruction Group, a prespecified sensitivity analysis was conducted by restricting the cohort to recipients with GRWR ≥ 0.8 (n = 154; ligation n = 16, reconstruction n = 138). In this subgroup, postoperative day 7 outcomes remained comparable between groups: INR (1.24 vs 1.27; p = 0.80), total bilirubin (1.46 vs 1.60 mg/dL; p = 0.38), and ascites volume (1100 vs 1178 mL; p = 0.83) (Table 5 ). The incidence of clinically significant ascites (≥ 1000 mL) was 63.6% in the Selective Ligation Group and 58.3% in the Reconstruction Group (p = 1.00). Early graft dysfunction (INR > 1.6) occurred in 16.7% and 11.5% of patients, respectively (p = 0.64). Table 5 Sensitivity Analysis: Early Postoperative Outcomes in Recipients With GRWR ≥ 0.8 Variable Selective Ligation Group (n = 16) Reconstruction Group (n = 138) P value INR, median (IQR) 1.24 (1.21–1.42) (n = 12) 1.27 (1.17–1.42) (n = 104) 0.80 Total bilirubin (mg/dL), median (IQR) 1.46 (0.79–2.46) (n = 12) 1.60 (1.15–3.23) (n = 104) 0.38 Ascites volume (mL), median (IQR) 1100 (970–1465) (n = 11) 1178 (559–2000) (n = 72) 0.83 Clinically significant ascites (≥ 1000 mL), n (%) 7/11 (63.6) 42/72 (58.3) 1.00 Early graft dysfunction (INR > 1.6), n (%) 2/12 (16.7) 12/104 (11.5) 0.64 Sensitivity analysis restricted to recipients with graft-to-recipient weight ratio ≥ 0.8 (n = 154). Data are presented as median (interquartile range) or n/N (%). Continuous variables were compared using the Mann–Whitney U test. Categorical variables were compared using Fisher’s exact test. Abbreviations: GRWR, graft-to-recipient weight ratio; INR, international normalized ratio; IQR, interquartile range. Multivariable regression in this restricted cohort confirmed that selective ligation was not independently associated with postoperative ascites (β = 0.242, 95% CI − 0.326 to 0.810; p = 0.407), while MELD score remained the only significant predictor (β = 0.036, 95% CI 0.011 to 0.062; p = 0.006). These results support the robustness of the primary analysis and suggest that the observed findings are not attributable to confounding by graft volume. Discussion Management of anterior sector venous drainage remains a key technical issue in adult right lobe living donor liver transplantation (LDLT). Since early reports advocating reconstruction of segment 5 and 8 veins ≥ 5 mm, diameter-based thresholds have been widely incorporated into surgical practice [ 3 , 6 , 12 , 13 ]. Although this approach is considered standard in many centers, the extent to which anatomical diameter alone determines functional necessity remains controversial. In the present study, selective ligation of V5/V8 veins ≥ 5 mm, when guided by intraoperative functional assessment, did not adversely affect early graft function. Postoperative coagulation parameters, bilirubin levels, and ascites volume were comparable between the reconstruction and ligation groups. Importantly, clinically significant ascites and early graft dysfunction rates were also similar, further supporting the absence of clinically meaningful early impairment. These findings suggest that the clinical relevance of anterior sector veins may depend not only on anatomical size but also on graft volume, portal inflow, intrahepatic collateral circulation, and overall hemodynamic conditions [ 9 , 10 , 14 ]. Venous congestion of the anterior sector has been associated with impaired regeneration and early graft dysfunction in right lobe grafts [ 4 , 5 , 15 ]. However, several lines of evidence support the capacity for compensatory venous outflow. Ito et al. [ 8 ] reported long-term V5 and V8 patency rates as low as 36% and 58%, respectively, following reconstruction, yet without measurable deterioration of graft function. In a landmark study of 253 recipients, Akamatsu et al. [ 7 ] demonstrated that anterior sector regeneration was significantly impaired when MHV tributaries were sacrificed, but this was compensated by enhanced posterior sector regeneration, resulting in comparable functional recovery and long-term outcomes across surgical strategies. Durairaj et al. [ 9 ], in a randomized clinical trial, reported that MHV reconstruction improved outcomes particularly in grafts with lower GRWR, highlighting the importance of graft volume in determining the necessity of venous reconstruction. Collectively, these observations indicate the presence of robust compensatory venous outflow pathways and underscore the potential for a more individualized approach to venous management. Operative complexity is another important consideration. Venous reconstruction requires additional vascular anastomoses, increases procedural demands, and may necessitate the use of interposition grafts such as cryopreserved homologous veins or synthetic conduits [ 16 , 17 ]. Although operative data were available only in a subset of patients (n = 5 in the ligation group) and did not reach statistical significance, the numerical trend toward shorter operative time observed in the Selective Ligation Group reflects the additional technical burden associated with reconstruction. A recent multicenter randomized trial by Reddy et al. [ 18 ] demonstrated that single outflow reconstruction techniques reduced warm ischemia time and operative duration compared with dual outflow approaches, further illustrating the clinical relevance of simplifying venous outflow management. Avoiding unnecessary venous reconstruction may therefore improve operative efficiency without compromising early graft function. The distribution of graft-to-recipient weight ratio (GRWR) should be interpreted cautiously. All recipients with GRWR < 0.8 underwent reconstruction, reflecting a deliberate risk-averse strategy rather than random allocation. Selective ligation was preferentially applied in recipients with adequate graft volume and favorable intraoperative perfusion findings. The importance of graft volume and portal inflow modulation in preventing small-for-size physiology is well established [ 2 , 10 , 14 ]. To address this potential allocation bias, a prespecified sensitivity analysis restricted to recipients with GRWR ≥ 0.8 was performed. In this more homogeneous subgroup, selective ligation remained non-significant as a predictor of postoperative ascites, confirming the robustness of the primary findings. Accordingly, our results support a risk-stratified approach rather than routine ligation. Multivariable analysis demonstrated that ligation of anterior sector veins ≥ 5 mm was not independently associated with postoperative ascites after adjusting for MELD score and GRWR (Table 4 ). MELD score emerged as the principal independent predictor of postoperative ascites. Ascites formation after liver transplantation is multifactorial and closely related to recipient disease severity and portal hemodynamics [ 10 , 15 , 19 ]. Within this broader physiological framework, the isolated impact of anterior sector venous strategy may be less decisive than traditionally assumed. This study has several limitations. First, the retrospective and nonrandomized design may introduce selection bias. In particular, recipients with GRWR < 0.8 were preferentially managed with venous reconstruction, which may have influenced group allocation. Although GRWR was included in multivariable analysis and a sensitivity analysis restricted to GRWR ≥ 0.8 recipients was performed, residual confounding cannot be entirely excluded. Second, operative variables and postoperative day 7 outcome data were available only in patients with complete documentation (operative data in 31.3% of the ligation group), which may limit the generalizability of intraoperative and early outcome findings. Third, the relatively small number of patients in the ligation group (n = 16) limits statistical power for detecting small differences in outcomes; the absence of statistically significant differences should not be equated with proof of equivalence. Future adequately powered prospective studies are needed to confirm these observations. Fourth, only early graft function was evaluated; long-term outcomes including graft survival, anterior sector regeneration patterns, and venous patency rates remain to be assessed. Finally, multiple endpoints were analyzed without formal adjustment for multiple comparisons, which should be considered when interpreting borderline results. Overall, our results suggest that routine reconstruction of all anterior sector drainage veins ≥ 5 mm may not be universally required in adult right lobe LDLT. An individualized strategy incorporating graft volume assessment and intraoperative hemodynamic evaluation may safely guide venous management without compromising early graft function. Conclusions Selective ligation of segment 5 and/or segment 8 veins ≥ 5 mm in adult right lobe living donor liver transplantation was not associated with impaired early graft function when guided by intraoperative functional assessment. Despite preferential reconstruction in recipients with lower graft-to-recipient weight ratio, both primary multivariable analysis and sensitivity analysis restricted to recipients with GRWR ≥ 0.8 did not demonstrate an independent adverse effect of selective ligation on postoperative ascites. These findings suggest that routine reconstruction of all anterior sector veins ≥ 5 mm may not be mandatory in carefully selected recipients with adequate graft volume and satisfactory intraoperative perfusion. Further prospective studies with larger sample sizes are warranted to confirm these observations and evaluate long-term outcomes. Abbreviations BMI: body mass index; CI: confidence interval; GRWR: graft-to-recipient weight ratio; INR: international normalized ratio; IQR: interquartile range; LDLT: living donor liver transplantation; MELD: Model for End-Stage Liver Disease; MHV: middle hepatic vein; SD: standard deviation; SPSS: Statistical Package for the Social Sciences. Declarations Ethics approval and consent to participate The study was approved by the Istanbul Aydin University Ethics Committee (Approval No: 121/2024). All procedures were performed in accordance with the ethical standards of the institutional and/or national research committee and with the Declaration of Helsinki. Written informed consent was obtained from all participants as part of the institutional transplantation consent process. Consent for publication Not applicable. Availability of data and materials The data that support the findings of this study are available from the corresponding author upon reasonable request. Due to the inclusion of patient-related clinical data, the dataset is not publicly available. Competing interests The authors declare that they have no competing interests. Funding The authors received no funding for this study. Authors’ contributions FST and ES contributed to the study conception and design, data collection and analysis, manuscript drafting, and critical revision. All authors read and approved the final manuscript. Acknowledgements Not applicable. References Chen CL, Kabiling CS, Concejero AM. Why living donor liver transplantation? J Gastroenterol Hepatol. 2012;27:403-407. Tanaka K, Ogura Y. Small-for-size graft and small-for-size syndrome in living donor liver transplantation. Yonsei Med J. 2004;45:1089-1094. Lee SG, Park KM, Hwang S, et al. Anterior segment congestion of a right liver lobe graft in living-donor liver transplantation and strategy to prevent congestion. J Hepatobiliary Pancreat Surg. 2003;10:16-25. Pravisani R, Soyama A, Takatsuki M, et al. Relationship between venous drainage patterns and regeneration of segments 5 and 8 in right lobe grafts in adult living-donor liver transplant recipients. Exp Clin Transplant. 2019;17:529-535. Fan ST, Lo CM, Liu CL, Yong BH, Wong J. Determinants of hospital mortality of adult recipients of right lobe live donor liver transplantation. Ann Surg. 2003;238:864-869. Guo HJ, Wang K, Chen KC, et al. Middle hepatic vein reconstruction in adult right lobe living donor liver transplantation improves recipient survival. Hepatobiliary Pancreat Dis Int. 2019;18:125-131. Akamatsu N, Sugawara Y, Nagata R, et al. Adult right living-donor liver transplantation with special reference to reconstruction of the middle hepatic vein. Am J Transplant. 2014;14:2777-2787. Ito K, Akamatsu N, Tani K, et al. Reconstruction of hepatic venous tributary in right liver living donor liver transplantation: the importance of the inferior right hepatic vein. Liver Transpl. 2016;22:410-419. Durairaj MS, Mathew JS, Mallick S, et al. Middle hepatic vein reconstruction in adult living donor liver transplantation: a randomized clinical trial. Br J Surg. 2021;108:1426-1432. Troisi R, Cammu G, Militerno G, et al. Modulation of portal graft inflow: a necessity in adult living-donor liver transplantation? Ann Surg. 2003;237:429-436. Marcos A, Ham JM, Fisher RA, Olzinski AT, Posner MP. Single-center analysis of the first 40 adult-to-adult living donor liver transplants using the right lobe. Liver Transpl. 2000;6:296-301. Jeng LB, Thorat A, Yang HR, Li PC. Venous outflow reconstruction in living donor liver transplantation: dealing with venous anomalies. World J Transplant. 2015;5:145-153. Yu PF, Wu J, Zheng SS. Management of the middle hepatic vein and its tributaries in right lobe living donor liver transplantation. Hepatobiliary Pancreat Dis Int. 2007;6:358-363. Ikegami T, Onda S, Furukawa K, et al. Small-for-size graft, small-for-size syndrome and inflow modulation in living donor liver transplantation. J Hepatobiliary Pancreat Sci. 2020;27:799-809. Sugawara Y, Makuuchi M. Small-for-size graft problems in adult-to-adult living-donor liver transplantation. Transplantation. 2003;75(Suppl 3):S20-S22. Balci D, Kirimker EO. Hepatic vein in living donor liver transplantation. Hepatobiliary Pancreat Dis Int. 2020;19:318-323. Campsen J, Hendrickson RJ, Zimmerman MA, et al. Adult right-lobe live donor liver transplantation without reconstruction of the middle hepatic vein: a single-center study of 109 cases. Transplantation. 2008;85:775-777. Kilercik H, Akbulut S, Elsarawy A, et al. Effect of complex venous outflow drainage reconstruction on postoperative graft function in right-lobe living donor liver transplantation. J Clin Med. 2025;14:2005. Reddy MS, Koneti AJ, Chaudhary A, et al. Multicenter randomised controlled trial of single versus double venous outflow reconstruction in right lobe living donor liver transplantation: Venous Outflow in Liver Transplantation Trial. Ann Surg. 2025;281:911-920. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9042712","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":604462085,"identity":"bc4158d5-dd18-4802-ad48-f8709962d9f7","order_by":0,"name":"Feyza Sonmez Topcu","email":"","orcid":"","institution":"Istanbul Aydın University","correspondingAuthor":false,"prefix":"","firstName":"Feyza","middleName":"Sonmez","lastName":"Topcu","suffix":""},{"id":604462086,"identity":"39928d9b-19af-455e-ac4d-a345f742213d","order_by":1,"name":"Emrah Sahin","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8ElEQVRIiWNgGAWjYDCCAxAqgYGBB8iuADKZmRtI0XIGpIWRBC0MjG0gNgEtfLcPMD66uccuT7797MHDhfNqo/nbgVp+VGzDqUXyXAKzcc6z5GKDM3kJh2duO5474zBjA2PPmds4tRicYWCTzjnAnLiBIcfgMO+2Y7kNQC3MjG14tbD/zjlQnzi//w1Qy5xjufOJ0MLGnHPgcGLDDZAtDTW5GwhpkTzD2Ax02PHEDTeAtvAcO5C7EajlID6/8J1hPvg550A10GE5xp95aupy550/fPDBjwrcWtBj4TCYPIBHPQaoI0XxKBgFo2AUjBAAAFmgYoqK0E9lAAAAAElFTkSuQmCC","orcid":"","institution":"Istanbul Aydın University","correspondingAuthor":true,"prefix":"","firstName":"Emrah","middleName":"","lastName":"Sahin","suffix":""}],"badges":[],"createdAt":"2026-03-05 16:53:30","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9042712/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9042712/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104781173,"identity":"40c4f4a2-21ad-4ee1-94f1-bc3a509806b0","added_by":"auto","created_at":"2026-03-17 07:55:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":744717,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9042712/v1/2552d689-7fd9-4124-b708-59a2d063eef6.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Early Graft Function After Intraoperative Assessment–Guided Selective Ligation of Segment 5/8 Veins in Adult Right Lobe Living Donor Liver Transplantation","fulltext":[{"header":"Background","content":"\u003cp\u003eLiving donor liver transplantation (LDLT) has become an essential strategy in regions with limited availability of deceased donor organs. In adult recipients, right lobe grafts are frequently preferred to meet metabolic demands and to reduce the risk of small-for-size syndrome [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. However, adult right lobe LDLT remains technically demanding and requires meticulous management of venous outflow to ensure adequate graft perfusion and early functional recovery.\u003c/p\u003e \u003cp\u003eWhen the middle hepatic vein (MHV) is preserved in the donor, venous drainage of the anterior sector (segments 5 and 8) becomes a critical determinant of graft hemodynamics. Inadequate drainage of this sector has been associated with graft congestion, impaired regeneration, and early graft dysfunction [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Consequently, reconstruction of segment 5 and 8 veins\u0026thinsp;\u0026ge;\u0026thinsp;5 mm has been widely adopted in many transplant centers as a preventive strategy [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Nevertheless, venous reconstruction increases operative complexity and duration and may not always guarantee long-term patency [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEmerging clinical evidence suggests that the functional relevance of anterior sector veins depends not only on anatomical diameter but also on graft volume, portal inflow, intrahepatic collateral circulation, and intraoperative hemodynamic conditions [\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In a large retrospective study of 253 recipients, Akamatsu et al. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] demonstrated that impaired anterior sector regeneration following MHV deprivation was compensated by posterior sector hypertrophy and did not adversely affect functional recovery or long-term outcomes. These considerations raise the question of whether rigid diameter-based reconstruction criteria are universally necessary.\u003c/p\u003e \u003cp\u003eThe present study aimed to evaluate whether an intraoperative assessment\u0026ndash;guided selective ligation strategy for segment 5 and/or 8 veins\u0026thinsp;\u0026ge;\u0026thinsp;5 mm affects early graft function in adult right lobe LDLT recipients.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Patient Selection\u003c/h2\u003e \u003cp\u003eThis retrospective cohort study included adult recipients who underwent right lobe living donor liver transplantation without inclusion of the middle hepatic vein between November 2021 and May 2025 at a high-volume transplant center. Patients were eligible if intraoperatively measured segment 5 and/or segment 8 anterior sector drainage veins were \u0026ge;\u0026thinsp;5 mm in diameter.\u003c/p\u003e \u003cp\u003eExclusion criteria were anterior sector veins\u0026thinsp;\u0026lt;\u0026thinsp;5 mm, dominant drainage through a distinct inferior right hepatic vein, left lobe grafts, pediatric recipients, and incomplete perioperative data.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSurgical Strategy and Intraoperative Assessment\u003c/h3\u003e\n\u003cp\u003ePatients were classified into two groups according to intraoperative venous management. In the Reconstruction Group, V5 and/or V8 veins were reconstructed using direct anastomosis or an interposition graft. In the Selective Ligation Group, V5 and/or V8 veins were ligated based on intraoperative functional assessment. One patient who had one anterior sector vein reconstructed and another ligated was assigned to the Selective Ligation Group, as the primary analytical interest was the safety of ligating at least one\u0026thinsp;\u0026ge;\u0026thinsp;5 mm tributary.\u003c/p\u003e \u003cp\u003eThe decision to reconstruct or ligate was not randomized. Reconstruction was preferentially performed in recipients considered at higher risk for venous congestion, including those with marginal graft-to-recipient weight ratio (GRWR) or unfavorable intraoperative perfusion findings. Notably, all recipients with a GRWR\u0026thinsp;\u0026lt;\u0026thinsp;0.8 were managed in the Reconstruction Group, reflecting a deliberate risk-averse strategy. Selective ligation was applied in recipients with adequate graft volume and satisfactory perfusion characteristics.\u003c/p\u003e \u003cp\u003eIntraoperative assessment consisted of macroscopic evaluation of graft color and congestion, venous backflow from anterior sector tributaries, Doppler ultrasonography findings, and portal venous flow characteristics. Donor hepatectomy with preservation of the middle hepatic vein was performed as previously described [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eData Collection and Outcomes\u003c/h3\u003e\n\u003cp\u003eRecipient demographic characteristics, preoperative clinical variables, and operative data were retrospectively collected. Graft-to-recipient weight ratio was calculated using standard methodology.\u003c/p\u003e \u003cp\u003eThe primary endpoints were early graft function parameters on postoperative day 7, including international normalized ratio (INR), total bilirubin level, and ascites volume. Secondary endpoints included operative time, intraoperative blood loss, early postoperative complications, clinically significant ascites (\u0026ge;\u0026thinsp;1000 mL), and early graft dysfunction (INR\u0026thinsp;\u0026gt;\u0026thinsp;1.6). Due to incomplete intraoperative documentation in some cases, operative variables were analyzed only in patients with complete operative data. Postoperative day 7 laboratory and ascites measurements were analyzed only in patients with available follow-up data.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eContinuous variables were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation or median (interquartile range), as appropriate, and compared using the Mann\u0026ndash;Whitney U test. Categorical variables were compared using Fisher\u0026rsquo;s exact test.\u003c/p\u003e \u003cp\u003eGiven the nonrandomized surgical strategy, GRWR was considered a potential confounder. Multivariable linear regression analysis was performed to identify independent predictors of postoperative ascites using logarithmically transformed ascites volume [log(ascites\u0026thinsp;+\u0026thinsp;1)]. The model included ligation status, MELD score, and GRWR as covariates. A prespecified sensitivity analysis was conducted by restricting the cohort to recipients with GRWR\u0026thinsp;\u0026ge;\u0026thinsp;0.8 to control for potential allocation bias related to graft volume. Statistical analyses were performed using SPSS software (version 26.0; IBM Corp., Armonk, NY, USA). A p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePatient Characteristics\u003c/h2\u003e \u003cp\u003eA total of 175 patients were included in the analysis, of whom 159 were assigned to the Reconstruction Group and 16 to the Selective Ligation Group. Baseline demographic and clinical characteristics were comparable between groups, including age, sex distribution, body mass index, MELD score, graft-to-recipient weight ratio, and graft weight (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). All recipients with a GRWR\u0026thinsp;\u0026lt;\u0026thinsp;0.8 (n\u0026thinsp;=\u0026thinsp;20) were managed in the Reconstruction Group.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline Demographic and Clinical Characteristics of the Study Groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelective Ligation Group (n\u0026thinsp;=\u0026thinsp;16)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReconstruction Group (n\u0026thinsp;=\u0026thinsp;159)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53.4\u0026thinsp;\u0026plusmn;\u0026thinsp;11.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51.2\u0026thinsp;\u0026plusmn;\u0026thinsp;14.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.69\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale sex, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (75.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e96 (60.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMELD score, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (11\u0026ndash;24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (10\u0026ndash;20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.7 (n\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.8\u0026thinsp;\u0026plusmn;\u0026thinsp;5.8 (n\u0026thinsp;=\u0026thinsp;126)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.93\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGraft weight (g), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e793\u0026thinsp;\u0026plusmn;\u0026thinsp;104\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e796\u0026thinsp;\u0026plusmn;\u0026thinsp;167\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.95\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGRWR, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.04 (0.94\u0026ndash;1.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.02 (0.89\u0026ndash;1.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.69\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGRWR\u0026thinsp;\u0026lt;\u0026thinsp;0.8, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (12.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eContinuous variables are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation or median (interquartile range). Comparisons were performed using the Mann\u0026ndash;Whitney U test for continuous variables and Fisher\u0026rsquo;s exact test for categorical variables.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eAbbreviations: BMI, body mass index; GRWR, graft-to-recipient weight ratio; IQR, interquartile range; MELD, Model for End-Stage Liver Disease; SD, standard deviation.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eOperative Outcomes\u003c/h3\u003e\n\u003cp\u003eOperative data were available in a subset of patients (Selective Ligation Group, n\u0026thinsp;=\u0026thinsp;5; Reconstruction Group, n\u0026thinsp;=\u0026thinsp;109). Median operative time was numerically lower in the Selective Ligation Group (240 vs 270 minutes; p\u0026thinsp;=\u0026thinsp;0.37), although this difference did not reach statistical significance (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Intraoperative blood loss was also numerically lower in the Selective Ligation Group (median 40 vs 60 mL; p\u0026thinsp;=\u0026thinsp;0.12). Statistical comparison of operative variables was limited by the small number of patients with complete intraoperative documentation in the ligation group (5 of 16; 31.3%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIntraoperative Findings (Subset Analysis: Patients With Complete Operative Data)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelective Ligation Group (n\u0026thinsp;=\u0026thinsp;5)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReconstruction Group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;109)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative time (min), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e277.6\u0026thinsp;\u0026plusmn;\u0026thinsp;100.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e284.0\u0026thinsp;\u0026plusmn;\u0026thinsp;70.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative time (min), median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e240 (230\u0026ndash;263)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e270 (242\u0026ndash;320)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood loss (mL), median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40 (40\u0026ndash;40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60 (50\u0026ndash;350)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eIntraoperative variables were analyzed only in patients with complete operative documentation. Data are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation or median (interquartile range). Comparisons were performed using the Mann\u0026ndash;Whitney U test.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eAbbreviations: IQR, interquartile range; SD, standard deviation.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eEarly Graft Function\u003c/h3\u003e\n\u003cp\u003ePostoperative day 7 data were available in 12 patients in the Selective Ligation Group and 119 patients in the Reconstruction Group for laboratory parameters, and in 11 and 84 patients, respectively, for ascites measurements. Postoperative day 7 graft function parameters are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. There were no statistically significant differences between groups in INR (1.24 vs 1.27; p\u0026thinsp;=\u0026thinsp;0.83), total bilirubin (1.46 vs 1.71 mg/dL; p\u0026thinsp;=\u0026thinsp;0.30), or ascites volume (1100 vs 1245 mL; p\u0026thinsp;=\u0026thinsp;0.88).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEarly Postoperative Outcomes on Postoperative Day 7\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelective Ligation Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReconstruction Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eINR, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.24 (1.21\u0026ndash;1.43) (n\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.27 (1.17\u0026ndash;1.42) (n\u0026thinsp;=\u0026thinsp;119)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.83\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal bilirubin (mg/dL), median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.46 (0.79\u0026ndash;2.46) (n\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.71 (1.20\u0026ndash;3.30) (n\u0026thinsp;=\u0026thinsp;119)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAscites volume (mL), median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1100 (970\u0026ndash;1465) (n\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1245 (590\u0026ndash;2000) (n\u0026thinsp;=\u0026thinsp;84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.88\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinically significant ascites (\u0026ge;\u0026thinsp;1000 mL), n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7/11 (63.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50/84 (59.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEarly graft dysfunction (INR\u0026thinsp;\u0026gt;\u0026thinsp;1.6), n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2/12 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15/119 (12.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny early complication, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2/16 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28/159 (17.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eData are presented as median (interquartile range) or n/N (%). Continuous variables were compared using the Mann\u0026ndash;Whitney U test. Categorical variables were compared using Fisher\u0026rsquo;s exact test. Sample sizes vary according to data availability.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eAbbreviations: INR, international normalized ratio; IQR, interquartile range.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe incidence of clinically significant ascites (\u0026ge;\u0026thinsp;1000 mL) did not differ between the Selective Ligation and Reconstruction groups (63.6% vs 59.5%; p\u0026thinsp;=\u0026thinsp;1.00). Similarly, early graft dysfunction (INR\u0026thinsp;\u0026gt;\u0026thinsp;1.6) was comparable between groups (16.7% vs 12.6%; p\u0026thinsp;=\u0026thinsp;0.66). The overall rate of early postoperative complications was 12.5% in the Selective Ligation Group and 17.6% in the Reconstruction Group (p\u0026thinsp;=\u0026thinsp;1.00).\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eMultivariable Analysis\u003c/h2\u003e \u003cp\u003eMultivariable linear regression analysis using log-transformed postoperative day 7 ascites volume [log(ascites\u0026thinsp;+\u0026thinsp;1)] was performed with ligation status, MELD score, and GRWR as covariates (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Ligation of an anterior sector vein\u0026thinsp;\u0026ge;\u0026thinsp;5 mm was not independently associated with postoperative ascites volume (β\u0026thinsp;=\u0026thinsp;0.214, 95% CI\u0026thinsp;\u0026minus;\u0026thinsp;0.334 to 0.762; p\u0026thinsp;=\u0026thinsp;0.445). MELD score was a significant independent predictor of postoperative ascites (β\u0026thinsp;=\u0026thinsp;0.029, 95% CI 0.007 to 0.052; p\u0026thinsp;=\u0026thinsp;0.012). GRWR was not independently associated with ascites in this model (β = \u0026minus;0.381, 95% CI\u0026thinsp;\u0026minus;\u0026thinsp;1.052 to 0.291; p\u0026thinsp;=\u0026thinsp;0.269).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariable Linear Regression Analysis for Postoperative Day 7 Ascites (Log-Transformed)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eβ Coefficient\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLigation of \u0026ge;\u0026thinsp;5 mm anterior sector vein (yes vs no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.214\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;0.334 to 0.762\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.445\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMELD score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.029\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.007 to 0.052\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.012\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGRWR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;0.381\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;1.052 to 0.291\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.269\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eDependent variable: log-transformed postoperative day 7 ascites volume [log(ascites\u0026thinsp;+\u0026thinsp;1)]. Values represent unstandardized β coefficients derived from multivariable linear regression analysis (n\u0026thinsp;=\u0026thinsp;94).\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eAbbreviations: CI, confidence interval; GRWR, graft-to-recipient weight ratio; MELD, Model for End-Stage Liver Disease.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eSensitivity Analysis: Recipients With GRWR\u0026thinsp;\u0026ge;\u0026thinsp;0.8\u003c/h2\u003e \u003cp\u003eTo address potential allocation bias arising from the exclusive assignment of all GRWR\u0026thinsp;\u0026lt;\u0026thinsp;0.8 recipients to the Reconstruction Group, a prespecified sensitivity analysis was conducted by restricting the cohort to recipients with GRWR\u0026thinsp;\u0026ge;\u0026thinsp;0.8 (n\u0026thinsp;=\u0026thinsp;154; ligation n\u0026thinsp;=\u0026thinsp;16, reconstruction n\u0026thinsp;=\u0026thinsp;138). In this subgroup, postoperative day 7 outcomes remained comparable between groups: INR (1.24 vs 1.27; p\u0026thinsp;=\u0026thinsp;0.80), total bilirubin (1.46 vs 1.60 mg/dL; p\u0026thinsp;=\u0026thinsp;0.38), and ascites volume (1100 vs 1178 mL; p\u0026thinsp;=\u0026thinsp;0.83) (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). The incidence of clinically significant ascites (\u0026ge;\u0026thinsp;1000 mL) was 63.6% in the Selective Ligation Group and 58.3% in the Reconstruction Group (p\u0026thinsp;=\u0026thinsp;1.00). Early graft dysfunction (INR\u0026thinsp;\u0026gt;\u0026thinsp;1.6) occurred in 16.7% and 11.5% of patients, respectively (p\u0026thinsp;=\u0026thinsp;0.64).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSensitivity Analysis: Early Postoperative Outcomes in Recipients With GRWR\u0026thinsp;\u0026ge;\u0026thinsp;0.8\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelective Ligation Group (n\u0026thinsp;=\u0026thinsp;16)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReconstruction Group (n\u0026thinsp;=\u0026thinsp;138)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eINR, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.24 (1.21\u0026ndash;1.42) (n\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.27 (1.17\u0026ndash;1.42) (n\u0026thinsp;=\u0026thinsp;104)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal bilirubin (mg/dL), median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.46 (0.79\u0026ndash;2.46) (n\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.60 (1.15\u0026ndash;3.23) (n\u0026thinsp;=\u0026thinsp;104)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAscites volume (mL), median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1100 (970\u0026ndash;1465) (n\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1178 (559\u0026ndash;2000) (n\u0026thinsp;=\u0026thinsp;72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.83\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinically significant ascites (\u0026ge;\u0026thinsp;1000 mL), n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7/11 (63.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42/72 (58.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEarly graft dysfunction (INR\u0026thinsp;\u0026gt;\u0026thinsp;1.6), n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2/12 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12/104 (11.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eSensitivity analysis restricted to recipients with graft-to-recipient weight ratio\u0026thinsp;\u0026ge;\u0026thinsp;0.8 (n\u0026thinsp;=\u0026thinsp;154). Data are presented as median (interquartile range) or n/N (%). Continuous variables were compared using the Mann\u0026ndash;Whitney U test. Categorical variables were compared using Fisher\u0026rsquo;s exact test.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eAbbreviations: GRWR, graft-to-recipient weight ratio; INR, international normalized ratio; IQR, interquartile range.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMultivariable regression in this restricted cohort confirmed that selective ligation was not independently associated with postoperative ascites (β\u0026thinsp;=\u0026thinsp;0.242, 95% CI\u0026thinsp;\u0026minus;\u0026thinsp;0.326 to 0.810; p\u0026thinsp;=\u0026thinsp;0.407), while MELD score remained the only significant predictor (β\u0026thinsp;=\u0026thinsp;0.036, 95% CI 0.011 to 0.062; p\u0026thinsp;=\u0026thinsp;0.006). These results support the robustness of the primary analysis and suggest that the observed findings are not attributable to confounding by graft volume.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eManagement of anterior sector venous drainage remains a key technical issue in adult right lobe living donor liver transplantation (LDLT). Since early reports advocating reconstruction of segment 5 and 8 veins\u0026thinsp;\u0026ge;\u0026thinsp;5 mm, diameter-based thresholds have been widely incorporated into surgical practice [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Although this approach is considered standard in many centers, the extent to which anatomical diameter alone determines functional necessity remains controversial.\u003c/p\u003e \u003cp\u003eIn the present study, selective ligation of V5/V8 veins\u0026thinsp;\u0026ge;\u0026thinsp;5 mm, when guided by intraoperative functional assessment, did not adversely affect early graft function. Postoperative coagulation parameters, bilirubin levels, and ascites volume were comparable between the reconstruction and ligation groups. Importantly, clinically significant ascites and early graft dysfunction rates were also similar, further supporting the absence of clinically meaningful early impairment. These findings suggest that the clinical relevance of anterior sector veins may depend not only on anatomical size but also on graft volume, portal inflow, intrahepatic collateral circulation, and overall hemodynamic conditions [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eVenous congestion of the anterior sector has been associated with impaired regeneration and early graft dysfunction in right lobe grafts [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. However, several lines of evidence support the capacity for compensatory venous outflow. Ito et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] reported long-term V5 and V8 patency rates as low as 36% and 58%, respectively, following reconstruction, yet without measurable deterioration of graft function. In a landmark study of 253 recipients, Akamatsu et al. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] demonstrated that anterior sector regeneration was significantly impaired when MHV tributaries were sacrificed, but this was compensated by enhanced posterior sector regeneration, resulting in comparable functional recovery and long-term outcomes across surgical strategies. Durairaj et al. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], in a randomized clinical trial, reported that MHV reconstruction improved outcomes particularly in grafts with lower GRWR, highlighting the importance of graft volume in determining the necessity of venous reconstruction. Collectively, these observations indicate the presence of robust compensatory venous outflow pathways and underscore the potential for a more individualized approach to venous management.\u003c/p\u003e \u003cp\u003eOperative complexity is another important consideration. Venous reconstruction requires additional vascular anastomoses, increases procedural demands, and may necessitate the use of interposition grafts such as cryopreserved homologous veins or synthetic conduits [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Although operative data were available only in a subset of patients (n\u0026thinsp;=\u0026thinsp;5 in the ligation group) and did not reach statistical significance, the numerical trend toward shorter operative time observed in the Selective Ligation Group reflects the additional technical burden associated with reconstruction. A recent multicenter randomized trial by Reddy et al. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] demonstrated that single outflow reconstruction techniques reduced warm ischemia time and operative duration compared with dual outflow approaches, further illustrating the clinical relevance of simplifying venous outflow management. Avoiding unnecessary venous reconstruction may therefore improve operative efficiency without compromising early graft function.\u003c/p\u003e \u003cp\u003eThe distribution of graft-to-recipient weight ratio (GRWR) should be interpreted cautiously. All recipients with GRWR\u0026thinsp;\u0026lt;\u0026thinsp;0.8 underwent reconstruction, reflecting a deliberate risk-averse strategy rather than random allocation. Selective ligation was preferentially applied in recipients with adequate graft volume and favorable intraoperative perfusion findings. The importance of graft volume and portal inflow modulation in preventing small-for-size physiology is well established [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. To address this potential allocation bias, a prespecified sensitivity analysis restricted to recipients with GRWR\u0026thinsp;\u0026ge;\u0026thinsp;0.8 was performed. In this more homogeneous subgroup, selective ligation remained non-significant as a predictor of postoperative ascites, confirming the robustness of the primary findings. Accordingly, our results support a risk-stratified approach rather than routine ligation.\u003c/p\u003e \u003cp\u003eMultivariable analysis demonstrated that ligation of anterior sector veins\u0026thinsp;\u0026ge;\u0026thinsp;5 mm was not independently associated with postoperative ascites after adjusting for MELD score and GRWR (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). MELD score emerged as the principal independent predictor of postoperative ascites. Ascites formation after liver transplantation is multifactorial and closely related to recipient disease severity and portal hemodynamics [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Within this broader physiological framework, the isolated impact of anterior sector venous strategy may be less decisive than traditionally assumed.\u003c/p\u003e \u003cp\u003eThis study has several limitations. First, the retrospective and nonrandomized design may introduce selection bias. In particular, recipients with GRWR\u0026thinsp;\u0026lt;\u0026thinsp;0.8 were preferentially managed with venous reconstruction, which may have influenced group allocation. Although GRWR was included in multivariable analysis and a sensitivity analysis restricted to GRWR\u0026thinsp;\u0026ge;\u0026thinsp;0.8 recipients was performed, residual confounding cannot be entirely excluded. Second, operative variables and postoperative day 7 outcome data were available only in patients with complete documentation (operative data in 31.3% of the ligation group), which may limit the generalizability of intraoperative and early outcome findings. Third, the relatively small number of patients in the ligation group (n\u0026thinsp;=\u0026thinsp;16) limits statistical power for detecting small differences in outcomes; the absence of statistically significant differences should not be equated with proof of equivalence. Future adequately powered prospective studies are needed to confirm these observations. Fourth, only early graft function was evaluated; long-term outcomes including graft survival, anterior sector regeneration patterns, and venous patency rates remain to be assessed. Finally, multiple endpoints were analyzed without formal adjustment for multiple comparisons, which should be considered when interpreting borderline results.\u003c/p\u003e \u003cp\u003eOverall, our results suggest that routine reconstruction of all anterior sector drainage veins\u0026thinsp;\u0026ge;\u0026thinsp;5 mm may not be universally required in adult right lobe LDLT. An individualized strategy incorporating graft volume assessment and intraoperative hemodynamic evaluation may safely guide venous management without compromising early graft function.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eSelective ligation of segment 5 and/or segment 8 veins\u0026thinsp;\u0026ge;\u0026thinsp;5 mm in adult right lobe living donor liver transplantation was not associated with impaired early graft function when guided by intraoperative functional assessment. Despite preferential reconstruction in recipients with lower graft-to-recipient weight ratio, both primary multivariable analysis and sensitivity analysis restricted to recipients with GRWR\u0026thinsp;\u0026ge;\u0026thinsp;0.8 did not demonstrate an independent adverse effect of selective ligation on postoperative ascites.\u003c/p\u003e \u003cp\u003eThese findings suggest that routine reconstruction of all anterior sector veins\u0026thinsp;\u0026ge;\u0026thinsp;5 mm may not be mandatory in carefully selected recipients with adequate graft volume and satisfactory intraoperative perfusion. Further prospective studies with larger sample sizes are warranted to confirm these observations and evaluate long-term outcomes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBMI: body mass index; CI: confidence interval; GRWR: graft-to-recipient weight ratio; INR: international normalized ratio; IQR: interquartile range; LDLT: living donor liver transplantation; MELD: Model for End-Stage Liver Disease; MHV: middle hepatic vein; SD: standard deviation; SPSS: Statistical Package for the Social Sciences.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Istanbul Aydin University Ethics Committee (Approval No: 121/2024). All procedures were performed in accordance with the ethical standards of the institutional and/or national research committee and with the Declaration of Helsinki. Written informed consent was obtained from all participants as part of the institutional transplantation consent process.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the corresponding author upon reasonable request. Due to the inclusion of patient-related clinical data, the dataset is not publicly available.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no funding for this study.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFST and ES contributed to the study conception and design, data collection and analysis, manuscript drafting, and critical revision. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eChen CL, Kabiling CS, Concejero AM. Why living donor liver transplantation? J Gastroenterol Hepatol. 2012;27:403-407.\u003c/li\u003e\n\u003cli\u003eTanaka K, Ogura Y. Small-for-size graft and small-for-size syndrome in living donor liver transplantation. Yonsei Med J. 2004;45:1089-1094.\u003c/li\u003e\n\u003cli\u003eLee SG, Park KM, Hwang S, et al. Anterior segment congestion of a right liver lobe graft in living-donor liver transplantation and strategy to prevent congestion. J Hepatobiliary Pancreat Surg. 2003;10:16-25.\u003c/li\u003e\n\u003cli\u003ePravisani R, Soyama A, Takatsuki M, et al. Relationship between venous drainage patterns and regeneration of segments 5 and 8 in right lobe grafts in adult living-donor liver transplant recipients. Exp Clin Transplant. 2019;17:529-535.\u003c/li\u003e\n\u003cli\u003eFan ST, Lo CM, Liu CL, Yong BH, Wong J. Determinants of hospital mortality of adult recipients of right lobe live donor liver transplantation. Ann Surg. 2003;238:864-869.\u003c/li\u003e\n\u003cli\u003eGuo HJ, Wang K, Chen KC, et al. Middle hepatic vein reconstruction in adult right lobe living donor liver transplantation improves recipient survival. Hepatobiliary Pancreat Dis Int. 2019;18:125-131.\u003c/li\u003e\n\u003cli\u003eAkamatsu N, Sugawara Y, Nagata R, et al. Adult right living-donor liver transplantation with special reference to reconstruction of the middle hepatic vein. Am J Transplant. 2014;14:2777-2787.\u003c/li\u003e\n\u003cli\u003eIto K, Akamatsu N, Tani K, et al. Reconstruction of hepatic venous tributary in right liver living donor liver transplantation: the importance of the inferior right hepatic vein. Liver Transpl. 2016;22:410-419.\u003c/li\u003e\n\u003cli\u003eDurairaj MS, Mathew JS, Mallick S, et al. Middle hepatic vein reconstruction in adult living donor liver transplantation: a randomized clinical trial. Br J Surg. 2021;108:1426-1432.\u003c/li\u003e\n\u003cli\u003eTroisi R, Cammu G, Militerno G, et al. Modulation of portal graft inflow: a necessity in adult living-donor liver transplantation? Ann Surg. 2003;237:429-436.\u003c/li\u003e\n\u003cli\u003eMarcos A, Ham JM, Fisher RA, Olzinski AT, Posner MP. Single-center analysis of the first 40 adult-to-adult living donor liver transplants using the right lobe. Liver Transpl. 2000;6:296-301.\u003c/li\u003e\n\u003cli\u003eJeng LB, Thorat A, Yang HR, Li PC. Venous outflow reconstruction in living donor liver transplantation: dealing with venous anomalies. World J Transplant. 2015;5:145-153.\u003c/li\u003e\n\u003cli\u003eYu PF, Wu J, Zheng SS. Management of the middle hepatic vein and its tributaries in right lobe living donor liver transplantation. Hepatobiliary Pancreat Dis Int. 2007;6:358-363.\u003c/li\u003e\n\u003cli\u003eIkegami T, Onda S, Furukawa K, et al. Small-for-size graft, small-for-size syndrome and inflow modulation in living donor liver transplantation. J Hepatobiliary Pancreat Sci. 2020;27:799-809.\u003c/li\u003e\n\u003cli\u003eSugawara Y, Makuuchi M. Small-for-size graft problems in adult-to-adult living-donor liver transplantation. Transplantation. 2003;75(Suppl 3):S20-S22.\u003c/li\u003e\n\u003cli\u003eBalci D, Kirimker EO. Hepatic vein in living donor liver transplantation. Hepatobiliary Pancreat Dis Int. 2020;19:318-323.\u003c/li\u003e\n\u003cli\u003eCampsen J, Hendrickson RJ, Zimmerman MA, et al. Adult right-lobe live donor liver transplantation without reconstruction of the middle hepatic vein: a single-center study of 109 cases. Transplantation. 2008;85:775-777.\u003c/li\u003e\n\u003cli\u003eKilercik H, Akbulut S, Elsarawy A, et al. Effect of complex venous outflow drainage reconstruction on postoperative graft function in right-lobe living donor liver transplantation. J Clin Med. 2025;14:2005.\u003c/li\u003e\n\u003cli\u003eReddy MS, Koneti AJ, Chaudhary A, et al. Multicenter randomised controlled trial of single versus double venous outflow reconstruction in right lobe living donor liver transplantation: Venous Outflow in Liver Transplantation Trial. Ann Surg. 2025;281:911-920.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"living donor liver transplantation, right lobe graft, middle hepatic vein, venous outflow, segment veins, selective ligation, graft function","lastPublishedDoi":"10.21203/rs.3.rs-9042712/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9042712/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eReconstruction of segment 5 and/or segment 8 anterior sector veins ≥5 mm is commonly recommended in adult right lobe living donor liver transplantation to prevent venous congestion. However, the necessity of routine reconstruction remains controversial.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this retrospective cohort study, adult recipients who underwent right lobe living donor liver transplantation without inclusion of the middle hepatic vein at a high-volume transplant center between November 2021 and May 2025 were analyzed. Patients with intraoperatively measured segment 5 and/or segment 8 veins ≥5 mm were included. Venous management was determined intraoperatively and was not randomized. Patients underwent either venous reconstruction or selective ligation based on functional graft assessment. Early graft function on postoperative day 7 was evaluated using international normalized ratio, total bilirubin, and ascites volume. Multivariable linear regression analysis was performed to adjust for potential confounders, including graft-to-recipient weight ratio (GRWR) and Model for End-Stage Liver Disease (MELD) score.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 175 recipients were included (16 in the selective ligation group and 159 in the reconstruction group). Baseline demographic and clinical characteristics were comparable between groups. Early graft function parameters on postoperative day 7 did not differ significantly between groups for international normalized ratio (1.24 vs 1.27; p = 0.83), total bilirubin (1.46 vs 1.71 mg/dL; p = 0.30), or ascites volume (1100 vs 1245 mL; p = 0.88). In multivariable analysis adjusting for GRWR and MELD score, selective ligation was not independently associated with increased postoperative ascites (β = 0.214; 95% CI −0.334 to 0.762; p = 0.445). In a sensitivity analysis restricted to recipients with GRWR ≥0.8, results remained consistent (β = 0.242; p = 0.407).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSelective ligation of segment 5 and/or segment 8 veins ≥5 mm, when guided by intraoperative functional assessment, was not associated with impaired early graft function. Routine reconstruction of all anterior sector veins ≥5 mm may not be mandatory in carefully selected recipients with adequate graft volume and satisfactory perfusion.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number: \u003c/strong\u003enot applicable.\u003c/p\u003e","manuscriptTitle":"Early Graft Function After Intraoperative Assessment–Guided Selective Ligation of Segment 5/8 Veins in Adult Right Lobe Living Donor Liver Transplantation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-12 11:18:13","doi":"10.21203/rs.3.rs-9042712/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-08T17:54:36+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-24T18:10:11+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-24T16:35:36+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-23T18:51:44+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-23T15:43:14+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-21T03:28:27+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-19T03:26:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"239365286410902944319676694300941232997","date":"2026-04-17T18:17:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"51181963581874486764758715261961490912","date":"2026-04-17T17:05:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"110326621145482855656780960202152511056","date":"2026-04-16T19:27:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"136975970004653235211193524545653537594","date":"2026-04-16T06:22:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"57970853411282133603314333111752903338","date":"2026-04-16T01:55:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"10815207225686798791853877032377159059","date":"2026-04-15T17:30:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"174452444883222259828739548785890496337","date":"2026-04-13T14:47:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"246914523360035844182912765545355884666","date":"2026-04-10T09:11:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"315582955057322392813559681391829840150","date":"2026-04-08T12:14:20+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-08T11:30:16+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-10T11:49:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-10T04:46:25+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-10T04:45:24+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2026-03-05T16:43:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d8b37ab1-4562-4e97-ab37-be3cb9e457d8","owner":[],"postedDate":"March 12th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-08T17:54:36+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-08T18:08:51+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-12 11:18:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9042712","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9042712","identity":"rs-9042712","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}