Small-for-size syndrome and transjugular intrahepatic portosystemic shunt

Authors

  • Sumihito Tamura M.D.,

    1. Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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  • Yasuhiko Sugawara M.D.,

    Corresponding author
    • Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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  • Norihiro Kokudo M.D., Ph.D.

    1. Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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  • This study was supported by a Grant-in-Aid for Scientific Research from the Japanese Ministry of Education, Culture, Sports, Science, and Technology and by Grants-in-Aid for Research on Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome and Research on Measures for Intractable Diseases from the Japanese Ministry of Health, Labor, and Welfare.

Address reprint requests to Yasuhiko Sugawara, M.D., Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, Japan. Telephone: 81-3-3815-5411; FAX: 81-3-5684-3989; E-mail: yasusuga-tky@umin.ac.jp

TO THE EDITORS:

A recent case report by Xiao et al.[1] provides a good example of the potential for misunderstanding regarding the recognition of small-for-size syndrome (SFSS).

In SFSS, a graft with a suboptimal hepatic parenchyma mass failing to meet the metabolic burden results in prolonged cholestasis, coagulopathy, and persistent ascites. Criteria from Zurich, Switzerland[2] and Fukuoka, Japan[3] have been widely adopted. Failed vascular anastomoses, infections, and rejection are considered exclusionary. A graft/recipient weight ratio less than 0.8% or a graft/standard liver volume ratio less than 40% is the cutoff.[2, 4] The role of portal flow modulation in preventing SFSS remains controversial.[5, 6]

Xiao et al.'s report[1] of a patient with a graft weighing 615 g (with a graft/standard liver volume ratio of 47.5% and a graft/recipient weight ratio of 0.85%) who was diagnosed with SFSS and was subsequently treated with a transjugular intrahepatic portosystemic shunt cannot be readily accepted as a case of SFSS. Although this graft was much lower in volume than the whole liver grafts available for deceased donor liver transplantation, many centers that perform living donor liver transplantation in Asia will accept a graft/standard liver volume ratio of 47.5% as sufficient with the expectation of an uneventful postoperative course.

Before proceeding with a discussion of the role of a transjugular intrahepatic portosystemic shunt in SFSS, we must first question the diagnosis of SFSS in this particular case. Anatomic complications require strict exclusion, and the quality of the graft should be further evaluated. We may learn more from the following information: the patency of the suprahepatic vein and tributaries from the anterior segment and details about the donor's liver function before donation and the pathological evaluation (eg, Masson's trichrome staining).

At present, caution must be taken before the authors' interpretation of this particular case is universally accepted.

  • Sumihito Tamura, M.D.

  • Yasuhiko Sugawara, M.D.

  • Norihiro Kokudo, M.D.

  • Artificial Organ and Transplantation Division

  • Department of Surgery

  • Graduate School of Medicine

  • University of Tokyo

  • Tokyo, Japan

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