Small for size syndrome (liver graft)

Last revised by Joshua Yap on 7 Sep 2022

Small for size syndrome (SFSS) is a clinical syndrome caused by the transplantation of a liver graft that is too small for a recipient. It occurs when the graft to recipient weight ratio (GRWR) is less than 0.8% or a graft volume to standard liver volume ratio (GV/SLV) is less than 35%.

Clinical presentation includes many non-specific signs and symptoms including:

  • persistent elevation of bilirubin level
  • large amount of ascites in early post-operative period
  • coagulopathy
  • gastrointestinal bleeding
  • encephalopathy and renal failure in severe cases

The small for size syndrome occurs due to an imbalance between rapid liver regeneration and increased demand of liver to perform its function. It is believed to be related to both factors in the donor graft and recipient, listed below.

  • high portal inflow
  • low venous outflow
  • pre-existing steatosis in the donor graft
  • advanced donor age
  • warm and cold ischemia times
  • severe preoperative end-stage liver disease
  • poor health status

The literature suggests that controlling graft inflow and outflow is beneficial.

This control can be accomplished in several ways:

  • control adequate portal inflow by several methods e.g. splenectomy, splenic artery embolization, splenic artery ligation, mesocaval or portocaval shunts
  • control hepatic vein outflow by preservation of any short hepatic vein >0.5 cm and anastomosing it with inferior vena cava

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