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“Small-for-Flow” Syndrome: Concept Evolution

  • Published:
Journal of Gastrointestinal Surgery

Abstract

Background

The “Small-for-Size” syndrome is defined as a liver failure after a liver transplant with a reduced graft or after a major hepatectomy. The later coined “Small-for-Flow” syndrome describes the same situation in liver resections but based on hemodynamic intraoperative parameters (portal pressure > 20 mmHg and/or portal flow > 250 ml/min/100 g). This focuses on the damage caused by the portal hyperafflux related to the volume of the remnant.

Methods

Relevant studies were reviewed using Medline, PubMed, and Springer databases.

Results

Portal hypertension after partial hepatectomies also leads to a higher morbidity and mortality. There are plenty of experimental studies focusing on flow rather than size. Some of them also perform different techniques to modulate the portal inflow. The deleterious effect of high posthepatectomy portal venous pressure is known, and that is why the idea of portal flow modulation during major hepatectomies in humans is increasing in everyday clinical practice.

Conclusions

Considering the extensive knowledge obtained with the experimental models and good results in clinical studies that analyze the “Small-for-Flow” syndrome, we believe that measuring portal flow and portal pressure during major liver resections should be performed routinely in extended liver resections. Applying these techniques, the knowledge of hepatic hemodynamics would be improved in order to advance against posthepatectomy liver failure.

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Abbreviations

ALPPS:

Associating liver partition and portal vein ligation for staged hepatectomy

HSCs:

Hematopoietic stem cells

IRI:

Ischemia-reperfusion injury

PHLF:

Posthepatectomy liver failure

PIM:

Portal inflow modulation

PVE:

Portal vein embolization

PVP:

Portal venous pressure

SFFS:

Small-for-Flow syndrome

SFSS:

Small-for-Size syndrome

VLR:

Volume liver remnant

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Authors and Affiliations

  1. Transplant and Hepatobiliopancreatic Surgery Unit, Department of General and Digestive Surgery, Hospital General Universitario Gregorio Marañón, Madrid, Spain

    Maitane I. Orue-Echebarria, Pablo Lozano, J L. García Sabrido & JM. Asencio

  2. Department of Surgery, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain

    Maitane I. Orue-Echebarria, J L. García Sabrido & JM. Asencio

  3. Department of Anesthesiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain

    Luis Olmedilla

  4. Servicio de Cirugía General y Aparato Digestivo, Hospital General Universitario Gregorio Marañón, c/ Doctor Esquerdo 46, 28007, Madrid, Spain

    JM. Asencio

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  1. Maitane I. Orue-Echebarria
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  2. Pablo Lozano
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Correspondence to JM. Asencio.

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Orue-Echebarria, M.I., Lozano, P., Olmedilla, L. et al. “Small-for-Flow” Syndrome: Concept Evolution. J Gastrointest Surg 24, 1386–1391 (2020). https://doi.org/10.1007/s11605-020-04576-9

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