Large-for-Size Orthotopic Liver Transplantation: a Systematic Review of Definitions, Outcomes, and Solutions

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We systematically reviewed the literature on definitions and outcomes of large-for-size (LFS) syndrome in orthotopic liver transplantation (LT).


This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The Cochrane Library, PubMed, and Embase were searched (January 1990–January 2019) for studies reporting LFS in LT. Primary outcomes were definitions and mortality of LFS LT.


Eleven studies reporting patients with LFS LT were identified. Four different formulas (graft-to-recipient weight ratio (GRWR), body surface area index (BSAi), donor standardized total liver volume (sTLV)–to–recipient sTLV ratio, and graft weight/right anteroposterior distance (RAP) ratio) with their critical thresholds were found. There were 81 patients (54% women) with a median weight and height of 62.5 kg (range, 40–105 kg) and 165 cm (range, 145–180 cm). The median graft weight was 1772 g (range, 1290–2400 g), and the median GWRW was 2.77% (range, 2.1–4.00%). Graft venous outflow obstruction was described in seven patients (8.6%). At the time of LT, fascial closure was not achieved in 24 patients (29.6%) and the graft size was reduced by a liver resection in three patients (3.7%). Thirteen deaths (16%) were reported in the first 90 postoperative days with two patients undergoing re-transplant.


LFS LT remains heterogeneously defined but characterized by high mortality rates despite the use of tailored surgical solutions (graft reduction and open abdomen). A composite definition is proposed in order to better describe LFS clinical syndrome.

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Substantial contributions to the conception or design of the work: PA, VN, BN, and PB. Acquisition, analysis, or interpretation of data for the work: PA, VN, BN, and PB. Drafting the work or revising it critically for important intellectual content: PA. Final approval of the version to be published: PA, VN, BN, and PB. Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: PA, VN, BN, and PB.

Correspondence to Pietro Addeo.

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Addeo, P., Noblet, V., Naegel, B. et al. Large-for-Size Orthotopic Liver Transplantation: a Systematic Review of Definitions, Outcomes, and Solutions. J Gastrointest Surg (2020) doi:10.1007/s11605-019-04505-5

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  • Anthropometrics
  • Graft reduction
  • Large-for-size
  • Liver transplantation
  • Mismatch
  • Negative pressure wound therapy