Transpl Int, 05 September 2022

How to Choose the Optimal Surgical Strategy to Predict and Prevent LFSS Following Liver Transplantation?

www.frontiersin.orgDiao He1, www.frontiersin.orgXingyu Pu2 and www.frontiersin.orgLi Jiang2,3*
  • 1Key Laboratory of Transplant Engineering and Immunology, Laboratory of Liver Transplantation, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
  • 2Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu, China
  • 3Department of General Surgery, West China Tianfu Hospital, Sichuan University, Chengdu, China

We appreciate the positive feedback that Zhou GP and his colleagues provided on our article, “A Novel Strategy for Preventing Posttransplant Large-For-Size Syndrome in Adult Liver Transplant Recipients: A Pilot Study” (1). Their article raised several concerns on our published article. We are grateful to the Editor for allowing us to respond to these comments.

It is crucial to match donor and recipient sizes appropriately to prevent Large-for-Size Syndrome (LFSS). A valuable idea presented by Zhou et al. is the incorporation of graft morphological parameters, particularly the anteroposterior (RAP) vertical distance and the longest horizontal distance, into the LFSS indicator (2). By combining the morphological parameter of graft, graft-recipient weight ratio (GRWR) and graft weight (GW)/RAP, it is possible to more accurately indicate the need for reduction of the right graft (3).

The point is how to measure the morphological parameter of graft using an appropriate method. As of today, computed tomography (CT) scan is the most accurate method to measure the right RAP vertical distance and the largest horizontal distance of grafts in living donor liver transplantation (LDLT) (4). However, Donation after Citizens Death (DCD) donors need to receive treatment in the intensive care unit and should not be moved, which limits the use of CT scans in for measuring graft parameters in deceased donor liver transplantation (DDLT). Doppler ultrasonography can be performed at the bedside, but DCD donors may experience edema in their gastrointestinal tracts during maintenance periods, affecting the accuracy of the measurement results. Alternatively, measurements can be taken during graft procurement period, which has the advantage of being done under naked eye conditions. In view of the fact that the graft does not have blood filling in vitro, the ex vivo measurement value is smaller than the actual one in vivo. For a closer match between in vitro and in vivo measurement values, we propose to combine several transplant centers and develop a new calculation formula with a large sample size.

Paterno et al. recently proposed a new solution, “bilateral marginal costotomy,” for rescuing a liver transplant recipient from severe graft compression caused by bilateral narrow rib cages after temporary abdominal closure failed (5). Yet, this method is more likely to be a salvage measure for donor-recipient matching fails than a conventional treatment since the thoracic cavity needs to be changed, increasing the risk of postoperative complications. In contrast, according to our observations using the HuaXi-eRPS technique, all recipients had intact hepatic arteries, hepatic veins, and biliary tracts as well as good blood supply without any biliary complications. Thus, HuaXi-eRPS under the existing conditions should be considered a safe and effective procedure for the prevention of posttransplant LFSS. With the advancement of technology, we will also try new detection methods and incorporate new predictive indicators in order to make more effective control strategies for posttransplant LFSS.

Data Availability Statement

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

Author Contributions

DH, XP, and LJ wrote the paper. All authors contributed to the article and approved the submitted version.


This study was supported by the Key R&D Support Plan of Chengdu Science and Technology Bureau (2021-YF05-00703-SN). The funding body had no role in the design of the study and writing of the manuscript.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


1. Pu, X, He, D, Liao, A, Yang, J, Lv, T, Yan, L, et al. A Novel Strategy for Preventing Posttransplant Large-For-Size Syndrome in Adult Liver Transplant Recipients: A Pilot Study. Transpl Int (2021) 35:10177. doi:10.3389/ti.2021.10177

PubMed Abstract | CrossRef Full Text | Google Scholar

2. Zhou, GP, Wei, L, and Zhu, ZJ. Adopting Individualized Strategies to Prevent Large-For-Size Syndrome in Adult Liver Transplant Recipients: The Graft Morphology Should Also Be Taken into Account. Transpl Int (2022) 35:10683. doi:10.3389/ti.2022.10683

CrossRef Full Text | Google Scholar

3. Allard, MA, Lopes, F, Frosio, F, Golse, N, Sa Cunha, A, Cherqui, D, et al. Extreme Large-For-Size Syndrome after Adult Liver Transplantation: A Model for Predicting a Potentially Lethal Complication. Liver Transpl (2017) 23:1294–304. doi:10.1002/lt.24835

PubMed Abstract | CrossRef Full Text | Google Scholar

4. Cai, L, Yeh, BM, Westphalen, AC, Roberts, JP, and Wang, ZJ. Adult Living Donor Liver Imaging. Diagn Interv Radiol (2016) 22(3):207–14. doi:10.5152/dir.2016.15323

PubMed Abstract | CrossRef Full Text | Google Scholar

5. Paterno, F, Amin, A, Lunsford, KE, Brown, LG, Pyrsopoulos, N, Lee, ES, et al. Marginal Costotomy: A Novel SurgicalTechnique to Rescue from "Large-For-Size Syndrome" in Liver Transplantation. Liver Transpl (2022) 28:317–20. doi:10.1002/lt.26252

PubMed Abstract | CrossRef Full Text | Google Scholar

Keywords: LFSS, prediction, prevention, adult, reduced-size liver transplantation

Citation: He D, Pu X and Jiang L (2022) How to Choose the Optimal Surgical Strategy to Predict and Prevent LFSS Following Liver Transplantation?. Transpl Int 35:10805. doi: 10.3389/ti.2022.10805

Received: 28 July 2022; Accepted: 17 August 2022;
Published: 05 September 2022.

Copyright © 2022 He, Pu and Jiang. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Li Jiang,