Adult Split Liver Transplantation Research Articles

The adverse impact of perioperative body composition abnormalities on outcomes after split liver transplantation: a multi-center retrospective cohort study.

Split liver transplantation increases graft availability, but its safe and effective utilization is insufficiently documented. This study aimed to investigate the association between perioperative body composition abnormalities and outcomes in adult split liver transplantation. 240 recipients who underwent split liver transplantation in three centers were enrolled in this retrospective cohort study. Body composition abnormalities including sarcopenia, myosteatosis, visceral obesity, and sarcopenic obesity were evaluated at baseline and one month after surgery using computed tomography. Their impact on outcomes including early allograft dysfunction, early complications, intensive care unit stay, graft regeneration rate and survival was analyzed. Recipients with sarcopenia or myosteatosis had a higher risk of early allograft dysfunction, higher early complication rate, and longer length of intensive care unit stay (all P<0.05), while there was no difference in graft regeneration rate. Recipient and graft survival were significantly worse for recipients with body composition abnormalities (all P<0.05). In multivariable Cox-regression analysis, sarcopenia (hazard ratio=1.765, P=0.015), myosteatosis (hazard ratio=2.066, P=0.002), and visceral obesity (hazard ratio=1.863, P=0.008) were independently associated with shorter overall survival. Piling up of the three factors increased the mortality risk stepwise (P<0.001). Recipients experienced skeletal muscle loss and muscle fat infiltration one month after surgery. Postoperative worsening sarcopenia (hazard ratio=2.359, P=0.009) and myosteatosis (hazard ratio=1.878, P=0.026) were also identified as independent risk factors for mortality. Sarcopenia, myosteatosis and their progression negatively affect outcomes including early allograft dysfunction, early complications, intensive care unit stay and survival after SLT. Systemic evaluation and dynamic monitoring of body composition are valuable.

Is it safe to expand the indications for split liver transplantation in adults? A single-center analysis of 155 in-situ splits.

IntroductionSplit liver transplantation (SLT) enables two recipients to be transplanted using a single donor liver; typically, an adult and a child. Despite equivalent long‐term outcomes to whole grafts in selected adults, the use of these grafts in high‐risk adult recipients with high model for end‐stage liver disease (MELD) scores (≥30), a poor pre‐transplant clinical status (ICU or hospital‐bound), acute liver failure or retransplantation remains controversial.MethodsWe retrospectively analyzed all deceased donor adult liver transplants performed between July 2002 and November 2019 at a single high‐volume center and performed a propensity score‐matched analysis. A subgroup analysis was performed to assess utility of these grafts for high‐risk recipients.ResultsA total of 1090 adult liver transplants were performed, including 155 SLT (14%). Graft survival at 1‐, 3‐ and 5‐years were comparable between recipients of split and whole liver grafts (82%, 79% and 74% vs. 86%, 81% and 77%, respectively, log rank P = .537), as was patient survival at 1‐, 3‐ and 5‐years. Recipients of split grafts were more likely to have biliary complications and hepatic artery thrombosis, but equivalent long‐term survival. Recipients with high MELD scores or a poor pre‐transplant clinical status had similar patient and graft survival and complication profiles irrespective of whether they received split or whole grafts.ConclusionsSLT is an important method for addressing donor shortages and provides comparable long‐term outcomes in adult recipients despite an increase in short‐term complications. SLT use in high‐risk recipients should be considered to allow for sickest‐first allocation policies.

Liberal Use of Interposition Grafts for Arterial Reconstruction Is Safe and Effective in Adult Split Liver Transplantation.

Background.Split liver transplantation (SLT) addresses donor shortages by providing 2 partial grafts from a single donor liver. Arterial reconstruction using an interposition graft facilitates the use of split grafts with difficult recipient anatomy. Its use, however, remains controversial because of a reported increased risk of complications.Methods.A retrospective review of the prospectively maintained Australian National Liver Transplantation Unit database was performed. Donor, recipient, operative, and complications data for adults receiving an SLT between July 2002 and November 2019 were extracted.Results.Arterial reconstruction required an interposition graft in 46 of 155 patients. Overall graft and patient survival were not significantly different between the groups with 1-, 3-, and 5-y graft survivals of 82%, 77%, and 69% for those with interposition grafts and 86%, 79%, and 77% for those without interposition grafts, respectively (P = 0.499). There were more cut liver bile leaks in the interposition graft group (26% versus 9%, P = 0.004), but otherwise, no significant differences in the rate of biliary complications (39% versus 29% P = 0.200), hepatic artery thrombosis (7% versus 10%, P = 0.545), or hepatic artery stenosis (13% versus 10%, P = 0.518).Conclusions.Liberal use of interposition grafts for arterial reconstruction in SLT is safe and does not result in increased complications.

Fates of retained hepatic segment IV and its prognostic impact in adult split liver transplantation using an extended right liver graft.

PurposeWhen splitting a liver for adult and pediatric graft recipients, the retained left medial section (S4) will undergo ischemic necrosis and the right trisection graft becomes an extended right liver (ERL) graft. We investigated the fates of the retained S4 and its prognostic impact in adult split liver transplantation (SLT) using an ERL graft.MethodsThis was a retrospective analysis of 25 adult SLT recipients who received split ERL grafts.ResultsThe mean model for end-stage liver disease (MELD) score was 27.3 ± 10.9 and graft-recipient weight ratio (GRWR) was 1.98 ± 0.44. The mean donor age was 26.5 ± 7.7 years. The split ERL graft weight was 1,181.5 ± 252.8 g, which resulted in a mean GRWR of 1.98 ± 0.44. Computed tomography of the retained S4 parenchyma revealed small ischemic necrosis in 16 patients (64.0%) and large ischemic necrosis in the remaining 9 patients (36.0%). No S4-associated biliary complications were developed. The mean GRWR was 1.87 ± 0.43 in the 9 patients with large ischemic necrosis and 2.10 ± 0.44 in the 15 cases with small ischemic necrosis (P = 0.283). The retained S4 parenchyma showed gradual atrophy on follow-up imaging studies. The amount of S4 ischemic necrosis was not associated with graft (P = 0.592) or patient (P = 0.243) survival. A MELD score of >30 and pretransplant ventilator support were associated with inferior outcomes.ConclusionThe amount of S4 ischemic necrosis is not a prognostic factor in adult SLT recipients, probably due to a sufficiently large GRWR.

Adult split liver transplantation: A PRISMA-compliant Chinese single-center retrospective case-control study.

Although pediatric split liver transplantation (SLT) has been proven safe and the waitlist mortality rate has been successfully reduced, the safety of adult SLT has not been confirmed.Using 1:2 matching, 47 recipients who underwent adult SLT were matched to 94 of 743 recipients who underwent adult whole graft liver transplantation (WGLT). Eventually, 141 recipients were included in the case-control study. Subgroup analysis of 43 recipients in the SLT group was performed based on the presence of the middle hepatic vein (MHV) in the grafts.No significant differences in 5-year survival (80.8% vs 81.6%, P = .465) were observed between the adult SLT and WGLT groups. However, compared to recipients in the WGLT group, those in the SLT group had more Clavien-Dindo grade III-V complications, longer hospitalization duration, and higher mortality within 45 days. Furthermore, on multivariate analysis, 45-day postoperative mortality in recipients in the SLT group was mainly affected by hyperbilirubinemia within postoperative day (POD) 7-14, surgery time, and intraoperative blood loss. Subgroup analysis showed no significant differences in hyperbilirubinemia within POD 7-14, complications, and survival rate between SLTMHV(+) and SLTMHV [-].Adult SLT is safe and effective based on long-term survival rates; however, a reduction in the incidence of short-term complications is required. Non-obstructive hyperbilirubinemia within POD 7 to 14 is an independent predictor of short-term mortality after SLT.

Fates of retained hepatic segment IV and its prognostic impact in adult split liver transplantation using an extended right liver graft

Fates of retained hepatic segment IV and its prognostic impact in adult split liver transplantation using an extended right liver graft

Prognosis of Split Liver Transplantation Compared with Whole Liver Transplantation in Adult Patients: Single-center Results under the Korean MELD Score-based Allocation Policy.

BackgroundSplit liver transplantation (SLT) has been occasionally performed in Korea. This study compared the incidence and prognosis of SLT with whole liver transplantation (WLT) in adult patients.MethodsBetween June 2016 and November 2019, 242 adult patients underwent a total of 256 deceased donor liver transplantation operations. SLT was performed in 7 patients (2.9%).ResultsThe mean age of SLT donors was 29.7 ± 7.4 years, and the mean age of recipients was 55.7 ± 10.6 years, with the latter having a mean model for end-stage liver disease score of 34.6 ± 3.1. Mean split right liver graft weight was 1,228.6 ± 149.7 g and mean graft-recipient weight ratio was 1.97 ± 0.39. Of the seven SLT recipients, Korean Network for Organ Sharing (KONOS) status was one in status 1, one in status 2 and five in status 3. The graft (P = 0.72) and patient (P = 0.84) survival rates were comparable in the SLT and WLT groups. Following propensity score matching, graft (P = 0.61) and patient (P = 0.91) survival rates remained comparable in the two groups. Univariate analysis showed that pretransplant ventilator support and renal replacement therapy were significantly associated with patient survival, whereas KONOS status category and primary liver diseases were not. Multivariate analysis showed that pretransplant ventilator support was an independent risk factor for patient survival.ConclusionSurvival outcomes were similar in adult SLT and WLT recipients, probably due to selection of high-quality grafts and low-risk recipients. Prudent selection of donors and adult recipients for SLT may expand the liver graft pool for pediatric patients without affecting outcomes in adults undergoing SLT.

Feasibility and Safety of Split-Liver Transplantation in a Nascent Framework of Deceased Donation.

Split-liver transplantation (SLT) is a valuable option for optimizing the use of good-quality deceased donor grafts. It is not routinely reported outside the West because of limited deceased donor numbers, technical and organizational constraints, lack of experience, and a predominant living donor liver transplantation (LDLT) practice. At our center, 20% of the liver transplantations (LTs) are from deceased donors. We report our experience of SLT and compare outcomes with pediatric and adult LDLT recipients. A prospectively maintained database of all LT recipients between September 2009 and March 2017 was analyzed. Each pediatric SLT recipient was matched to 2 pediatric LDLT recipients for age, weight, urgency, and year of transplant. Each adult SLT recipient was similarly matched to 2 adult LDLT recipients for age, Model for End-Stage Liver Disease score, and year of transplant. Intraoperative and postoperative parameters, including recovery time, morbidity (biliary and vascular complications, Clavien grade >IIIA complications), and mortality were compared. In total, 40 SLTs were performed after splitting 20 deceased donor livers (in situ, n=11; hybrid split, n=3; and ex vivo, n=6). Recipients included 22 children and 18 adults. There were 18 livers that were split conventionally (extended right lobe and left lateral segment [LLS]), and 2 were right lobe-left lobe SLTs. Also, 3 LLS grafts were used as auxiliary grafts for metabolic liver disease. Perioperative mortality in SLT recipients occurred in 3 patients (2 children and 1 adult). Incidence of vascular, biliary, and Clavien grade >IIIA complications were similar between matched adult and pediatric SLT and LDLT groups. In conclusion, SLT is an effective technique with outcomes comparable to living donor grafts for adult and pediatric recipients. Using SLT techniques at centers with limited deceased donors optimizes the use of good-quality whole grafts and reduces the gap between organ demand and availability.

Split liver transplantation in adults.

Split liver transplantation (SLT), while widely accepted in pediatrics, remains underutilized in adults. Advancements in surgical techniques and donor-recipient matching, however, have allowed expansion of SLT from utilization of the right trisegment graft to now include use of the hemiliver graft as well. Despite less favorable outcomes in the early experience, better outcomes have been reported by experienced centers and have further validated the feasibility of SLT. Importantly, more than two decades of experience have identified key requirements for successful SLT in adults. When these requirements are met, SLT can achieve outcomes equivalent to those achieved with other types of liver transplantation for adults. However, substantial challenges, such as surgical techniques, logistics, and ethics, persist as ongoing barriers to further expansion of this highly complex procedure. This review outlines the current state of SLT in adults, focusing on donor and recipient selection based on physiology, surgical techniques, surgical outcomes, and ethical issues.

Outcomes of Full-Right-Full Left Split Liver Transplantation in Adults in US: A Propensity-Score Matched Ananlysis.

Outcomes of Full-Right-Full Left Split Liver Transplantation in Adults in US: A Propensity-Score Matched Ananlysis.

Split liver transplantation in adults: Preoperative estimation of the weight of right and left hemiliver grafts

Split liver transplantation in adults: Preoperative estimation of the weight of right and left hemiliver grafts

Split and living donor liver transplantation

The split liver transplant allows for the division of a graft in two parts, usually the right side for an adult and the left side for use in a child. To date, many centres have confirmed the efficacy and safety of the procedure. However, the highly demanding surgery and the relatively low activity, associated with the low number of ideal donors, and few adequate recipients, and most of all, the compromised long-term outcome, have resulted in a significant decrease of adult to adult split liver transplantation. The real incidence of morbidity and mortality has been a matter of controversy. While some authors suggest a 15% morbidity rate, others have pointed out a higher incidence reaching up to 70%. Recent data, however, show that at least 38% of all donors had some type of complication: The official European Liver Transplant Registry (ELTR) guarantees that the mortality rate associated to the donor operation is well established in Europe (0.2%, 1997–2007). To date post-transplant survival at one and three years are 92% and 84.8% respectively. To summarize, currently, adult living donor liver transplantation has the same probability of survival at 1 and 5 years when compared to deceased donor liver transplantation.

Reduction in bile leaks following adult split liver transplant using a fibrin-collagen sponge: A pilot study

Bile leaks are a frequent complication of adult split liver transplantation. We compared surgical complications in patients who had the cut surface of the donor liver treated with a patch to those in whom the cut surface of the liver was treated with fibrin glue. Two consecutive cohorts of 16 patients undergoing adult right lobe split liver transplant were compared. In the first cohort, the liver surface was treated with fibrin glue and in the second the liver surface was treated with TachoSil fibrinogen-thrombin-collagen patches. Post-operative complications were analyzed. Bile leaks were significantly fewer among patients in whom the cut surface of the liver was treated with fibrin-collagen sponge compared to those where fibrin glue was used on the cut surface: 1/16 (6.25%) vs. 7/16 (43.75%), respectively; p=0.03. There were some differences in biliary anastomotic techniques used in the two groups but 7/8 leaks (87.5%) arose from the cut surface, and only one was from the anastomosis. Using a fibrinogen-thrombin-collagen sponge patch may reduce bile leaks from the cut surface of the liver during adult right lobe split liver transplants.

Improved Results for Adult Split Liver Transplantation With Extended Right Lobe Grafts: Could We Enhance Its Application?

Objective Split liver transplantation (SLT) allows grafting of 2 recipients with 1 allograft. Results of adult SLT have improved since its first introduction. Children benefit most from SLT, while among some adult liver transplanters there are concerns about splitting a liver, turning a good quality graft into a marginal one. We performed a single center retrospective review to address this issue. Patients and Methods Between June 2001 and August 2008, we performed 22 extended right liver graft (eRLG) transplantations in 21 adult patients. Results Eleven donors (50%) did not meet the Eurotransplant criteria for optimal donors. Forty-one percent of eRLG donors showed hemodynamic instability at the time of harvest. Eighteen (82%) splitting procedures were performed ex situ. The main indications for transplantation were alcoholic liver cirrhosis (32%), hepatitis C-related cirrhosis (18%), and acute liver failure (18%). Mean recipient age was 54 years (range, 17–69 years); median Model for End-Stage Liver Disease (MELD) score was 15 (range, 7–40). Patients were followed for a median of 16 months (range, 4–92 months) following transplantation. We observed 5 (23%) vascular and 3 (14%) biliary complications. Overall patient survival was 84% at 3 years; overall graft survival was 79%. For the 11 patients who had undergone transplantation after 2007, we observed a 100% patient and graft survival. Conclusion After an initial learning curve and provided careful selection, exceptions to classical donor criteria for splitting can be accepted with successful outcomes comparable to those after whole liver transplantation.

WITHDRAWN: Improved Results for Adult Split Liver Transplantation With Extended Right Lobe Grafts: Could We Enhance Its Application?

Split liver transplantation (SLT) allows grafting of 2 recipients with 1 allograft. Results of adult SLT have improved since its first introduction. Children benefit most from SLT, while among some adult liver transplanters there are concerns about splitting a liver, turning a good quality graft into a marginal one. We performed a single center retrospective review to address this issue. Between June 2001 and August 2008, we performed 22 extended right liver graft (eRLG) transplantations in 21 adult patients. Eleven donors (50%) did not meet the Eurotransplant criteria for optimal donors. Forty-one percent of eRLG donors showed hemodynamic instability at the time of harvest. Eighteen (82%) splitting procedures were performed ex situ. The main indications for transplantation were alcoholic liver cirrhosis (32%), hepatitis C-related cirrhosis (18%), and acute liver failure (18%). Mean recipient age was 54 years (range, 17-69 years); median Model for End-Stage Liver Disease (MELD) score was 15 (range, 7-40). Patients were followed for a median of 16 months (range, 4-92 months) following transplantation. We observed 5 (23%) vascular and 3 (14%) biliary complications. Overall patient survival was 84% at 3 years; overall graft survival was 79%. For the 11 patients who had undergone transplantation after 2007, we observed a 100% patient and graft survival. After an initial learning curve and provided careful selection, exceptions to classical donor criteria for splitting can be accepted with successful outcomes comparable to those after whole liver transplantation.

Geriatric pharmacotherapy updates

Bile leaks are a frequent complication of adult split liver transplantation. We compared surgical complications in patients who had the cut surface of the donor liver treated with a patch to those in whom the cut surface of the liver was treated with fibrin glue.Two consecutive cohorts of 16 patients undergoing adult right lobe split liver transplant were compared. In the first cohort, the liver surface was treated with fibrin glue and in the second the liver surface was treated with TachoSil® fibrinogen-thrombin-collagen patches. Post-operative complications were analyzed.Bile leaks were significantly fewer among patients in whom the cut surface of the liver was treated with fibrin-collagen sponge compared to those where fibrin glue was used on the cut surface: 1/16 (6.25%) vs. 7/16 (43.75%), respectively; p = 0.03. There were some differences in biliary anastomotic techniques used in the two groups but 7/8 leaks (87.5%) arose from the cut surface, and only one was from the anastomosis.Using a fibrinogen-thrombin-collagen sponge patch may reduce bile leaks from the cut surface of the liver during adult right lobe split liver transplants.

Does middle hepatic vein omission in a right split graft affect the outcome of liver transplantation? A comparative study of right split livers with and without the middle hepatic vein

Preservation of the middle hepatic vein (MHV) for a right split liver transplantation (SLT) in an adult recipient is still controversial. The aim of this study was to evaluate the graft and patient outcomes after liver transplantation (LT) using a right split graft, according to the type of venous drainage. From February 2000 to May 2006, 33 patients received 34 cadaveric right split liver grafts. According to the type of recipient pairs (adult/adult or adult/child), the right liver graft was deprived of the MHV or not. The first group (GI, n = 15) included grafts with only the right hepatic vein (RHV) outflow, the second (GII, n = 18) included grafts with both right and MHV outflows. The 2 groups were similar for patient demographics, initial liver disease, and donor characteristics. In GI and GII, graft-to-recipient-weight ratio (GRWR) was 1.2 +/- 0% and 1.6 +/- 0.3% (P < 0.05), and cold ischemia time was 10 hours 55 minutes +/- 2 hours 49 minutes and 10 hours 47 minutes +/- 3 hours 32 minutes, respectively (P = not significant). Postoperative death occurred in 1 patient in each group. Vascular complications included anastomotic strictures: 2 portal vein (PV), 1 hepatic artery (HA), and 1 RHV anastomotic strictures; all in GI. Biliary complications occurred in 20% and 22% of the patients, in GI and GII, respectively (P = not significant). There were no differences between both groups regarding postoperative outcome and blood tests at day 1-15 except for a significantly higher cholestasis in GI. At 1 and 3 yr, patient survival was 94% for both groups and graft survival was 93% for GI and 90% for GII (P = not significant). In conclusion, our results suggest that adult right SLT without the MHV is safe and associated with similar long-term results as compared with those of the right graft including the MHV, despite that early liver function recovered more slowly. Technical refinements in outflow drainage should be evaluated in selected cases.

Temporary transjugular intrahepatic portosystemic shunt to overcome small-for-size syndrome after right lobe adult split liver transplantation

Temporary transjugular intrahepatic portosystemic shunt to overcome small-for-size syndrome after right lobe adult split liver transplantation

A case report of split liver transplantation for two adult recipients in Korea

We report a case of split liver transplantation (SLT) for two adult recipients, which was the first successful case in Korea. The brain-dead donor was a 22-year-old man weighing 65 kg, but his liver volume was estimated as 2120 mL on computed tomographic volumetry. As it seemed to be too large for a 60-kg recipient candidate, SLT was planned after assessment of lobar liver volume and middle hepatic vein anatomy. The right lobe was mobilized first and the liver parenchyma transected along the right border of the middle hepatic vein. The 1240-g right lobe (segments 5 to 8) graft was implanted into a 57-year-old male patient with acute-on-chronic liver failure in the same manner as a living-donor graft. After that, routine procedures of cadaveric multiorgan procurement were performed. The 670-g left lobe (segments 1 to 4) with a retrohepatic vena cava, common bile duct, and aortic patch was implanted into another 37-year-old male recipient. These two recipients recovered uneventfully surviving 12 months to date. We integrated the surgical techniques learned from hundreds of adult-to-adult living donor liver transplants into this first trial of two adult SLT.

Living-donor and split-liver transplantation in adults: right versus left-sided grafts.

The pioneers of liver transplantation established thetechnical aspects of orthotopic grafting and its efficacyas a treatment for endstage liver disease. Progress washampered by rejection, but the improved immuno-therapy provided by cyclosporine was followed by ex-ponential growth in clinical liver transplantation duringthe 1980s, with expansion in the number of transplantcenters around the world and the consequent rapidincrease in the number of transplants performed. Thesuccess of the procedure, the reduction in the absoluteand relative contraindications to liver transplantation,and the widening of the spectrum of disease processesdeemed amenable to liver replacement led to the num-ber of patients waiting for a liver transplant far exceed-ing the available donor liver grafts. Due to the paucityof whole organs from pediatric donors, this discrepancywas always present for young children, for whom therewas a pretransplant mortality of greater than 25%.