A systematic review of small for size syndrome after major hepatectomy and liver transplantation

Abstract

Background: Major hepatectomy (MH) and particular types of liver transplantation (LT) (reduced size graft, living-donor and split-liver transplantation) lead to a reduction in liver mass. As the portal venous return remains the same it results in a reciprocal and proportionate rise in portal venous pressure potentially resulting in small for size syndrome (SFSS). The aim of this study was to review the incidence, diagnosis and management of SFSS amongst recipients of LT and MH.Methods: A systematic review was performed in accordance with the 2010 Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. The following terms were used to search PubMed, Embase and Cochrane Library in July 2019: ("major hepatectomy" or "liver resection" or "liver transplantation") AND ("small for size syndrome" or "post hepatectomy liver failure"). The primary outcome was a diagnosis of SFSS.Results: Twenty-four articles met the inclusion criteria and could be included in this review. In total 2728 patients were included of whom 316 (12%) patients met criteria for SFSS or post hepatectomy liver failure (PHLF). Of these, 31 (10%) fulfilled criteria for PHLF following MH. 8 of these patients developed intractable ascites alongside elevated portal venous pressure following MH indicative of SFSS. Conclusion: SFSS is under-recognised following major hepatectomy and should be considered as an underlying cause of PHLF. Surgical and pharmacological therapies are available to reduce portal congestion and reverse SFSS.

Analysis of factors associated with discrepancies between predicted and observed liver weight in liver transplantation

“…The scenarios of inappropriate matching, such as a small-or large-sized recipients receiving a larger or smaller liver graft, have been associated with 90-day mortality rates up to 40%. 7 These high rates of mortality might be explained by mechanical and physiological factors: (a) direct compression by nearby structures of a large liver with vascular hypo-perfusion in case of a large-for-size LT and (b) vascular hyper-perfusion of a small graft in case of a small-for-size LT. 4,5 The margin of error in this study was chosen as ≥20%, which could have a different TA B L E 5 Analyses of factors associated with liver weight underestimation and overestimation after propensity score matching of individuals (1 vs 3) with similar anthropometrics or a 24% increase has been shown to impact graft survival mainly due to an increased incidence of primary non-function and acute rejection. 3 However, successful LT has been reported in women of small stature despite BSAi > 1.24 in a large study on the UNOS database.…”

“…[1][2][3] Transplantation of extremely small-or large-weight livers in recipients who are not appropriately matched with the donors has been associated with reduced graft and recipient survival. 4,5 In the field of living-donor liver transplantation and liver resection, accurate determination of liver volumes are rapidly obtained by using computed-tomography (CT)-based segmentation systems. 6 For adult LT, volumetric assessment of livers from brain-dead donors is rarely done for several reasons: (a) the large availability of donors with different anthropometric characteristics, (b) greater compliance of the abdominal cavity in adults, (c) limited amount of time available to select donors, and (d) restricted availability of segmentation software in all hospitals practicing organ procurements.…”

“…Even if heterogeneously defined, however, the so-called "small-forsize" and "large-for-size" syndromes have been recently described in adults and are characterized by both reduced graft and patient survival. [3][4][5]7 Currently, the choice of a potential liver graft relies on a donor's clinical data and anthropometric characteristics that are "virtually" matched by surgeons with the corresponding characteristics of a given recipient. Several formulas predicting hepatic weight or volume based on anthropometric characteristics have been proposed as shown in Table 1.…”

Effect of pre‐transplant sarcopenia on the estimation of standard liver volume in living‐donor liver transplant candidates: risk factor for post‐transplant small‐for‐size syndrome? A retrospective study

“…To investigate the prevalence of small‐for‐size syndrome (SFSS) after LT, the two most frequently reported definitions were used [12]: Dahm et al . [13] definition: presence of two of the following on 3 consecutive days after exclusion of any vascular or biliary complication as well as any infection or episode of rejection: bilirubin >100 µmol/l (5.85 mg/dl), international normalized ratio (INR) > 2, encephalopathy grade 3 or 4, during the first postoperative week; Kyushu [14] definition: presence of both total bilirubin >10 mg/dl at postoperative day 14 without any other definitive cause for cholestasis and a daily production of ascites of >1000 ml at postoperative day (POD) 14, or > 500 ml at POD 28. …”

Livers From Pediatric Donation After Circulatory Death Donors Represent a Viable and Underutilized Source of Allograft

“…These outcomes are attributed to mechanical and functional consequences of size mismatch, including HAT and small-for-size syndrome, which is an inability of the donor liver to meet the physiologic demands of the recipient. (29)(30)(31)(32)(33) This phenomenon is exacerbated by recipient portal venous hypertension, which has been shown to cause hepatic arterial hypoperfusion through the compensatory hepatic artery buffer response. (34) Although variable rates are reported, the risk of HAT is increased in recipients of smaller organs with a reported incidence of 3.6% in adult recipients of pediatric livers versus 1.9% in adult-to-adult transplantation.…”