Adult Liver Transplantation With a Rotated Left Liver Lobe From an “In Situ” Splitting Procedure

Abstract

The “in situ” split liver for two adults is an accepted procedure to improve graft pool in the present scenario of organs shortage (1). With this technique, we obtain a left (S I–IV) and a right split graft (S V–VIII). However, this technique is difficult to perform and still not very common. The European Liver Transplant Registry data report 584 left livers splits from 1989 to 2005 and only 28 in 2006 (personal communication). Moreover, the experience with transplantation of left lobe graft from deceased donors in Europe is poor with a 1-year graft survival of 47% (2). These disappointing results may be related to the inadequate liver mass for an adult recipient or to the technical issues such as disproportionate size of liver grafts. We describe a modification of the left split graft implantation, the graft deriving from an “in situ” splitting procedure for two adults. We placed the graft heterotopically in the right upper quadrant fossa after a 180° rotation, because it was too large to be placed in the epigastric region. The left graft, procured from a brain-dead 26-year-old man, was harvested with the middle hepatic vein and retro hepatic vena cava. The graft suprahepatic vena cava was anastomized to the three hepatic veins common cloacae of the recipient, followed-by end-to-end portal and biliary anastomosis. The aortic patch of the graft was implanted on the recipient right hepatic artery (Fig. 1). The graft (687 g) was transplanted in a 50-years-old woman (62 kg) with hepatitis C virus cirrhosis and hepatocellular carcinoma. The graft-to-recipient body-weight ratio was 1.1%. After surgery the left graft showed an adequate liver function (pick of alanine aminotransferase=446 at day 1) and the patient stayed in intensive care unit for 5 days. Computed tomography at day 10 after transplantation showed patent vascular and biliary anastomoses. In the postoperative course, the patient bled from esophageal varices and required endoscopic sclerotherapy. The discharge was 30 days after surgery with normal hepatic function. To our knowledge this procedure was previously performed only for a left lateral segment or for a left lobe split in the setting of living donor (3) but never for a left split graft derived from cadaveric donor (4). This case shows that the volume of the right upper quadrant fossa can host a rotated left liver when it cannot be placed orthotopically, without any evidence of compression or kinking of vascular anastomosis resulting in a good postoperative graft function. We hope that the described alternative placement of left liver graft will stimulate the more experienced transplant teams to split livers without strictly considering the anatomical parameters for graft placement, that is, recipient weight and abdominal transversal circumference. Considering that 85% of liver transplants in Europe are from cadaveric donors (5), the application of this technique would result in increased graft availability. It remains to be shown if and to what extent this left split graft placement technique will improve the split liver transplant programs.FIGURE 1.: Schematic representation of the rotated left liver split graft.Giuseppe Maria Ettorre Giovanni Vennarecci Roberto Santoro Pasquale Lepiane Riccardo Lorusso General Surgery and Liver Transplantation Department San Camillo Hospital Rome, Italy Mario Antonini Intensive Care Unit National Institute for Infectious Disease “Lazzaro Spallanzani” Rome, Italy