‘Small-for-Size Syndrome (SFSS)’ has been an important issue in the field of living donor liver transplantation (LDLT) or split-graft deceased donor liver transplantation(DDLT). With understanding of its pathophysiology regarding excessive portal flow to remnant liver with limited capacity or volume, the application of this concept has been recently expanded to include posthepatectomy hepatic failure (PHHF) in non-transplant settings.1 SFSS or PHHF resulting from the small remnant liver or graft can result in life-threatening complications and have been recognized as a major challenge to overcome, influencing whole process of surgical treatment of liver disease not just limited to patient selection or treatment outcomes.
To prevent or manage PHHF or SFSS, several procedures such as portal vein banding, splenic artery embolization, mesocaval or portocaval shunts, and splenectomy have been introduced.2, 3 However, these procedures are invasive and often times irreversible. When the liver requires more portal flow after successful regeneration, another invasive procedure may be required to reverse relative portal insufficiency. Complications such as prolonged shunts or post-splenectomy sepsis after those invasive procedures have also been reported.4
If effective agents can be applied instead of invasive procedures to reduce the risk of PHHF or SFSS, the risk of potential complications may be avoided or at least minimized, and treatment itself can be readily reversible depending on the patient’s condition.
In this session, potential candidates of medical treatment for SFSS will be reviewed using data from published and on-going studies.

References
1. Golriz M, Majlesara A, El Sakka S, et al. Small for Size and Flow (SFSF) syndrome: An alternative description for posthepatectomy liver failure. Clin Res Hepatol Gastroenterol 2016; 40(3):267-75.
2. Ikegami T, Shimada M, Imura S, et al. Current concept of small-for-size grafts in living donor liver transplantation. Surg Today 2008; 38(11):971-82.
3. Gruttadauria S, Pagano D, Luca A, et al. Small-for-size syndrome in adult-to-adult living-related liver transplantation. World J Gastroenterol 2010; 16(40):5011-5.
4. Gonzalez HD, Liu ZW, Cashman S, et al. Small for size syndrome following living donor and split liver transplantation. World J Gastrointest Surg 2010; 2(12):389-94.