The small-for-size syndrome in living donor liver transplantation: current management

Small-for-size syndrome poses a significant challenge in living donor liver transplantation, with potentially severe consequences including liver failure and death. This review explores the management strategies for SFSS, starting from the pathophysiology of the disease. SFSS arises from insufficient liver mass in the graft and hyperdynamic circulation in cirrhotic recipients, leading to portal hyperperfusion and subsequent liver injury. Risk factors include graft size, quality, recipient factors, and hemodynamic changes during transplantation.Hemodynamic monitoring is crucial during living donor liver transplantation to optimize portal vein and hepatic artery flow. Prevention strategies focus on donor-recipient matching and intraoperative graft inflow modulation. Optimizing venous outflow and avoiding portal hyperperfusion is essential. Management of established small-for-size syndrome involves supportive care, pharmacologic interventions, and radiological and surgical options. Pharmacotherapy includes somatostatin analogues, beta-blockers, and vasopressin analogues to reduce portal flow and pressure. Surgical interventions aim to modulate portal flow and mitigate complications. Retransplantation may be necessary in severe cases, guided by persistent graft dysfunction despite liver flow modulations. In conclusion, preventing and managing small-for-size syndrome in living donor liver transplantation requires comprehensive assessment and tailored interventions. Advancements in graft/recipient matching, hemodynamic monitoring, pharmacologic and surgical techniques aiming to inflow modulation have improved outcomes, enabling successful transplantation even with ultra-small grafts.