Split Liver Grafts Research Articles

Normothermic Liver Machine Perfusion and Successful Transplantation of Split Liver Grafts: From Proof of Concept to Clinical Implementation.

Normothermic liver machine perfusion (NLMP) is advancing the field of liver transplantation (LT). Beyond improved preservation and organ assessment, NLMP helps to increase organ utilization. We herein address the feasibility and merit of NLMP in split liver transplantation (SLT) to postpone the transplantation of the second split graft to the following day. We analyzed the perfusion characteristics and outcomes of all consecutive adult recipients who underwent SLT following NLMP from February 1, 2018, to June 30, 2023. The primary endpoint was 90-d graft and patient survival. Secondary endpoints were posttransplant complications and 90-d morbidity. Three right and 3 extended right SLT following NLMP have been performed. NLMP was uneventful in all cases. Perfusion characteristics differed according to graft volume. Mean perfusion time was 17:00 h (±05:13) and bile production ranged between 8 and 21 mL/h. All split grafts fulfilled predefined center viability criteria during NLMP and were transplanted on the following day. The 90-d graft and patient survival rate was 100%. Three patients (50%) required an early relaparotomy, and 2 patients (33.3%) developed biliary complications. The 90-d morbidity as recorded by the comprehensive complication index was 62.7 (±24.7). NLMP of split liver grafts is technically feasible and safe. Through prolongation of preservation time, NLMP allows to safely postpone transplantation of the second split liver graft to the next day.

Combining living and deceased donation for pediatric first isolated liver transplantation: A win-win even in countries with high deceased donor donation rates.

Split and living donor liver transplantations are both key surgical strategies for development of pediatric liver transplant programs. Often, however, teams tend to prioritize only one preferentially. In the context of a very active national split liver graft allocation program (Italy), retrospective study of 226 consecutive pediatric first isolated liver transplants performed by a single team using organs from both deceased and living donors. Clinical characterisitics and outcome were compared. In the context of a steadily slowly decreasing split graft offer, living donation activity steadily increased. Deceased and living donation accounted for 52.6% and 47.4% of transplantations, respectively. Both strategies were equally used for transplanting patients up to 30 kg of weight, while deceased donors were predominantly used for older recipients. Technical variants represented 86% of all transplants, with 183 conisting of left lateral segment grafts (76 split liver grafts and 107 left grafts from living donors). Outcome of both surgical strategies was similar, with excellent outcomes at early, mid-, and long-term. Splitting livers of deceased donors and using living donation were complementary and non-competitive strategies for developping pediatric liver transplant activity. Implementing both activities in parallell allowed to maintain stable the number of annual transplant in Italy and allowed to reach superior outcomes. This analysis provides evidence that living donation plays a role in Italy despite an existing very active "mandatory-split" national policy.

Improving outcomes of in situ split liver transplantation in Italy over the last 25 years

Split liver transplant(ation) (SLT) is still considered a challenging procedure that is by no means widely accepted. We aimed to present data on 25-year trends in SLT in Italy, and to investigate if, and to what extent, outcomes have improved nationwide during this time. The study included all consecutive SLTs performed from May 1993 to December 2019, divided into three consecutive periods: 1993-2005, 2006-2014, and 2015-2019, which match changes in national allocation policies. Primary outcomes were patient and graft survival, and the relative impact of each study period. SLT accounted for 8.9% of all liver transplants performed in Italy. A total of 1,715 in situ split liver grafts were included inthe analysis: 868 left lateral segments (LLSs) and 847 extended right grafts (ERGs). A significant improvement in patient and graft survival (p <0.001) was observed with ERGs over the three periods. Predictors of graft survival were cold ischaemia time (CIT) <6h (p= 0.009), UNOS status 2b (p <0.001), UNOS status 3 (p= 0.009), and transplant centre volumes: 25-50 cases vs. <25 cases (p= 0.003). Patient survival was significantly higher with LLS grafts in period 2 vs. period 1 (p= 0.008). No significant improvement in graft survival was seen over the three periods, where predictors of graft survival were CIT <6h (p= 0.007), CIT <6h vs. ≥10h (p= 0.019), UNOS status 2b (p= 0.038), and UNOS status 3 (p= 0.009). Retransplantation was a risk factor in split liver graft recipients, with significantly worse graft and patient survival for both types of graft (p <0.001). Our analysis showed Italian SLT outcomes to have improved over the last 25 years. These results could help to dispel reservations regarding the use of this procedure. Split liver transplant(ation) (SLT) is still considered a challenging procedure and is by no means widely accepted. This study included all consecutive in situ SLTs performed in Italy from May 1993 to December 2019. With more than 1,700 cases, it is one of the largest series, examining long-term national trends in in situ SLT since its introduction. The data presented indicate that the outcomes of SLT improved during this 25-year period. Improvements are probably due to better recipient selection, refinements in surgical technique, conservative graft-to-recipient matching, and the continuous, yet carefully managed, expansion of donor selection criteria under a strict mandatory split liver allocation policy. These results could help to dispel reservations regarding the use of this procedure.

135: Use of a split liver graft to facilitate adult mutlivisceral transplantation in a small adult recipient

135: Use of a split liver graft to facilitate adult mutlivisceral transplantation in a small adult recipient

Where to Draw the Line in Ex-Situ Split Liver Transplantation for Adult Recipients? – A Benchmarking Analysis

Abstract Background A comprehensive outcome analysis of ex situ right split liver graft transplantation (RSLT) is currently lacking. Aims Benchmarking outcomes of RSLT against best achievable results from whole LT offers a novel comparative approach. Methods This retrospective study includes all consecutive ex-situ RSLT for adult recipients performed from 2014-2019 at 4 high volume transplant centers (&amp;gt;70 LT/year). Outcomes including overall morbidity expressed by the comprehensive complication index (CCI) and graft related complications were compared to the published benchmark cutoffs for whole graft LT. Results We included 129 ex-situ RSLT with 76% H45678 (n=98) and 24% (n=31) H5678 grafts. The median follow-up was 4.8 years. Overall and severe 1-year morbidity expressed by the CCI were within established whole graft LT benchmarks. Biliary complication rates were slightly higher than the benchmark due to the occurrence of cut-surface leaks. The arterial thrombosis rate was outside the benchmark cutoff (7% vs ≤4.4%) leading to a higher retransplantation rate. However, overall 1-year graft and recipient mortality were well within the benchmark cutoffs, resulting in a 5-year overall recipient survival of 88.5%. Selecting benchmark cases for RSLT defined by low-risk recipient-donor criteria including static cold storage time ≤10h and recipient MELD≤20 points, did not significantly reduce overall morbidity nor arterial complication rate. In contrast, the type of split graft (H45678 vs.H5678) did impact on both arterial and biliary complications. Conclusions This large multicenter series of ex-situ right split grafts disclosed an overall 1-year morbi-mortality comparable to the best achievable results in whole graft LT. The results show that the main morbidity burden in adult RSLT is related to technical criteria rather than graft-recipient matching.

Applicability of the histidine-tryptophan-ketoglutarate solution as a machine perfusion solution for marginal liver grafts.

There are very few reports comparing the use of the University of Wisconsin solution and histidine-tryptophan-ketoglutarate solution as machine perfusion solutions for marginal liver grafts. We aimed to clarify whether the use of the histidine-tryptophan-ketoglutarate solution in hypothermic machine perfusion improves the split-liver graft function in a large animal model. Porcine split-liver grafts were created by 75% liver resection. Hypothermic machine perfusion experimental groups were divided as follows: Group 1, perfusate, University of Wisconsin gluconate solution (UW group; n=5), and Group 2, perfusate, histidine-tryptophan-ketoglutarate solution (HTK group; n=4). After 4h of preservation, the liver function was evaluated using an isolated liver reperfusion model for 2h. In the HTK group, the portal vein and hepatic artery resistance during hypothermic machine perfusion and the portal vein resistance during isolated liver reperfusion were lower than those in the UW group. In addition, the total Suzuki score for hepatic ischemia-reperfusion injury in the HTK group was significantly better than that in the UW group. The number of anti-ETS-related genes staining-positive sinusoid epithelial cell nuclei in the HTK group was higher than that in the UW group (not significant). The histidine-tryptophan-ketoglutarate solution can be perfused with lower vascular resistance than the University of Wisconsin solution, reducing shear stress and preventing sinusoid epithelial cell injury in marginal grafts used as split-liver grafts.

Biliary complications following split liver transplantation in adult recipients: a matched pair analysis on single-center experience.

The utilization of split liver grafts can increase access to liver transplantation (LT) for adult patients, particularly when liver grafts are shared between 2 adult recipients. However, it is yet to be determined whether split liver transplantation (SLT) increases the risk of biliary complications (BCs) compared with whole liver transplantation (WLT) in adult recipients. This retrospective study enrolled 1441 adult patients who underwent deceased donor LT at a single-site between January 2004 and June 2018. Of those, 73 patients underwent SLTs. Graft type for SLT includes 27 right trisegment grafts, 16 left lobes, and 30 right lobes. A propensity score matching analysis selected 97 WLTs and 60 SLTs. Biliary leakage was more frequently seen in SLTs (13.3% vs. 0%; p <0.001), whereas the frequency of biliary anastomotic stricture was comparable between SLTs and WLTs (11.7% vs. 9.3%; p=0.63). Graft and patient survival rates of patients undergoing SLTs were comparable to those undergoing WLTs (p=0.42 and 0.57, respectively). In the analysis of the entire SLT cohort, BCs were seen in 15 patients (20.5%) including biliary leakage in 11 patients (15.1%) and biliary anastomotic stricture in 8 patients (11.0%) [both in 4 patients (5.5%)]. The survival rates of recipients who developed BCs were significantly inferior to those without BCs (p <0.01). By multivariate analysis, the split grafts without common bile duct increased the risk of BCs. In conclusion, SLT increases the risk of biliary leakage compared with WLT. Biliary leakage can still lead to fatal infection and thus should be managed appropriately in SLT.

Clinical outcomes of transjugular intrahepatic portosystemic shunt with PTFE-covered stents after liver transplantation and technical results in split and whole liver graft recipients.

To assess the outcomes of transjugular intrahepatic portosystemic shunt (TIPS) creation using PTFE-covered stents in liver transplant (LT) recipients and to analyze the technical result of TIPS creation in split grafts (SG) compared with whole liver grafts (WG). Single-center, retrospective study, analyzing LT patients who underwent TIPS using PTFE-covered stents. Clinical and technical variables were analyzed. Between 2005 and 2021, TIPS was created using PTFE-covered stents in 48 LT patients at a median of 43 months (range, 0.5-192) after LT. TIPS indications were refractory ascites (RA) in 33 patients (69%), variceal bleeding (VB) in 9 patients (19%), others in 6 (12%). Ten patients (21%) received a SG. Technical success rate was 100% in both groups: in two WG recipients, (5%) a second attempt was required. An unconventional approach (combined transhepatic or transplenic access) was needed in 2 WG (5%) and 2 SG recipients (20%). Two procedure-related death occurred in the WG group. After a median follow-up of 22 months (range, 0,1-144), 16 patients (48%) in the RA group did not require post-TIPS paracentesis, in the VB group rebleeding occurred in 3 patients (33%). Fifteen patients (31%) underwent TIPS revision. Overt hepatic encephalopathy occurred in 14 patients (29%). Patient survival at 6 months, 1 year, and 3 years was 77%, 66%, and 43%, respectively. The feasibility and safety of TIPS creation in SG are comparable to that of WG. TIPS creation using PTFE-covered stents represents a viable option to treat portal hypertensive complications in LT recipients. • TIPS creation using PTFE-covered stents represents a viable option to treat complications of PH in LT recipients. • TIPS creation in LT SG recipients appears to be safe and feasible as in WG. • Results from this study may help to refine the management of LT patients with recurrent portal hypertensive complications encouraging physicians to consider TIPS creation as a treatment option in both SG and WG recipients.

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.

The Use of a Single, Novel Preservation Solution in Split Liver Transplantation and Hypothermic Oxygenated Machine Perfusion.

Split liver transplantation was introduced to increase organ availability, but its inherent prolonged cold ischemia raises the risks of ischemia/reperfusion injury (IRI). For this reason, the split partial liver grafts are considered to be marginal grafts, which also occur for fatty liver grafts. These organs are highly vulnerable to IRI, which can lead to different types of organ failure (such as small-for-size syndrome) after transplantation. Under these conditions, hypothermic oxygenated perfusion (HOPE) techniques constitute a promising strategy to minimize the deleterious effects of IRI, as shown by Muller et al1 in the context of controlled donation after circulatory death. Besides, all trials using split liver grafts are excluded when applying HOPE. Thus, the communication by Mabrut et al2 is highly relevant for the field. Specifically, Mabrut et al2 proposed a surgical design that allows cold static preservation to be combined with HOPE in the setting of split liver preservation. This approach not only reduces the time of cold ischemia (and therefore injury sustained due to it) but also reduces the warm ischemic injury inherent to surgical manipulation that occurs in normothermic conditions when conventional split techniques are used for liver transplantation. In our opinion, it is noteworthy that the HOPE application has been extended to different pools of organs, improving their preservation. Here, we would like to highlight that there is still a window to further reduce cold ischemic injuries associated with surgical procedures, such as in split liver strategies. Based on our previous experimental works in rats, we have tested the benefits of a new preservation solution, for decreasing cold ischemic injuries during static and HOPE preservation using steatotic grafts and normal grafts.3,4 In addition, the use of a unique solution for both static preservation and HOPE—and especially when they are combined—would provide further benefit by facilitating the whole preservation period. In our group experience, the use of this solution/perfusate for cold static and dynamic preservation, containing polyethylene glycol 35 rather than hydroxyethyl starch and an increased concentration of glutathione, improves preservation in both strategies (eg, cold static and dynamic preservation).3,4 In addition, its use may prevent the proaggregating effects of hydroxyethyl starch and favor the mechanotransduction mechanisms inherent to HOPE, thereby protecting the glycocalyx and contributing to maintaining its integrity.5 Moreover, this new preservation solution has a lower viscosity as compared with University of Wisconsin or Belzer-MPS solutions, which facilitates rinsing the organ and HOPE procedures.3,5 This lower viscosity also helps to improve the glycocalyx preservation, which in turn promotes the microcirculation of the graft, as well as the generation of nitric oxide; notably, nitric oxide acts as a vasodilator, which is beneficial in steatotic grafts.3 All of these effects would be consistent with the relevance of solution/perfusate associated with the modulation of inflammation events existing in liver graft preservation procedures,3,4 which influence the graft outcome after transplantation. In addition, we would like to note that, presumably, the polyethylene-glycol-35–promoted mitochondrial protection and the induction of protective autophagy during hypothermic preservation are linked to the reduction of graft injury.3-5 In sum, we believe that the use of a single solution for split graft flushing, preservation, and perfusion by HOPE—such as Institut Georges Lopez 2—should be considered for reducing the deleterious effects of IRI and thereby maximizing the benefits of ex vivo liver splitting and the HOPE strategies reported by Mabrut et al2 for split liver transplantation purposes.

Recurrent graft failure secondary to portal vein steal syndrome: a case report with an unusual indication for a third liver transplant

BackgroundPortal vein shunt is common in chronic hepatic diseases and after a liver transplant. Ensuring a satisfactory portal flow is essential to support a rapid liver recovery, of paramount importance to meet the recipient’s metabolic needs.Case presentationWe report the case of a 32-year-old female undergoing a third liver transplant due to recurrence of graft failure secondary to portosystemic shunting. The patient, affected with biliary atresia, was first transplanted in 2009 with a right split liver graft. The clinical course was complicated by biliary stenosis of the Roux-en-Y anastomosis and multiple episodes of acute rejection treated with steroid boluses, plastic dilation of the biliary anastomosis, and biliary catheter placement. Unfortunately, in 2017 a liver biopsy showed an autoimmunity with histological evidence of ANA 1:80 (granular and nucleolar pattern). This was a contributing factor of liver function impairment, leading to the need to perform a second liver transplant, complicated by an acute rejection, with only a partial response to steroid therapy. Due to the further worsening of the liver function (MELD: 40, Child–Pugh: C11), the patient was relisted for a liver transplant. After five days, she received her third liver transplant, with an entire graft of an AB0 identical group. Intraoperative exploration revealed multiple collaterals and large splenocaval shunts, with a significant alteration of the portal flow and hypertension, isolated and closed with a vascular stapler to restore the graft's regular portal vein flow.ConclusionsIn patients listed for a liver transplant, portal steal syndrome should be identified prior to the transplant. Our recommendation is to consider intraoperative or perioperative closure of the portal collateral varices.

Liver Transplant in Adult Recipients Using Split Liver Grafts

Introduction: Split liver transplantation (SLT) has gained prominence in transplantation due to its potential to overcome the organ shortage. However, SLT is technically challenging and has been associated with higher rates of postoperative complications leading to concerns about graft and patient survival. Moreover, there are few studies on matched-pair recipients of SLT and whole-liver transplant (WLT), with conflicting results.

Beneficial effects of end-ischemic oxygenated machine perfusion preservation for split-liver transplantation in recovering graft function and reducing ischemia\u2013reperfusion injury

This study examined the efficacy of end-ischemic hypothermic oxygenated machine perfusion preservation (HOPE) using an originally developed machine perfusion system for split-liver transplantation. Porcine split-liver grafts were created via 75% liver resection after 10 min of warm ischemia. In Group 1, grafts were preserved by simple cold storage (CS) for 8 h (CS group; n = 4). In Group 2, grafts were preserved by simple CS for 6 h and end-ischemic HOPE for 2 h (HOPE group; n = 5). All grafts were evaluated using an isolated ex vivo reperfusion model with autologous blood for 2 h. Biochemical markers (aspartate aminotransferase and lactate dehydrogenase levels) were significantly better immediately after reperfusion in the HOPE group than in the CS group. Furthermore, the HOPE group had a better histological score. The levels of inflammatory cytokines (tumor necrosis factor-α, interferon-γ, interleukin-1β, and interleukin-10) were significantly lower after reperfusion in the HOPE group. Therefore, we concluded that end-ischemic HOPE for split-liver transplantation can aid in recovering the graft function and reducing ischemia–reperfusion injury. HOPE, using our originally developed machine perfusion system, is safe and can improve graft function while attenuating liver injury due to preservation.

Impact of length of donor ICU stay on outcome of patients after pediatric liver transplantation with whole and ex situ split liver grafts.

Patients who have a prolonged stay in the intensive care unit (ICU) are often excluded for organ donation because of supposed deleterious effects of a lengthy ICU stay. We aimed to determine the effects of a prolonged donor stay in the ICU on the outcome of liver transplantation (LT) in children. Retrospective review of 89 pediatric LT patients, age 0-18years, period 2003-2018, including patients having undergone whole organ or in situ split LT. The patients were divided into two groups according to the donor length of stay in the ICU. A prolonged stay was defined as >5days. Recipient, graft, and donor characteristics were compared; outcome parameters included recipient and graft survival rates and postoperative complications. Group short (donor ICU stay <5days) included 75 patients, group long (donor ICU stay >5days) 14 patients. Baseline characteristics between recipients did not differ. Donors in group long had significantly more infectious complications and a higher gamma glutamyl transferase (gGT) the day of organ recovery. Incidence of biliary complications post-LT was significantly higher in group long (p=.029). Patient and graft survival rates did not differ significantly between groups. Donors with a prolonged stay in the ICU should still be considered for liver donation if they fulfill most other selection criteria. Recipients from donors having stayed in ICU >5days may be at increased risk of biliary complications.

Increased use of split liver grafts in adult recipients following implementation of a pediatric liver transplant program.

Split liver transplantation (SLT) is a strategy to address organ shortage, but is a technically more demanding procedure than whole graft liver transplantation (LT). We aimed to determine the outcomes following SLT in adult recipients as well as to highlight the impact that having a pediatric LT program has on SLT implementation. All SLTs conducted at a single-center from 2010 to 2019 were identified. Patient data was obtained through retrospective review of the electronic medical record. Kaplan-Meier analysis assessed primary outcomes of 1-,3-, and 5-year graft and patient survival. We identified 37 SLTs performed at our institution from 2010 to 2019. Twenty-four donated livers resulted in 21 extended right lobes and 16 left lateral segments for adults and pediatrics recipients, respectively. Eighty-one percent (30/37) of the SLTs were performed after introduction of the combined pediatric program in 2016. 13/24 donor livers were split with both grafts allocated and used at our institution and 92% occurred after introduction of the pediatric program. Graft survival rates at 1-, 3-, and 5-years were 94% in adult recipients and 100% for all time periods in pediatric recipients. Actuarial post-transplant patient survival was 100% at 1-, 3-, and 5-years in both. The introduction of a pediatric liver transplantation program resulted in more than a fourfold increase in the number of SLTs performed at our center. Increase in allocation and use of both grafts at our institution was also seen.

Are split liver grafts a suitable option in high-risk liver transplant recipients?

To assess the outcomes of split liver transplantation (SLT) in adults and children and evaluate its role in high-risk recipients with a high model for end-stage liver disease (MELD) score, an urgent indication or requiring retransplantation. Split liver grafts in general have equivalent long-term survival outcomes to whole grafts despite an increase in biliary complications. Recent success and technical advances have encouraged use of these grafts in high-risk recipients. Split liver grafts can be used successfully in recipients with a high MELD score if there is adequate weight-matching. There are mixed results in urgent indication recipients and for retransplantation such that use in this group of patients remains controversial. SLT addresses donor shortages by facilitating the transplant of two recipients from the same donor liver. By using careful donor and recipient selection criteria, SLT can achieve equivalent long-term outcomes to whole grafts. These grafts have been used successfully in recipients with a high MELD score, but should be used selectively in urgent indication recipients and for retransplantation.

Novel Composite Endpoint for Assessing Outcomes in Liver Transplantation: Arterial and Biliary Complication-Free Survival.

Transplant and patient survival are the validated endpoints to assess the success of liver transplantation (LT). This study evaluates arterial and biliary complication–free survival (ABCFS) as a new metric. ABC, considered as an event, was an arterial or biliary complication of Dindo‐Clavien grade ≥III complication dated at the interventional, endoscopic, or surgical treatment required to correct it. ABCFS was defined as the time from the date of LT to the dates of first ABC, death, relisting, or last follow‐up (transplant survival is time from LT to repeat LT or death). Following primary whole LT (n = 532), 106 ABCs occurred and 99 (93%) occurred during the first year after LT. An ABC occurring during the first year after LT (overall rate 19%) was an independent factor associated with transplant survival (hazard ratio [HR], 3.17; P < 0.001) and patient survival (HR, 2.7; P = 0.002) in univariate and multivariate analyses. This result was confirmed after extension of the cohort to split‐liver graft, donation after circulatory death, or re‐LT (n = 658). Data from 2 external cohorts of primary whole LTs (n = 249 and 229, respectively) confirmed that the first‐year ABC was an independent prognostic factor for transplant survival but not for patient survival. ABCFS was correlated with transplant and patient survival (ρ = 0.85 [95% CI, 0.78‐0.90] and 0.81 [95% CI, 0.71‐0.88], respectively). Preoperative factors known to influence 5‐year transplant survival influenced ABCFS after 1 year of follow‐up. The 1‐year ABCFS was indicative of 5‐year transplant survival. ABCFS is a reproducible metric to evaluate the results of LT after 1 year of follow‐up and could serve as a new endpoint in clinical trials.

Bile duct anatomical variations: Relevance for liver division and preparing left split liver grafts for pediatric transplantation: Cohort study

Backgroundliver lateral section graft is the most common graft type used for transplantation in children worldwide. Compared to whole liver grafts, a higher rate of biliary complications has been described. Historically, 2 techniques have been described for transection of liver - trans-hilar or trans-umbilical parenchymal transection. Though these techniques allow dividing the biliary system at two distinct positions, the usual surgical strategies do not take advantage of this advantage. Material and methodsA retrospective study was conducted on 40 candidates who volunteered for donation of their left lateral liver section for transplantation, between October 2017 and April 2019. Preoperative imaging was analyzed to depict the arterial and biliary anatomy of the liver and their variations, with a dedicated attention to the left liver (segments 2, 3 and 4). Anatomy of the biliary system was taken into account for defining the optimal surgical strategy - either through a trans-hilar or a trans-umbilical parenchymal transection. ResultsIn 26/40 patients, arterial or biliary variations were much relevant for decision-making on the optimal plane of liver division (trans-umbilical (N = 14) and trans-hilar (N = 26)). This resulted in 23 grafts with a single artery and bile duct, 6 grafts with double arteries and a single bile duct, and 9 grafts with double bile ducts and a single artery; only two grafts had complex anatomy. There was no arterial complication and the overall incidence of biliary problems was 14.7%. All grafts are functioning well at a mean follow-up of 19.6 ± 8.5 months. ConclusionsAnatomical variations are frequent and their knowledge is relevant for procurement of lateral section liver graft. Knowledge of these variation, or -better- preoperative biliary imaging is helpful in guiding parenchymal transection at procurement and preparing optimal liver grafts.

Super selective percutaneous transhepatic coil embolization of intrahepatic pseudoaneurysm after pediatric liver transplantation: a case report

BackgroundIntrahepatic arterial pseudoaneurysms are a rare, life-threatening complication after pediatric liver transplantation. Treatment of choice represents interventional radiological management with endovascular embolization of the segmental artery proximal and distal to the aneurysm. However, this technique results in loss of arterial perfusion distal to the aneurysm with subsegment arterial ischemia.Case presentationWe report a case of a 1-year-old girl with a pseudoaneurysm in the split-liver graft. Direct percutaneous, transhepatic access to the pseudoaneurysm was performed followed by super selective coil application into the aneurysm.ConclusionSuper selective percutaneous, transhepatic coil application is feasible even in pediatric patients after liver transplantation and results in preservation of the entire course of the liver artery.

Can Post-Transplant Outcomes Predicted at the Time of Liver Graft Allocation?

Introduction: Liver grafts are a scarce resource. Both medical urgency and expected post-transplant outcomes should be considered when allocating livers for transplantation. For allocation decisions, it is important to identify variables known at the time of liver allocation that may affect transplant outcomes. Method: Recipient and donor data from the Australia and New Zealand Liver Transplant Registry from January 1998 to May 2019 were used. All interactions between donor and recipient variables were included. The outcome was graft failure, including patient death. Penalised regression with elastic net analysis was performed to select variables for the final multivariable Cox model. The c-statistic was used to assess score discrimination. Results: 3734 patients were included, with 636 graft failures. 714 recipient, donor and interaction variables were considered, with 35 variables selected using elastic net for the multivariable Cox model. Variables with the largest hazard ratios were transplant for liver tumour other than hepatocellular cancer (HR 2.47, 95% CI 1.33-4.61) , retransplant with a donation after cardiac death donor (HR 2.08, CI 1.38-3.13) and split-liver graft (HR 1.5, CI 1.11-1.95). Internal validation on the same data used for model creation resulted in a c-statistic of 0.72. Conclusions: Prediction of post-transplant outcomes from only variables known at the time of liver allocation is challenging. Further improvements are needed in the context of the prioritisation of patients for transplantation.