Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, Japan.
Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, Japan.
Hepatobiliary Pancreat Dis Int. 2020 Aug;19(4):334-341. doi: 10.1016/j.hbpd.2020.06.015. Epub 2020 Jun 30.
Since the first success in an adult patient, living donor liver transplantation (LDLT) has become an universally used procedure. Small-for-size syndrome (SFSS) is a well-known complication after partial LT, especially in cases of adult-to-adult LDLT. The definition of SFSS slightly varies among transplant physicians. The use of a partial liver graft has risks of SFSS development. Persistent portal vein (PV) hypertension and PV hyper-perfusion after LT were identified as the main factors. Hence, various approaches were explored to modulate PV flow and decrease PV pressure in order to alleviate this syndrome. Herein, the definition, clinical symptoms, pathophysiology, basic research, as well as preventive and treatment strategies for SFSS are reviewed based on an extensive review of the literature and on our own experiences.
The articles were collected through PubMed using search terms "liver transplantation", "living donor liver transplantation", "living liver donation", "partial graft", "small-for-size graft", "small-for-size syndrome", "graft volume", "remnant liver", "standard liver volume", "graft to recipient body weight ratio", "sarcopenia", "porcine", "swine", and "rat". English publications published before March 31, 2020 were included in this review.
Many transplant surgeons performed PV flow modulation, including portocaval shunt, splenic artery ligation and splenectomy. With these techniques, patient outcome has been improved even when using a "small" graft. Other factors, such as preoperative recipients' nutritional and skeletal muscle status, graft congestion, and donor factors, were also identified as risk factors which all have been addressed using various strategies.
The surgical approach controlling PV flow and pressure could help to prevent SFSS especially in severely ill recipients. In the absence of efficacious medications to resolve SFSS, conservative treatments, including aggressive fluid balance correction for massive ascites, anti-microbiological therapy to prevent or control sepsis and intensive nutritional therapy, are all required if SFSS could not be prevented.
自首例成人患者成功接受活体肝移植（LDLT）以来，该技术已得到广泛应用。小体积供肝综合征（SFSS）是部分肝移植后一种众所周知的并发症，尤其是成人对成人 LDLT 时。SFSS 的定义在移植医生之间略有不同。使用部分肝移植物存在发生 SFSS 的风险。肝移植后持续性门静脉（PV）高压和 PV 高灌注被认为是主要因素。因此，为了缓解这种综合征，探索了各种方法来调节 PV 血流并降低 PV 压力。在此，通过广泛的文献回顾和我们自己的经验，综述了 SFSS 的定义、临床症状、病理生理学、基础研究以及预防和治疗策略。
通过使用术语“liver transplantation”、“living donor liver transplantation”、“living liver donation”、“partial graft”、“small-for-size graft”、“small-for-size syndrome”、“graft volume”、“remnant liver”、“standard liver volume”、“graft to recipient body weight ratio”、“sarcopenia”、“porcine”、“swine”和“rat”在 PubMed 上搜索，收集文章。本综述纳入了 2020 年 3 月 31 日前发表的英文出版物。
许多移植外科医生采用了调节 PV 血流的方法，包括门腔分流术、脾动脉结扎和脾切除术。通过这些技术，即使使用“小”移植物，患者的预后也得到了改善。其他因素，如术前受者的营养和骨骼肌状况、移植物淤血以及供者因素等，也被确定为危险因素，所有这些因素都已通过各种策略得到解决。
控制 PV 血流和压力的手术方法有助于预防 SFSS，尤其是在病情严重的受者中。在没有有效的药物来解决 SFSS 的情况下，如果不能预防 SFSS，则需要采用保守治疗，包括积极纠正大量腹水的液体平衡、预防或控制脓毒症的抗感染治疗和强化营养治疗。
