Abbreviations
- EAD
early allograft dysfunction
- GRWR
graft‐to‐recipient weight ratio
- GV
graft volume
- LDLT
living donor liver transplantation
- SAL
splenic artery ligation
- SFSG
small‐for‐size graft
- SFSS
small‐for‐size syndrome
- SLV
standard liver volume
We enjoyed the recent excellent article presented by Yugawa et al. [1], describing small‐for‐size graft syndrome (SFSS) grade B/C in living donor liver transplantation (LDLT) still occurred in one in five patients even though who underwent splenectomy (Spx) for inflow modulation. LDLT. They concluded that patients with high recipient neutrocyte lymphocyte ratio (NLR), high model for end‐stage liver disease (MELD) score over 30, or older donor age over 50 years have increased risk of SFSS despite performing Spx.
The risk factors they presented for advanced grade SFSS are very reasonable and acceptable. However, we imagine LDLT usually has given us enough time for evaluating and deliberate donor and recipient matching for having higher survival rate after LDLT, although it may not feasible in emergent cases like acute on chronic liver setting. In their cohort, graft recipient weight ratio resulting in Graft B//C SFSS was 0.72 (0.63–0.87) and the graft size is overall regular size of right lobe graft. If LDLT is the only choice for high MELD and aged donor, LDLT might be limited for cases with GRWR > 1 or waiting whole liver transplantation [2, 3], which the authors already do so.
The positive impact of splenectomy for portal decompression and increasing graft survival rate in LDLT using propensity matching analysis has been already published by Yoshizumi et al. [4] It revealed 10% dramatic increase in graft survival after LDLT by routine splenectomy. However, determining indicating effective splenectomy has very complex issues, including spleen size and collateral vessels around spleen. If spleen size is small, the impact of splenectomy on portal decompression should be small. If huge collateral vessels are present, splenectomy jeopardizes collateral vessels resulting in increase in portal pressure. In such cases, maybe only the solution is using larger right lobe graft or whole liver diseased graft.
Thus, we would friendly like to ask whether he authors LDLT grafts with GRWR of 0.72 (0.63–0.87) were used, and how to determine the portal decompression procedures in cases with small spleen and peri‐splenic huge collaterals, and how do you think is the best way to have better outcomes in high risk cases described in your article.
Author Contributions
Haruka Kobayashi drafted the manuscript; Takashi Aida and Kenei Furukawa critically revised the manuscript; Toru Ikegami finally approved the manuscript.
Funding
The authors have nothing to report.
Conflicts of Interest
The authors declare no conflicts of interest.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.
References
- 1. Yugawa K., Toshima T., Itoh S., et al., “Risk Factors for Small‐For‐Size Syndrome Grade B/C After Simultaneous Splenectomy in Adult Living‐Donor Liver Transplantation,” Annals of Gastroenterological Surgery 10, no. 4 (2026): 1165–1173. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Ikegami T., Tsunematsu M., Onda S., et al., “Essential Updates 2024/2025: History, Pathogenesis, Definition, Prevention, and Management of Small‐For‐Size Syndrome in Living‐Donor Liver Transplantation,” Annals of Gastroenterological Surgery 10, no. 1 (2025): 35–41. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Ikegami T., Furukawa K., Haruki K., and Yanagaki M., “Letter to the Editor: Can Sexagenarian Donors Be Feasibly Indicated for Living Donor Liver Transplantation?,” Liver Transplantation 29, no. 9 (2023): E28–E29. [DOI] [PubMed] [Google Scholar]
- 4. Yoshizumi T., Itoh S., Shimokawa M., et al., “Simultaneous Splenectomy Improves Outcomes After Adult Living Donor Liver Transplantation,” Journal of Hepatology 74, no. 2 (2021): 372–379. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.