Retrospective Cohort Study
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Jul 28, 2017; 9(21): 930-944
Published online Jul 28, 2017. doi: 10.4254/wjh.v9.i21.930
Small for size syndrome difficult dilemma: Lessons from 10 years single centre experience in living donor liver transplantation
Hany Shoreem, Emad Hamdy Gad, Hosam Soliman, Osama Hegazy, Sherif Saleh, Hazem Zakaria, Eslam Ayoub, Yasmin Kamel, Kalid Abouelella, Tarek Ibrahim, Ibrahim Marawan
Hany Shoreem, Emad Hamdy Gad, Hosam Soliman, Osama Hegazy, Sherif Saleh, Hazem Zakaria, Eslam Ayoub, Kalid Abouelella, Tarek Ibrahim, Ibrahim Marawan, Hepatobiliary Surgery Department, National Liver Institute, Menoufiya University, Shibin El-Koum 32817, Egypt
Yasmin Kamel, Anesthesia Department, National Liver Institute, Menoufiya University, Shibin El-Koum 32817, Egypt
Author contributions: Forms of support received by each author for this study included good selection of cases, instructive supervision, continuous guidance, valuable suggestions and good instructions. Furthermore, the authors of the manuscript shared in its data collection, writing, and publication; moreover, the corresponding author did statistical analysis as well.
Institutional review board statement: The study was reviewed and approved for publication by our institutional reviewers.
Informed consent statement: The data were collected from our records in the LT unit and written informed consents were obtained from both donors and recipients regarding operations and researches.
Conflict-of-interest statement: All the authors have no conflict of interest related to the manuscript.
Data sharing statement: The technical appendix and original anonymous dataset is available on request from the corresponding author at emadgadsalemaa@yahoo.com.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Emad Hamdy Gad, MD, Lecturer of Hepatobiliary and Liver Transplantation Surgery, Hepatobiliary Surgery Department, National Liver Institute, Menoufiya University, 77 Algala albahary Street, Mansour Building, Shibin El-Koum 32817, Egypt. emad.gad1@liver.menofia.edu.eg
Telephone: +20-100-3031128 Fax: +20-48-2234685
Received: December 15, 2016
Peer-review started: December 19, 2016
First decision: March 28, 2017
Revised: April 14, 2017
Accepted: June 19, 2017
Article in press: June 20, 2017
Published online: July 28, 2017
Processing time: 222 Days and 5.2 Hours
Abstract
AIM

To analyze the incidence, risk factors, prevention, treatment and outcome of small for size syndrome (SFSS) after living donor liver transplantation (LDLT).

METHODS

Through-out more than 10 years: During the period from April 2003 to the end of 2013, 174 adult-to-adults LDLT (A-ALDLT) had been performed at National Liver Institute, Menoufiya University, Shibin Elkoom, Egypt. We collected the data of those patients to do this cohort study that is a single-institution retrospective analysis of a prospectively collected database analyzing the incidence, risk factors, prevention, treatment and outcome of SFSS in a period started from the end of 2013 to the end of 2015. The median period of follow-up reached 40.50 m, range (0-144 m).

RESULTS

SFSS was diagnosed in 20 (11.5%) of our recipients. While extra-small graft [small for size graft (SFSG)], portal hypertension, steatosis and left lobe graft were significant predictors of SFSS in univariate analysis (P = 0.00, 0.04, 0.03, and 0.00 respectively); graft size was the only independent predictor of SFSS on multivariate analysis (P = 0.03). On the other hand, there was lower incidence of SFSS in patients with SFSG who underwent splenectomy [4/10 (40%) SFSS vs 3/7 (42.9%) no SFSS] but without statistical significance, However, there was none significant lower incidence of the syndrome in patients with right lobe (RL) graft when drainage of the right anterior and/or posterior liver sectors by middle hepatic vein, V5, V8, and/or right inferior vein was done [4/10 (28.6%) SFSS vs 52/152 (34.2%) no SFSS]. The 6-mo, 1-, 3-, 5-, 7- and 10-year survival in patients with SFSS were 30%, 30%, 25%, 25%, 25% and 25% respectively, while, the 6-mo, 1-, 3-, 5-, 7- and 10-year survival in patients without SFSS were 70.1%, 65.6%, 61.7%, 61%, 59.7%, and 59.7% respectively, with statistical significant difference (P = 0.00).

CONCLUSION

SFSG is the independent and main factor for occurrence of SFSS after A-ALDLT leading to poor outcome. However, the management of this catastrophe depends upon its prevention (i.e., selecting graft with proper size, splenectomy to decrease portal venous inflow, and improving hepatic vein outflow by reconstructing large draining veins of the graft).

Keywords: Living donor liver transplantation; Outcome after living donor liver transplantation; Small for size syndrome; Small for size graft; Portal inflow; Venous outflow

Core tip: Small for size syndrome (SFSS) was diagnosed in 20 (11.5%) of our recipients where, small for size dysfunction affected 16 of patients (80%) and small for size non function was present in four patients (20%). Regarding graft size in patients with SFSS; 10, 5 and 5 of patients had extra-small graft [small for size graft (SFSG), graft recipient weight ratio (GRWR) < 0.8], small graft (GRWR ≥ 0.8 and < 1) and medium sized graft (GRWR ≥ 1) respectively. Extra small graft (SFSG), portal hyper-perfusion, severe portal hypertension (PHTN), and venous outflow obstruction were the main direct causes of SFSS in 10 (50%), 3 (15%), 4 (20%), and 3 (15%) of patients respectively. While extra-small graft, PHTN, steatosis and left lobe graft were significant predictors of SFSS in univariate analysis, only graft size was independent predictor of SFSS on multivariate analysis. On the other hand, there was non-significant lower incidence of SFSS in patients with SFSG when splenectomy was done, furthermore, there was non-significant lower incidence of the syndrome in patients with right lobe graft when drainage of the right anterior and/or posterior liver sectors by middle hepatic vein, V5, V8, and/or right inferior vein was done. The SFSS related mortalities were recorded in 13/20 of patients (65%). The 6-mo, 1-, 3-, 5-, 7- and 10-year survival in patients with SFSS were 30%, 30%, 25%, 25%, 25% and 25% respectively, while, the 6-mo, 1-, 3-, 5-, 7- and 10-year survival in patients without SFSS were 70.1%, 65.6%, 61.7%, 61%, 59.7%, and 59.7% respectively, with statistical significant difference.