Liver function impairment in liver transplantation and after extended hepatectomy

Abstract

Extended hepatectomy, or liver transplantation of reduced-size graft, can lead to a pattern of clinical manifestations, namely “post-hepatectomy liver failure” and “small-for-size syndrome” respectively, that can range from mild cholestasis to irreversible organ non-function and death of the patient. Many mechanisms are involved in their occurrence but in the recent past, high portal blood flow through a relatively small liver vascular bed has taken a central role. Therefore, several techniques of inflow modulation have been attempted in cases of portal hyperperfusion first in liver transplantation, such as portocaval shunt, mesocaval shunt, splenorenal shunt, splenectomy or ligation of the splenic artery. However, high portal flow is not the only factor responsible, and before major liver resections, preoperative assessment of the residual liver function is necessary. Techniques such as portal vein embolization or portal vein ligation can be adopted to increase the future liver volume, preventing post-hepatectomy liver failure. More recently, a new surgical procedure, that combines in situ splitting of the liver and portal vein ligation, has gradually come to light, inducing remarkable hypertrophy of the healthy liver in just a few days. Further studies are needed to confirm this hypothesis and overcome one of the biggest issues in the field of liver surgery.

Keywords: Small-for-size syndrome; Liver transplantation; Extended hepatectomy; Liver failure; Cirrhosis

Core tip: In this review we focus on the small-for-size syndrome and post-hepatectomy liver failure, the most feared complications of liver surgery, fundamentally similar in pathogenesis and clinical manifestations, occurring when the residual liver is not large enough to accommodate the markedly increased portal vein blood flow. Our aim is to simplify a concept, which has been a major concern in hepatic surgery for some time. Many efforts have been and are being made to overcome such an important problem in this field.