Small for size syndrome difficult dilemma: Lessons from 10 years single centre experience in living donor liver transplantation

Table 1 Characteristics of patients and their donors

Character	n (%) 174 (100%) (mean ± SD)
Donor age (yr) (mean ± SD)	27.2 ± 6.7
Recipient age (yr) (mean ± SD)	46.5 ± 8.1
Donor gender
Males	118 (67.8)
Females	56 (32.2)
Recipient gender
Males	154 (88.5)
Females	20 (11.5)
Child class
A	9 (5.2)
B	53 (30.5)
C	112 (64.4)
MELD score
< 18	114 (65.5)
18-24	50 (28.7)
> 24	10 (5.7)
MELD score (mean ± SD)	16.09 ± 4.3
Pre LT PHTN	144 (82.8)
Steatosis	9 (5.2)
Graft type
Right lobe	166 (95.4)
Left lobe	8 (4.6)
MHV with the graft
RL graft	10 (5.7)
LL graft	7 (4.1)
No of HV anastomoses
1	110 (63.2)
2	53 (30.5)
3	10 (5.7)
4	1 (0.6)
Drainage of RT anterior and/or posterior sectors by MHV, V5, V8, and/or RIV in RT lobe grafts (n = 166)	56/166 (33.7)
Actual graft weight (g) (mean ± SD)	820.9 ± 174.2
Actual GRWR	1.04 ± 0.2
SFSG (GRWR < 0.8)	17 (9.8)
Splenectomy in SFSG (n = 17)	7/17 (41.2)
Cold ischemia time (min) (mean ± SD)	74.9 ± 51.2
Warm ischemia time (min) (mean ± SD)	52.9 ± 15.2
Intraoperative blood transfusion (units) (mean ± SD)	7.05 ± 7.4
Intraoperative plasma transfusion (units) (mean ± SD)	8.2 ± 8.9
Operative time (h) (mean ± SD)	13.1 ± 3.2
Hospital stay post LT (d) (mean ± SD)	22.4 ± 15.9

MELD: Model for end stage liver disease; PHTN: Portal hypertension; MHV: Middle hepatic vein; RIV: RT inferior vein; GRWR: Graft recipient weight ratio; SFSG: Small for size graft.

Table 2 Some characteristics of patients with small for size syndrome

Character	n (%)
SFSS	20 (100)
Type of SFSS
SFSD	16 (80)
SFSNF	4 (20)
Main presentation
Hyperbilirubinaemia	20 (100)
Large volume of ascites	18 (90)
Coagulopathy	17 (85)
Graft size
GRWR < 0.8 (SFSG)	10 (50)
GRWR ≥ 0.8 and < 1	5 (25)
GRWR ≥ 1	5 (25)
Main aetiology of SFSS
Extra small graft (SFSG)	10 (50)
Portal hyperperfusion	3 (15)
Severe PHTN	4 (20)
Outflow obstruction	3 (15)

SFSS: Small for size syndrome; SFSD: Small for size dysfunction; SFSNF: Small for size non function; PHTN: Portal hypertension.

Table 3 Comparison between patients with and without small for size syndrome (Univariate analysis)

Character	SFSS, n (%) 20 (100) (mean ± SD)	No SFSS, n (%) 154 (100) (mean ± SD)	P value
Child class			< 0.05
A	1 (5)	8 (5.2)
B	7 (35)	46 (29.9)
C	12 (60)	100 (64.9)
MELD score			< 0.05
< 18	16 (80)	98 (63.6)
18-24	4 (20)	46 (29.9)
> 24	0 (0)	10 (6.5)
Pre LT PHTN			0.046
Yes	20 (100%)	128 (83.1%)
No	0 (0)	26 (16.9%)
Steatosis			0.035
Yes	3 (15)	6 (3.9)
No	17 (85)	148 (96.1)
Graft type			0
RL	14 (70)	152 (98.7)
LL	6 (30)	2 (1.3)
SFSG (GRWR < 0.8)			0
Yes	10 (50)	7 (4.5)
No	10 (50)	147 (95.5)
Actual graft weight (g) (mean ± SD)	640.50 ± 211.049	844.39 ± 154.888	0
Actual GRWR (g) (mean ± SD)	0.862 ± 0.2158	1.065 ± 0.1922	0.001
Cold ischemia time (min) (mean ± SD)	73.95 ± 55.350	75.13 ± 50.923	< 0.05
Warm ischemia time (min) (mean ± SD)	50.95 ± 14.248	52.08 ± 16.336	< 0.05
Intraoperative plasma transfusion (units) (mean ± SD)	11.40 ± 7.816	7.81 ± 8.943	0.021
No. of HV anastomoses			< 0.05
1	11 (55)	99 (64.3)
2	8 (40)	45 (29.2)
3	1 (5)	9 (5.8)
4	0 (0)	1 (0.6)
Splenectomy in patients with SFSG (n = 17)			< 0.05
Yes	4 (40)	3 (42.9)
No	6 (60)	4 (57.1)
Drainage of RT anterior and/or posterior sectors (MHV, V5, V8, RIV) in RL graft with or without MHV (n = 166)			< 0.05
Yes	4 (28.6)	52 (34.2)
No	10 (71.4)	100 (65.8)
MHV reconstruction in patients with RL graft (n = 166)			< 0.05
Yes	1 (7.1)	9 (5.9)
No	13 (92.9)	143 (94.1)
Drainage of RT anterior and/or posterior sectors (V5, V8, RIV) in RL graft without MHV(n = 156)			< 0.05
Yes	3 (23.1)	43 (30.1)
No	10 (76.9)	100 (69.9)

MELD: Model for end stage liver disease; Pre LT PHTN: Pre liver transplant portal hypertension; RL: Right lobe; LL: Left lobe; SFSG: Small for size graft; GRWR: Graft recipient weight ratio; MHV: Middle hepatic vein; RIV: Right inferior vein.

Table 4 Multivariate analysis of predictors of small for size syndrome (Binary logistic regression)

	P value	Exp(B)	95%CI for EXP (B)
			Upper	Lower
Pre LT PHTN	0.998	0.000	0.000
Steatosis	0.060	0.145	0.020	1.074
Graft type	0.166	6.407	0.463	88.717
Actual GRWR < 0.8	0.050	4.303	1.024	18.082
Actual graft WT	0.030	1.004	1.000	1.008
Intraoperative plasma transfusion (units)	0.235	0.963	0.905	1.025

Pre LT PHTN: Pre liver transplant portal hypertension; GRWR: Graft recipient weight ratio.

Table 5 Outcome of patients

Total number	SFSS n (%) 20 (100)	-	No SFSS n (%) 154 (100)	-	P value
Overall mortality	15 (75)	Grade	62 (40.3)	Grade	0.003
Cause of mortality and their Dindo-Clavien score
Sepsis from causes other than SFSS	0	-	19 (30.6)	V	0
SFSS (sepsis, graft failure, DIC, renal failure, ARDS, MOF)	13 (86.7)	V	0	-
MOF from causes other than SFSS	0	-	11 (17.7)	V
Post-operative bleeding	2 (13.3)	V	10 (16.1)	V
Intra-operative bleeding	0	-	8 (12.9)	V
PVT	0	-	4 (6.4)	V
Renal impairment from causes other than SFSS	0	-	2 (3.2)	V
Metastatic cholangiocarcinoma	0	-	2 (3.2)	V
Early graft dysfunction from causes other than SFSS	0	-	2 (3.2)	V
HCC recurrence	0	-	2 (3.2)	V
Ischemic reperfusion injury	0	-	1 (1.6)	V
HAT	0	-	1 (1.6)	V
6-mo survival	6 (30)	-	108 (70.1)	-	0.000
1-yr survival	6 (30)	-	101 (65.6)	-	0.002
3-yr survival	5 (25)	-	95 (61.7)	-	0.002
5-yr survival	5 (25)	-	94 (61)	-	0.002
7-yr survival	5 (25)	-	92 (59.7)	-	0.003
10-yr survival	5 (25)	-	92 (59.7)	-	0.003
Survival per months (mean ± SD)	16.3 ± 28.9	-	39.9 ± 34.3	-	0.002
Graft survival	4 (20)		89 (57.8)		0.001
Graft survival per months (mean ± SD)	16.2 ± 28.9		39.7 ± 34.3		0.003

SFSS: Small for size syndrome; DIC: Disseminated intravascular coagulation; ARDS: Adult respiratory distress syndrome; MOF: Multi organ failure; PVT: Portal vein thrombosis; HCC: Hepatocellular carcinoma; HAT: Hepatic artery thrombosis.