Results after Adult Ex Situ Split Liver Transplantation Since 1987 and the Influence of Biliary Complications

Abstract

Introduction: Some transplant centres still hesitate to use split liver grafts in adults obtained by an ex situ split either in general or for complicated or retransplant cases due to the inherently increased risks of significant biliary complications. This study investigates the frequency, the treatment and the long-term results of biliary complications after adult ex situ split liver transplantation from deceased heart-beating donors. Patients and methods: This is a single centre analysis with ongoing data collection. Included were all consecutive split liver transplants performed in adult recipients (minimum age 18 years) in our centre between the 01.12.1987 and the 31.12.2010. Excluded were all combined transplants (e.g. combined split liver and kidney transplantation) and living-related organ donor transplants as well as reduced size liver transplantation. We investigated 132 consecutive split liver transplants including 7 acute retransplants (defined as retransplantation within 30 days after the previous transplant) and 5 chronic retransplants (primary transplantation n = 119, 90.8 %; secondary transplantation n = 12, 9.2 %) in a total of 131 patients (median age: 43.8 years, range: 18-66 years; males n = 52, 39.7 %; females n = 79, 60.3 %). The post-transplant observational period ended on the 31.03.2011. Results: The overall 30-day mortality rate, the 1-year and the 3-year patient survival rates after adult ex situ split liver transplantation for all patients were 13%, 76.3% and 66.4%, respectively. The overall 1-year and 3-year graft survival rates of all transplants performed were 63.4% and 54.2%, respectively. The occurrence of any type of biliary complication had a significant influence on 1-year and 3-year graft survival (p=0.025 and p=0.020, respectively, Chi2-test). The individual types of biliary complications did not show a statistically significant influence on long-term patient or graft survival (Cox regression analysis) with central bile duct lesions leading to significantly worse patient survival as compared to all other types of biliary complications (p=0.014, Log Rank). The absence or presence of biliary complications had no statistically significant influence on long-term patient and graft survival (p>0.05; Kaplan-Meier analysis, Log Rank test). The majority of patients with biliary complications were treated surgically (57.1%, n=20). A large proportion of patients with biliary complications required interventional treatment (40%, n=14). Hepatic artery thrombosis occurred in 17 of 129 (13.2%) patients and in 4 of 34 (11.8%) patients with biliary complications following split-liver transplantation (difference not significant). Our results reveal that the era during which the split liver transplant was performed had a significant impact on patient long-term patient survival (p=0.016; Cox regression analysis; see also Figure 1) but not on transplant survival (era 1 = 01.12.1987-31.12.1991, era 2 = 01.01.1992-31.12.1994, era 3 = 01.01.1995-31.12.1998, era 4 = 01.01.1999-31.12.2003, era 5 = 01.01.2004-31.12.2007, era 6 = 01.01.2006-31.12.2010). Conclusions: This is a long-term series of adult ex situ split liver transplantation and currently one of the largest series in the world and shows that biliary complications after ex situ split liver transplantation have no significant influence on long-term patient and graft survival and that the results have improved since its invention.