SPLIT LIVER TRANSPLANTATION FOR TWO ADULTS WITH FULL-LEFT AND RIGHT LOBES

Abstract

O27 Aims: To evaluate results of split liver transplantation in two adults. Patients and methods: From february 2000 to january 2004, 26 adult patients received 13 full-left lobes grafts and 13 right liver grafts. All livers were split ex-situ. Donors were 11 males and 2 females with a mean age of 25 years (range : 19 – 38); of those, 7 (54%) had one episode of hemodynamic instability. Exact knowledge of vascular and biliary distribution was assessed by careful pedicle dissection and back table arteriography and cholangiography. Section of the liver was performed with harmonic scalpel along the main portal scissure, hemostasis and biliostasis was completed with running sutures along both cut surfaces. The left lobe comprised segments 1 to 4 according to the Couinaud classification, the middle hepatic vein and the inferior vena cava. For each graft, arterial and portal supply was preserved according to vascular anatomy, in most cases separation was achieved at the origin of the left and right branches. The common bile duct was retained with the right liver graft in all cases. All grafts were transplanted orthotopically with preservation of the inferior vena cava for the right liver grafts and after removal of it for the left liver grafts. All grafts were weighted and when the graft-to-recipient weight ratio (GRWR) was less than 0.9%, a porto-mesenterical disconnexion was done by performing a H-graft meso-caval shunt and ligation of the superior mesenteric vein downstream the shunt. Results: Mean GRWR was 1.12% (range : 0.9 – 1.6) in patients who received the right liver and 0.81% (range : 0.57 – 1.36) in patients with left liver. For those who had porto-mesenterical disconnexion, the mean GRWR was 0.7% (range : 0.57 – 0.89). mean cold ischemia time was 695 min (range : 420 – 940) and 743 min (range : 490 – 980) for the right and left liver grafts respectively (NS). After LT, none of the patients had initial primary graft non-function, hepatic artery or portal vein thrombosis. In patients with left livers main complications comprised bacterial hepatitis (n=3), sepsis (n=4), progressive hepatic ischemia due to spontaneous porto-systemic shunts (n=2), biliary stenosis (n=1) and cardiac failure (n=1). Two of these patients had early retransplantation. In patients with right liver grafts, 2 patients experienced hepatic vein stenosis which resolved after radiologic balloon dilatation, 2 sepsis and 1 biliary stenosis. Both biliary stenosis were successfully treated with endoscopic manœuvrers. After a mean follow-up of 20 months (range : 3 – 48), patient and graft survivals are 92% and 92% and 69% and 60% for right and left grafts respectively. Causes of patient death were sepsis in 3 patients and cardiac failure in 2. Conclusions: While transplanted right liver cadaveric grafts give good results in adult recipients, outcome is less satisfactory with full-left split liver grafts. Improvement of results with left grafts will necessitate better selection of donors and recipients as well as more technical refinements.