Ewha Med J.  2022 Apr;45(2):29-34. 10.12771/emj.2022.45.2.29.

Prevention and Management of Small-for-Size Syndrome of Liver Transplantation

• Yi NJ

• KMID: 2529433
• DOI: http://doi.org/10.12771/emj.2022.45.2.29

Abstract

Small-for-size syndrome (SFSS) is a critical complication of partial liver transplantation, particularly in adult-to-adult living donor liver transplantation (ALDLT) using a small graft. Minimally required liver graft size for a successful ALDLT is classically 40% of a standard recipient’s liver volume or 0.8% of recipient body weight. Recent progress in perioperative care and technical improvement push the lower limit of safe graft size to 25% of the recipient’s standard liver volume or 0.6% of the graft versus recipient weight ratio although this is an ongoing debate. The clinical manifestations of SFSS include various symptoms and signs related to graft dysfunction and portal hypertension in patients with small grafts. The risk factors for SFSS include poor preoperative patient condition, including portal pressure, surgical techniques to reduce portal pressure, and graft quality and size. Hence, various approaches have been explored to modulate inflow and pressure to a small graft and to decrease the outflow block to alleviate this SFSS as well as the selection of a patient and graft. Additionally, recent research and efforts to prevent and treat SFSS are reviewed.

Keyword

Graft failure; Graft versus recipient weight ratio; Living donor liver transplantation; Small-for-size syndrome

Figure

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  Fig. 1. A small partial graft during adult-to-adult living donor liver transplantation. The patient has undergone a small right liver graft with a 0.7% graft-versus-recipient weight ratio.

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  Fig. 2. Auxiliary partial orthotopic liver transplantation to prevent the small-for-size syndrome. A 36-yr-old patient with Wilson’s disease has undergone living-donor liver transplantation from a 54-yr-old mother using a right posterior section graft. The graft-versus-recipient weight ratio is 0.64%. He has undergone a native liver hepatectomy 11 mo after transplantation. (A) A preoperative recipient computed tomography (CT) scan. (B) A CT scan of postoperative day 9. (C) A CT scan of postoperative 11 mo.

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  Fig. 3. Post-transplant splenic arterial embolization to reduce portal hypertension. A 40-yr-old woman with hepatitis B-related liver cirrhosis with the hepatorenal syndrome and uncontrolled ascites underwent living-donor liver transplantation from his 35-yr-old wife using a right liver graft. He underwent gastrorenal shunt occlusion before transplantation to control variceal bleeding and encephalopathy. One mo after transplantation, the patient underwent partial occlusion of the splenic artery because of uncontrolled ascites related to small-for-size syndrome (arrow, material for gastrorenal shunt occlusion). (A) A preoperative recipient computed tomography (CT) scan. (B) A CT scan of postoperative day 7. (C) A CT scan 2 yrs after transplantation.

Reference

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