Small-for-flow liver failure after extended hepatectomy: hot questions and an update

Small-for-size liver syndrome and posthepatectomy liver failure remain a major challenge for surgeons. Recently, updates in literature points to describe this two syndrome as two face of the same coin. These syndromes are characterized by hyperbilirubinemia, coagulopathy, hyper-GGT, high portal pressure and flow in liver remnant, occurring within the first postoperative week. It can lead to post-operative sepsis and bleeding, increasing mortality and morbidity. Despite the large experience in the field of transplantation, few studies are focused on small-for-size syndrome after major hepatectomy. For years, scientists were focused on the size of liver remnant, supposing a small liver remnant, in relation with the primary liver size, was the cause of the syndrome. The strategies used to prevent it after transplantation, have however shown a predominant role of high portal pressure and flow, leading to an alteration in functional regeneration of liver parenchyma, as the prevalent mechanism. According to these evidences, we suggest adopting another nomenclature for the two syndromes: small-for-flow-liver failure. In this article, we analyze and summarize different experiences, proposing our inward algorithm, including the role of portal flow and pressure measurements. This review seeks to be an operative instrument for surgeons and hepatologists in an effort to find a common point of view regarding small for flow liver failure and its management strategies.