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

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          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).

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          Most cited references 82

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          When is steatosis too much for transplantation?

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            Portal pressure <15 mm Hg is a key for successful adult living donor liver transplantation utilizing smaller grafts than before.

            To prevent small-for-size syndrome in adult-to-adult living donor liver transplantation (A-LDLT), larger grafts (ie, right lobe grafts) have been selected in many transplant centers. However, some centers are investigating the benefits of portal pressure modulation. Five hundred sixty-six A-LDLT procedures using right or left lobe grafts were performed between 1998 and 2008. In 2006, we introduced intentional portal pressure control, and we changed the graft selection criteria to include a graft/recipient weight ratio >0.7% instead of the original value of >0.8%. All recipients were divided into period I (1998-2006, the era of unintentional portal pressure control; n = 432) and period II (2006-2008, the era of intentional portal pressure control; n = 134). The selection of small-for-size grafts increased from 7.8% to 23.9%, and the selection of left lobe grafts increased from 4.9% to 32.1%. Despite the increase in the number of smaller grafts in period II, 1-year patient survival was significantly improved (87.9% versus 76.2%). In 129 recipients in period II, portal pressure was monitored. Patients with a portal pressure or=15 mm Hg (n = 43, 66.3%). The recovery from hyperbilirubinemia and coagulopathy after transplantation was significantly better in patients with a portal pressure <15 mm Hg. In conclusion, our strategy for A-LDLT has changed from larger graft-based A-LDLT to controlled portal pressure-based A-LDLT with smaller grafts. A portal pressure <15 mm Hg seems to be a key for successful A-LDLT. (c) 2010 AASLD.
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              Small-for-size graft in living donor liver transplantation: how far should we go?

              With the extensive use of living donor liver grafts in adult patients, controversy over small-for-size syndrome has escalated in recent years. Although several symptoms have been suggested as manifestations of the syndrome, small-for-size syndrome remains difficult to diagnose because these symptoms are neither specific nor inevitable. The occurrence of small-for-size syndrome also seems to depend on a number of recipient and graft factors. Potential pathogenic mechanisms include persistent portal hypertension and portal overperfusion. At present, several techniques are being explored in an attempt to ameliorate the impact of small-for-size syndrome. Recent experience suggests that the occurrence of small-for-size syndrome is multifactorial and that complications relating to small-for-size grafts should be examined in relation to a variety of graft, recipient, and technical factors.
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                Author and article information

                Journal
                World J Hepatol
                WJH
                World Journal of Hepatology
                Baishideng Publishing Group Inc
                1948-5182
                28 July 2017
                28 July 2017
                : 9
                : 21
                : 930-944
                Affiliations
                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 notes

                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.

                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@ 123456liver.menofia.edu.eg

                Telephone: +20-100-3031128 Fax: +20-48-2234685

                Article
                jWJH.v9.i21.pg930
                10.4254/wjh.v9.i21.930
                5545138
                ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.

                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/

                Categories
                Retrospective Cohort Study

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