Del Prete Luca, Quintini Cristiano, Diago Uso Teresa
General Surgery and Liver Transplant Unit, IRCCS Fondazione Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy.
Translational Medicine PhD Program, University of Milan, Milan, Italy.
Updates Surg. 2025 Oct;77(6):1797-1806. doi: 10.1007/s13304-024-01964-7. Epub 2024 Oct 29.
Small-for-size syndrome poses a significant challenge in living donor liver transplantation, with potentially severe consequences including liver failure and death. This review explores the management strategies for SFSS, starting from the pathophysiology of the disease. SFSS arises from insufficient liver mass in the graft and hyperdynamic circulation in cirrhotic recipients, leading to portal hyperperfusion and subsequent liver injury. Risk factors include graft size, quality, recipient factors, and hemodynamic changes during transplantation.Hemodynamic monitoring is crucial during living donor liver transplantation to optimize portal vein and hepatic artery flow. Prevention strategies focus on donor-recipient matching and intraoperative graft inflow modulation. Optimizing venous outflow and avoiding portal hyperperfusion is essential. Management of established small-for-size syndrome involves supportive care, pharmacologic interventions, and radiological and surgical options. Pharmacotherapy includes somatostatin analogues, beta-blockers, and vasopressin analogues to reduce portal flow and pressure. Surgical interventions aim to modulate portal flow and mitigate complications. Retransplantation may be necessary in severe cases, guided by persistent graft dysfunction despite liver flow modulations. In conclusion, preventing and managing small-for-size syndrome in living donor liver transplantation requires comprehensive assessment and tailored interventions. Advancements in graft/recipient matching, hemodynamic monitoring, pharmacologic and surgical techniques aiming to inflow modulation have improved outcomes, enabling successful transplantation even with ultra-small grafts.
小体积综合征在活体肝移植中构成了重大挑战，可能导致包括肝衰竭和死亡在内的严重后果。本综述从疾病的病理生理学出发，探讨了小体积综合征的管理策略。小体积综合征源于移植肝体积不足以及肝硬化受者的高动力循环，导致门静脉高灌注及随后的肝损伤。危险因素包括移植肝大小、质量、受者因素以及移植过程中的血流动力学变化。在活体肝移植过程中，血流动力学监测对于优化门静脉和肝动脉血流至关重要。预防策略侧重于供受者匹配及术中移植肝血流调节。优化静脉流出道并避免门静脉高灌注至关重要。已确诊的小体积综合征的管理包括支持治疗、药物干预以及放射学和外科治疗选择。药物治疗包括使用生长抑素类似物、β受体阻滞剂和血管加压素类似物以减少门静脉血流和压力。外科干预旨在调节门静脉血流并减轻并发症。在严重病例中，尽管进行了肝血流调节但移植肝仍持续功能障碍，此时可能需要再次移植。总之，预防和管理活体肝移植中的小体积综合征需要全面评估和量身定制的干预措施。在移植物/受者匹配、血流动力学监测、旨在调节血流的药物和外科技术方面的进展改善了治疗效果，即使使用超小移植物也能实现成功移植。
