Small for size syndrome (SFSS) after living donor liver transplantation (LLDT) is a syndrome including cases with various severities, including mild SFS; total bilirubin of 5-10 mg/dl and ascites 1-2 L/day with good general performance status, moderate SFSS with total bilirubin of 10-20mg with decreased general activity, severe SFSS with total bilirubin > 20mg/dl with prolonged INR and poor performance status, requiring re-LDLT or listing up for DDLT. Much attention needs to e paid to prevent severe SFSS.
In cases with Child B recipient with minor shunts with good graft of GRWR 1.0 from young male, LDLT surgery is very straight forward and splenectomy is unnencessary and not portal steal should happen. This case is the easiest one. However, if a recipient is fatty 50 yeas old male with MELD score of 24 with major coronary shunt splenorenal shutn with big spleen, and the donor is also 50 years old wife giving right lobe with GRWR of 0.7. In this situation, after laparotomy, splenic artery is controlled and the shunts were also controlled. After hepatectomy and reperfusion, if PVP is >15 mmHg, splenic artery is ligated and splenectomy is performed. Then all the major shunts were divided manually or using endostapling devices with PVP <20 mmHg, to normalized the fully deformed portal circulation.
Our current plan in adult LDLT for chronic liver diseases, is to take spleen out and to ligate major shunts to normalize the portal hemodynamics. We are aginst to make additional shunt for decompress PVP. These strategies (Khushu Style) are established from the learning of old painful cases.