SPLIT LIVER TRANSPLANTATION FOR EXPANSION OF THE DONOR POOL

Abstract

21 Background: Rapidly rising mortality rates for patients awaiting liver transplantation has greatly increased the interest in split liver transplantation (SLT) to expand the donor pool. However, earlier reports on SLT were associated with poor outcomes and increased rate of complications. This report evaluates the results of SLT performed on fifty cadaveric donors. Methods: From July 1996 to December 1998, 47 cadaveric livers were split by the in vivo technique and 3 were split ex vivo. Ninety-two transplants that included 45 right trisegmental (segments 1 and 4-8) grafts and 47 left lateral segments (segments 2 and 3) were transplanted in 85 recipients aged 3 months - 67 years. Median range of follow up was 7.2 months. Results: Overall patient (pt) survival at time of median follow up was 83 %. Overall survival in pts who received a left lateral segment was 90%, compared to 76% in pts receiving a right trisegmentectomy graft (P 0.22). Forty-six of 92 transplants (50%) were performed in urgent recipients (UNOS status 1 and 2A). Overall, pt survival of urgent recipients was 85%, which was not significantly different from survival of non-urgent (UNOS status 2, 2B, and 3) recipients (n=46, 92%; P 0.1). Similarly, in pts receiving a right trisegmental graft, pt survival of urgent recipients (n=28, 78%) was not different from non-urgent recipients (n=17, P 0.12). However, in urgent recipients that received a left segment (n=18), pt survival (82%) was lower than non-urgent (n=29, 96% P 0.07) recipients. Overall death-censored graft survival estimates at median follow up time was 80%. Overall right segment survival was 79% (n=45) compared to 81% of the left segment (n=47, P 0.63). Overall graft survival was significantly better in urgent (n=46) than in non-urgent (n=46) recipients (89% versus 73%, P 0.05), respectively. Left segment survival in urgent (n=18) and non-urgent recipients (n=29) was 94% and 72% (P 0.14), respectively; while right the trisegment survival was 85% in urgent recipients (n=28) and 73% in non-urgent recipients (n=17, P 0.27). Primary non-function (PNF) occurred in 3 of 43 trisegmental grafts (6.9%), 4 of 44 (9%) of left segments that were split in vivo and in 1 of 5 ex vivo SLTs. Four of seven PNFs following in vivo split occurred from 2 donor organs. Portal vein thrombosis developed in one and hepatic artery thrombosis in 3 (3.5%) recipients of left segmental grafts. Only two pts required exploration for bile leaks from the cut surface of the liver. Conclusion: SLT can be performed in transplant recipients with patient and graft survival that are comparable to whole organ liver transplantation. Excellent patient and graft survival can be successfully achieved in urgent recipients. SLT is not without complications and familiarity with the procedure is required to achieve good results.