First report of successful liver transplantation following supermicrosurgical lymphaticovenous anastomoses for lymphorrhea with intractable infection: A case report

BACKGROUND Liver transplant (LT) candidates face a heightened risk of infection both pre- and post-transplant, owing to immunosuppressive therapy and complications from chronic liver disease. Infections during the pre-transplant period, such as lymphorrhea-induced cellulitis, can cause significant delays in transplantation and increase mortality while on the waiting list. Lymphorrhea, characterized by substantial lymphatic leakage and recurrent skin infections, presents a significant challenge in managing patients who are already immunocompromised. Effective preoperative infection control is critical to enhancing the prospects for a successful liver transplantation. CASE SUMMARY We report the case of a 50-year-old female diagnosed with Hepatitis C virus-related cirrhosis (Child-Pugh C) and recurrent cellulitis due to lymphorrhea in her left lower leg. She suffered repeated episodes of cellulitis over five years, which prevented her from undergoing LT. Initial conservative treatments were unsuccessful in managing the lymphatic leakage and accompanying infections. In February 2019, she underwent supermicrosurgical lymphaticovenous anastomoses (LVA) to address her lymphorrhea. This procedure, which created multiple lymphatic-venous connections in the lower limb, led to significant improvements in her condition. After the LVA, she experienced no further episodes of cellulitis. Eighteen months later, she successfully underwent a deceased donor liver transplantation. Postoperative complications, including a wound hematoma, were effectively managed, and she was discharged 3 months post-operation. At her 3-year follow-up, her liver function was stable, with no recurrence of cellulitis. CONCLUSION Despite numerous challenges, the patient achieved a successful recovery with satisfactory graft function and was free from lymphorrhea/lymphedema in her left lower limb 3 years post-transplantation. This case underscores the importance of robust infection control during both the pre- and post-transplantation phases and highlights the potential of LVA as a treatment option for managing lymphorrhea and infections in patients with liver cirrhosis.