“Small-for-flow” syndrome: Shifting the “size” paradigm

Focusing on the “flow” rather than in the “size” may improve our understanding of the pathophysiology of the “small-for-size” syndrome and “post-hepatectomy liver failure” and it would have important implications for the clinical management of patients at risk. First, hepatic hemodynamic parameters would have to be measured in hepatic surgeries. Second, these parameters (in addition to liver mass) would be the principal basis for deciding the “safe” threshold of viable liver parenchyma. Third, the hepatic hemodynamic parameters are amenable to manipulation and, consequently, the “safe” threshold may also be manipulated. Shifting the paradigm from “small-for-size” to “small-for-flow” syndrome would thus represent a major step for optimizing the use of donor livers, for expanding the indications of hepatic surgery, and for increasing the safety of these procedures.