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This case report describes an obese patient with chronic liver disease classified as Child-Pugh class C who underwent dual-lobe LDLT because the calculated graft-to-recipient weight ratio with a single right-lobe graft was only 0.54. Modified donor selection and implantation technique were used, prioritizing the number of bile ducts, while coordinating cold and warm ischemia times to remain manageable. A postoperative low-output bile leakage resolved 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was dual-lobe living-donor liver transplantation chosen for this patient?","Question",{"text":63,"@type":64},"A single-lobe graft posed a high risk of small-for-size syndrome because the graft-to-recipient weight ratio was calculated as only 0.54, below accepted thresholds for adequate function.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"How were grafts selected in the dual-lobe approach described?",{"text":68,"@type":64},"Graft selection criteria were adjusted from standard protocols, with priority given to the number of bile ducts, and the right lobes from both donors had nearly equal volumes.",{"name":70,"@type":61,"acceptedAnswer":71},"What complication occurred after the procedure, and how was it managed?",{"text":72,"@type":64},"The patient experienced low-output bile leakage, which resolved spontaneously without further intervention described in the report text 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[https://doi.org/10.4285/ctr.25.0013](https://doi.org/10.4285/ctr.25.0013)  \npISSN 3022-6783 eISSN 3022-7712  \nReceived February 12, 2025  \nRevised May 16, 2025  \nAccepted June 4, 2025  \nCorresponding author:  \nBhabani Sankar Sahoo  \nLiver and Digestive Disease Institute, R-block, B22, Sector 62, Noida 201301, India  \nE-mail: [bhabani.sankar87@gmail.com](bhabani.sankar87@gmail.com)  \n© The Korean Society for Transplantation This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ([http://creativecommons.org/licenses/](http://creativecommons.org/licenses/)[ ](http://creativecommons.org/licenses/)[by-nc/4.0/](by-nc/4.0/)) [which](which) permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.  \nA dual-lobe strategy in living-donor liver transplantation: overcoming small-for-size graft limitations in an obese patient:  \na case report  \nBhabani Sankar Sahoo, Kausar Makki, Yogesh Yadav, Tathagata Karan, Piyush Srivastava, Vivek Vij  \nLiver and Digestive Disease Institute, Fortis Hospital, Noida, India  \nThe primary goal of living donor liver transplantation (LDLT) is to optimize outcomes for the recipient while ensuring donor safety. However, there is a risk of small-for-size syndrome, particularly in obese patients, where graft weight might be inadequate. In such scenarios, dual-lobe LDLT represents a more viable alternative. Although ethical concerns exist regarding potential risks posed to two healthy donors, this method maybe most appropriate when deceased donor grafts are unavailable. Here, we describe a case involving an obese patient classified as Child-Pugh class C with chronic liver disease who underwent dual-lobe LDLT. The criteria for selecting the right lobe graft differed slightly from standard protocols, as did the implantation technique. The patient experienced low-output bile leakage, which resolved spontaneously. Priority in graftselection was given to the number of bile ducts, as the right lobes of both donors had nearly equal volumes. Despite simultaneous implantation, cold and warm ischemia times remained manageable due to effective coordination. Although the literature suggests a higher incidence of vascular and biliary complications in dual-lobe LDLT than in single-lobe procedures, these risks can be mitigated by careful planning and coordination.  \nKeywords: Small for size syndrome; Living donor liver transplantation; Graft-to-recipient weight ratio; Case report  \nINTRODUCTION  \nThe liver graft volume is critical for survival in living donor liver transplantation (LDLT) . Introduced in 1999, grafts with a graft-to-recipient weight ratio (GRWR) of \u003C0 .8 ora volume \u003C40% of standard liver volume are considered small-for-size grafts (SFSGs) . When SFSGs are insufficient to meet functional requirements, recipients may develop small-for-size syndrome (SFSS) [1,2] . The incidence  \nof SFSS following LDLT is approximately 20%[3] . LDLT is the predominant method of liver transplantation in India, yet some patients remain unable to receive transplants due to unsuitable donors. One particularly affected group is obese patients [4] . Dual-lobe LDLT offers a promising alternative for obese patients with end-stage liver disease. This technique, which involves partial liver grafts from two donors, utilizes the regenerative capacity of the liver and can significantly enhance the recipient's quality  \n[www.ctrjournal.org](www.ctrjournal.org) 389  \nClin Transplant Res · December  \n2025 · Volume 39 · Issue 4  \nHIGHLIGHTS  \n• Dual-lobe living donor liver transplantation (LDLT) is a known technique to overcome small-for-size syndrome, and graft selection is a very important part.  \n• The number of bile ducts can be prioritized in graft selection.  \n• With proper coordination, dual-lobe LDLT can be performed safely at a high-volume center.  \nof l","cbCaiifLpJUzHFih","https://ap.wps.com/l/cbCaiifLpJUzHFih","pdf",12434621,"English","# Introduction\n# Highlights\n# Case report","[{\"question\":\"Why was dual-lobe living-donor liver transplantation chosen for this patient?\",\"answer\":\"A single-lobe graft posed a high risk of small-for-size syndrome because the graft-to-recipient weight ratio was calculated as only 0.54, below accepted thresholds for adequate function.\"},{\"question\":\"How were grafts selected in the dual-lobe approach described?\",\"answer\":\"Graft selection criteria were adjusted from standard protocols, with priority given to the number of bile ducts, and the right lobes from both donors had nearly equal volumes.\"},{\"question\":\"What complication occurred after the procedure, and how was it managed?\",\"answer\":\"The patient experienced low-output bile leakage, which resolved spontaneously without further intervention described in the report text provided.\"}]","A dual-lobe strategy in living-donor liver transplantation - overcoming small-for-size graft limitations in an obese patient: a case report | PDF",1790756070,18]