“Small-For-Flow” Liver Failure after Extended Hepatectomy: A Call for Update

Abstract

Emond et al. [1] first described, in 1996, a new syndrome occurring in small grafts in transplantation field, named small for Size Syndrome. After surgery, patients with a small grafts were affected by unpredictable elevation of bilirubin (not linked with surgical procedures), coagulopathy, prolonged cholestasis, portal hypertension and, if severe, ascites. The continuing liver dysfunction predisposes to further complications, including sepsis and gastrointestinal bleedings, leading to a clear liver failure. In the meantime, in liver resection field, the same syndrome was noticed after major hepatectomy (>3 segments resected), and it was named Post-Hepatectomy Liver Failure. With improvement of knowledge, nowadays we know that SFSS and PHLF are two side of the same coin. Different strategies, more in transplantation context, have been described to prevent and to treat the syndrome, but lack of data regarding the resection context is still a matter. In fact, where in transplant, pathophysiological studies and randomized clinical trial have been published to evaluate the etiology and the efficacy of procedures proposed, in resection field we are just translate transplantation experience, without a whole consensus between physician on how to predict, to diagnose, and to treat this post-hepatectomy liver failure. Diagnostic criteria, treatments, and pathophysiology are still unclear, with different opinion between physicians, and also disaccording if small for size and post-hepatectomy liver failures are really the same. Our opinion a part, we think it's time to start to analyze in deep this syndrome that account for more than 60% of death after major liver resections.