Essential Updates 2024/2025: History, Pathogenesis, Definition, Prevention, and Management of Small‐for‐Size Syndrome in Living‐Donor Liver Transplantation

Although living-donor liver transplantation (LDLT) has become the standard treatment for end-stage liver disease, one of its major challenges is small-for-size syndrome (SFSS). SFSS is characterized by severe icterus and intractable ascites, although the severity of the condition can vary. Some cases are managed with medical treatment alone, others require interventions such as splenic embolization, and some may result in graft loss or necessitate re-transplantation. A recent area of interest in this field is the new grading system introduced through collaboration between the International Liver Transplantation Society, the International Living-Donor Liver Transplantation Study Group, and the Liver Transplant Society of India in 2003. This grading system has helped define SFSS in the context of LDLT. Recent trends also include right lobe graft selection with V5/V8 reconstruction and optimal outflow to manage the high venous pressure associated with end-stage liver disease. To develop effective strategies for transplanting small-for-size grafts and preventing SFSS, it is crucial to have a comprehensive understanding of how to evaluate graft quality and volume, alongside portal pressure management, during LDLT. We review the latest literature on the pathogenesis of SFSS and the strategies for overcoming it after LDLT.