title: Successful treatment of small-for-size syndrome in adult-to-adult living-related liver transplantation: single center series.
abstract: The portal hyperperfusion, or small-for-size syndrome (SFSS), is a widely recognized clinical complication that may occur after segmental liver transplantation. Several surgical strategies have been proposed to reduce portal blood inflow and portal pressure after partial liver transplantation. In particular, splenic artery ligation and splenectomy have been used without a firm hemodynamic basis for these procedures. Our group recently demonstrated that, in patients with cirrhosis and portal hypertension, the occlusion of the splenic artery causes a significant reduction in the portal pressure gradient, which is directly related to the spleen volume and indirectly related to the liver volume. This concept is at the center of our strategy for performing early splenic artery embolization (SAE) for the treatment of SFSS after living-related liver transplantation (LRLT). Six patients developed small-for-size syndrome, defined as: onset within the first week after LRLT of progressive hyperbilirubinemia without mechanical cause; marked cholestasis; centrilobular sinusoidal dilatation and hepatocyte atrophy at liver biopsy; and refractory ascites in the absence of vascular complications. All six patients who underwent SAE rapidly improved their clinical condition, with an evident decrease in the value of bilirubin in the serum, in the production of ascites, and improvement in condition of pancytopenia. Coagulopathy expressed by the international normalized ratio value (INR) was not a reliable early marker of SFSS in this series; in fact a slight improvement in the result of this test was already present immediately after LRLT and before SAE. Because splenic flow clearly contributes to portal hyperperfusion, an early SAE can relieve the partial graft from the deleterious effect of this portal overflow.
authors.affiliation: Istituto Mediterraneo Trapianti e Terapie ad Alta Specializzazione, University of Pittsburgh Medical Center in Italy, Palermo, Italy. sgruttadauria@ismett.edu
authors.forename: Salvatore
authors.initials: S
authors.lastname: Gruttadauria
authors.forename: Lucio
authors.initials: L
authors.lastname: Mandala'
authors.forename: Roberto
authors.initials: R
authors.lastname: Miraglia
authors.forename: Settimo
authors.initials: S
authors.lastname: Caruso
authors.forename: Marta Ida
authors.initials: MI
authors.lastname: Minervini
authors.forename: Domenico
authors.initials: D
authors.lastname: Biondo
authors.forename: Riccardo
authors.initials: R
authors.lastname: Volpes
authors.forename: Giovanni
authors.initials: G
authors.lastname: Vizzini
authors.forename: J Wallis
authors.initials: JW
authors.lastname: Marsh
authors.forename: Angelo
authors.initials: A
authors.lastname: Luca
authors.forename: Amadeo
authors.initials: A
authors.lastname: Marcos
authors.forename: Bruno
authors.initials: B
authors.lastname: Gridelli
mesh_terms: D000328:Adult; D000714:Anastomosis, Surgical / Q000009:adverse effects; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D006975:Hypertension, Portal / Q000209:etiology* / Q000503:physiopathology / Q000601:surgery; D008026:Ligation / Q000379:methods; D008099:Liver / Q000033:anatomy & histology*; D016031:Liver Transplantation / Q000009:adverse effects*; D019520:Living Donors; D008297:Male; D008875:Middle Aged; D009929:Organ Size; D017082:Portal Pressure / Q000502:physiology; D011183:Postoperative Complications; D011379:Prognosis; D012189:Retrospective Studies; D013157:Splenic Artery / Q000601:surgery; D013577:Syndrome