Split Liver Transplantation Group Research Articles

Clinical application of split liver transplantation: a single center report of 203 cases

Objective: To investigate the safety and therapeutic effect of split liver transplantation (SLT) in clinical application. Methods: This is a retrospective case-series study. The clinical data of 203 consecutive SLT, 79 living donor liver transplantation (LDLT) and 1 298 whole liver transplantation (WLT) performed at the Third Affiliated Hospital of Sun Yat-sen University from July 2014 to July 2023 were retrospectively analyzed. Two hundred and three SLT liver grafts were obtained from 109 donors. One hundred and twenty-seven grafts were generated by in vitro splitting and 76 grafts were generated by in vivo splitting. There were 90 adult recipients and 113 pediatric recipients. According to time, SLT patients were divided into two groups: the early SLT group (40 cases, from July 2014 to December 2017) and the mature SLT technology group (163 cases, from January 2018 to July 2023). The survival of each group was analyzed and the main factors affecting the survival rate of SLT were analyzed. The Kaplan-Meier method and Log-rank test were used for survival analysis. Results: The cumulative survival rates at 1-, 3-, and 5-year were 74.58%, 71.47%, and 71.47% in the early SLT group, and 88.03%, 87.23%, and 87.23% in the mature SLT group, respectively. Survival rates in the mature SLT group were significantly higher than those in the early SLT group (χ2=5.560,P=0.018). The cumulative survival rates at 1-, 3- and 5-year were 93.41%, 93.41%, 89.95% in the LDLT group and 87.38%, 81.98%, 77.04% in the WLT group, respectively. There was no significant difference among the mature SLT group, the LDLT group and the WLT group (χ2=4.016, P=0.134). Abdominal hemorrhage, infection, primary liver graft nonfunction,and portal vein thrombosis were the main causes of early postoperative death. Conclusion: SLT can achieve results comparable to those of WLT and LDLT in mature technology liver transplant centers, but it needs to go through a certain time learning curve.

Comparative analysis of whole vs. split liver transplantation in infants.

Liver transplantation (LT) in infants can be challenging due to their small size and small vasculature. Although both whole LT (WLT) and split LT (SLT) have been described in infants, the head-to-head comparison of these techniques in this population is sparse. We retrospectively analyzed the records of all patients with age ≤1 year at Indiana University between 2016 and 2022. All SLT were left lateral segment grafts split in situ. A total of 24 infants were transplanted, with 11 SLT and 13 WLT. The median follow-up time was 52.1 months. Donor and recipient characteristics were comparable except for donor age (19 years vs. 2 years; p < .01) and weight (64 kg vs. 14.2 kg; p < .01). Early allograft dysfunction, primary nonfunction, and hepatic artery thrombosis developed more frequently in the WLT group. There were no biliary complications. There were two early deaths (2 and 4 days) in the WLT group. One-year graft survival (100% vs. 77%; p = .10) and patient survival (100% vs. 85%; p = .18) were numerically higher in the SLT group. SLT with LLS offers a safe and viable option for liver transplantation in infants and is associated with a trend toward superior outcomes. SLT should be considered as a strategy to reduce waitlist times for infants in the absence of small, deceased donors for WLT.

Clinical efficacy of split liver transplantation in the treatment of children with biliary atresia

Objective: To compare the clinical efficacy of split liver transplantation (SLT) and living donor liver transplantation(LDLT) in the treatment of children with biliary atresia. Methods: The clinical data of 64 children with biliary atresia who underwent SLT and 44 children who underwent LDLT from June 2017 to May 2022 at Liver Surgery & Liver Transplantation Center,the Third Affiliated Hospital of Sun Yat-sen University were retrospectively analyzed. Among the children who received SLT, there were 40 males and 24 females. The median age at transplantation was 8 months (range:4 to 168 months). Among the patients who received LDLT, there were 24 males and 20 females. The age at transplantation ranged from 4 to 24 months,with a median age of 7 months. Sixty-four children with biliary atresia were divided into two groups according to the SLT operation time: 32 cases in the early SLT group(June 2017 to January 2019) and 32 cases in the technically mature SLT group (February 2019 to May 2022). Rank sum test or t test was used to compare the recovery of liver function between the LDLT group and the SLT group,and between the early SLT group and the technically mature SLT group. The incidence of postoperative complications was compared by χ2 test or Fisher exact probability method. Kaplan-Meier method and Log-rank test were used for survival analysis. Results: The cold ischemia time(M (IQR)) (218 (65) minutes), intraoperative blood loss(175 (100) ml) and graft-to-recipient body weight ratio (3.0±0.7) in the LDLT group were lower than those in the SLT group(500 (130) minutes, 200 (250) ml, 3.4±0.8) (Z=-8.064,Z=-2.969, t=-2.048, all P<0.05). The cold ischemia time(457(158)minutes) and total hospital stay ((37.4±22.4)days) in the technically mature SLT group were lower than those in the early SLT group(510(60)minutes, (53.0±39.0)days).The differences were statistically significant (Z=-2.132, t=1.934, both P<0.05).The liver function indexes of LDLT group and SLT group showed unimodal changes within 1 week after operation. The peak values of ALT, AST, prothrombin time, activeated partial thromboplasting time, international normalized ratio, fibrinogen and creatinine all appeared at 1 day after operation, and the peak value of prothrombin activity appeared at 3 days after operation. All indicators returned to normal at 7 days after operation. The 1-,2-,and 3-year overall survival rates were 95.5% in LDLT group and 93.5% in the technically mature SLT group, and the difference was not statistically significant. The 1-,2-,and 3-year overall survival rates were 90.2% in the early SLT group and 93.5% in the technically mature SLT group, and there was no significant difference between the two groups(P>0.05). The main complications of the early SLT group were surgery-related complications(28.1%,9/32), and the main complications of the technically mature SLT group were non-surgery-related complications(21.9%,7/32). There were 5 deaths in the SLT group,including 4 in the early SLT group and 1 in the technically mature SLT group. Conclusion: The survival rate of SLT in the treatment of biliary atresia is comparable to that of LDLT.

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.

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.

Vasculobiliary complications following adult right lobe split liver transplantation from the perspective of reconstruction techniques

Split liver transplantation (SLT) compensates for the organ shortage and provides an alternative solution for recipients disadvantaged by a smaller body size. Variations in the hepatic arterial anatomy and reconstructive techniques may lead to more technical complications, and we sought to analyze the incidence and risk factors of vasculobiliary complications with respect to reconstructive techniques. We identified 171 adult right lobe SLT procedures and 1412 whole liver transplantation (WLT) procedures between January 2000 and June 2012 and compared the results of these 2 groups. In the SLT group, arterial reconstruction techniques were classified into 4 subgroups (I-IV), and biliary reconstruction was classified into 2 groups [duct-to-duct (DD) anastomosis and Roux-en-Y hepaticojejunostomy (RH)]. Specific surgical complications were analyzed against reconstruction techniques. The overall incidence of vascular and biliary complications in the SLT group was greater than that in the WLT group (P = 0.009 and P = 0.001, respectively). There was no difference in hepatic artery thrombosis (HAT), but we saw a tendency toward early HAT in the presence of multiple hepatic arteries supplying the right lobe graft (group IV; 20%) in comparison with the other arterial reconstruction groups (P = 0.052). No difference was noticed in the overall incidence of biliary complications in either DD or RH recipients across 4 arterial reconstruction groups. When the arterial reconstruction involved a right hepatic artery (groups II and III) combined with a DD biliary anastomosis, there was a significant preponderance of biliary complications (P = 0.04 and P = 0.01, respectively). There was no survival difference between SLT and WLT grafts. In conclusion, the complications of SLT are directly related to arterial and biliary reconstruction techniques, and this classification helps to identify high-risk reconstructive techniques.

P90 Outcomes of cadaveric split liver transplantation for hepatitis C infected patients. A single centre cohort

IntroductionConcern exist as to the outcome of patients with liver cirrhosis secondary to hepatitis C virus (HCV) infection who receive split liver transplantation (SLT).AimTo determine the graft and patient outcomes...

Extended right liver grafts obtained by an ex situ split can be used safely for primary and secondary transplantation with acceptable biliary morbidity

Split liver transplantation (SLT) is clearly beneficial for pediatric recipients. However, the increased risk of biliary complications in adult recipients of SLT in comparison with whole liver transplantation (WLT) remains controversial. The objective of this study was to investigate the incidence and clinical outcome of biliary complications in an SLT group using split extended right grafts (ERGs) after ex situ splitting in comparison with WLT in adults. The retrospectively collected data for 80 consecutive liver transplants using ERGs after ex situ splitting between 1998 and 2007 were compared with the data for 80 liver transplants using whole liver grafts in a matched-pair analysis paired by the donor age, recipient age, indications, Model for End-Stage Liver Disease score, and high-urgency status. The cold ischemic time was significantly longer in the SLT group (P = 0.006). As expected, bile leakage from the transected surface occurred only in the SLT group (15%) without any mortality or graft loss. The incidence of all other early or late biliary complications (eg, anastomotic leakage and stenosis) was not different between SLT and WLT. The 1- and 5-year patient and graft survival rates showed no statistical difference between SLT and WLT [83.2% and 82.0% versus 88.5% and 79.8% (P = 0.92) and 70.8% and 67.5% versus 83.6% and 70.0% (P = 0.16), respectively]. In conclusion, ERGs can be used safely without any increased mortality and with acceptable morbidity, and they should also be considered for retransplantation. The significantly longer cold ischemic time in the SLT group indicates the potential for improved results and should thus be considered in the design of allocation policies.

Outcomes in right liver lobe transplantation: a matched pair analysis

Split liver transplantation (SLT) has proven to be an effective technique of increasing the donor pool and thereby reducing adult and paediatric waiting list mortality. There remains concern regarding complications in adult recipients. Here, we compare SLT with matched whole liver grafts. Adult recipients of primary extended right lobe grafts (ERL) were matched to recipients of whole liver transplantations (WLTs) according to the following criteria: model of end-stage liver disease (MELD) score, recipient age, indication for liver transplantation and year of transplantation. Twenty-seven pairs of recipients were transplanted for chronic liver disease. The overall 30-day patient survival rates after ERL and WLT were 88.9% and 92.5% and 3-year survival rates after SLT and WLT were 77.8% and 85.2% respectively (log-rank = 0.38). Two patients with SLTs had hepatic artery thromboses and were retransplanted with none from the WLT group. The prevalence of a biliary leak was higher among the SLT group (n = 4) compared with none in the WLT group (P = 0.05). Patients with preoperative hyponatraemia showed a trend towards poorer survival after SLT compared with WLT. Our data suggest that SLT with extended right liver lobes, although not significantly different, shows a trend towards a poorer outcome.

Long-term Outcome of Split Liver Transplantation Using Right Extended Grafts in Adulthood

Shortage of suitable organs led to the development of alternative techniques in liver transplantation. Split liver transplantation (SLT) is well established in pediatric patients. SLT is not completely accepted in adult recipients due to potential increased risk of complications. Despite satisfying results of short-term outcome, there is a leak on information of the long-term outcome. Therefore, we compared the outcome after transplantation of the right extended liver lobe with whole liver transplantation (WLT) using a matched pair's analysis. From the period of January 1993 to February 2005, 70 SLT recipients were matched with 70 WLT recipients of whole livers. Matching criteria were: 1) indication for transplantation, 2) United Network for Organ Sharing (UNOS) status, 3) recipient age, 4) donor age, 5) cold ischemic time, and 6) year of transplantation. The outcome was analyzed retrospectively. Mean follow-up was 36 months. The 2- and 5-year patient survival rates after SLT and WLT were 86.3% and 82.6%, and 78.4% and 75.6%, respectively (log rank, P = 0.2127). Two- and 5-year graft survival rates were 77.3% and 77.3% after SLT and 71.9% and 65.8% after WLT, respectively (log rank, P = 0.3822). The total biliary complication rate was 11.4% in the SLT group versus 10.0% in the WLT group in the short-term course, while it was 8.5% after SLT and 10.0% after WLT in the long-term course. We did not observe significant differences between the groups in term of short- and long-term morbidity. Transplantation of the right extended lobe deriving from left lateral splitting of deceased donor livers is followed by the same long-term patient and graft survival, which is known from WLT. There were no differences in the complication rates even in long-term outcome implementing that SLT does not put the adult recipient to an increased early and late risk. Transplantation of the extended right liver lobe provides a safe and efficient procedure in adult patients to expand the number of available grafts.

Analysis of renal function in the immediate postoperative period after partial liver transplantation

Although renal dysfunction is common after liver transplantation, postoperative renal function after split liver transplantation (SLT) has not been well studied. Renal function immediately after surgery was analyzed retrospectively in 16 patients that received a SLT (SLT group). The results were compared with corresponding data from 31 matched patients that received a full-size liver transplant (FSLT group) during the same period. Serum creatinine (SCr) was measured before surgery, and, after transplantation, daily during the first week and at days 14, 21, and 28. Renal dysfunction (RD) was defined as the requirement for renal replacement therapy (RRT) or a 100% increase in SCr if the basal value had been <1.0 mg/dL or a 50% increase in SCr if the basal value had been >1.0 mg/dL. SCr had to be at least 1.5 mg/dL for a diagnosis of RD to be considered. The classification of RD was: mild, SCr 1.5-2.4 mg/dL; moderate, SCr 2.5-4.0 mg/dL; or severe, SCr >4.0 mg/dL (the requirement for RRT). Both donor and recipient age and cold ischemia time were lower in the SLT group than in the FSLT group (P < 0.05). Length of surgery was longer in the SLT group (P < 0.05). There were no significant differences between groups with respect to Model for End-Stage Liver Disease scores, the need for transfusions, the length of admission to the intensive care unit (ICU), survival rate, individual severity index, or sepsis-related organ failure assessment scores at the time of diagnosing RD. Immunosuppression regimens were similar in both groups. RD developed in 82% of SLT patients, but in only 58% of FSLT patients (P = not significant [NS]). Among SLT patients, RD (23.0% mild, 15.5% moderate, and 61.5% severe) was more severe (P = 0.007) than in FSLT patients (63.1% mild, 15.8% moderate, and 24.1% severe). The requirement for RRT in the SLT group (43.7%) was significantly greater (P < 0.05) than that in the FSLT group (12.9%). This finding may be due to the different incidence of sepsis in the 2 groups (SLT 37.5% vs. FSLT 9.7%; P < 0.05). In conclusion, although the number of patients studied was small, our data suggest a higher incidence of RD and a greater requirement for RRT in patients that receive a split liver graft than in those that receive a full size liver graft.

Cavocaval adult liver transplantation and retransplantation without venovenous bypass and without portocaval shunting: a prospective feasibility study in adult liver transplantation.

The original method of liver transplantation (LT) included recipient inferior vena cava (IVC) resection and the use of extracorporeal venovenous bypass (VVB). Refinements in technique permit transplantation to be done with IVC preservation and without VVB use. Between November 1993 and November 2000, 202 consecutive grafts were performed in 188 adults (>/=16 years of age). Twelve patients (6.4%) received two and three retransplants (re-LT). Split grafting was performed 19 times (19 of 202 grafts, 9.4%). Risk factors included United Network of Organ Sharing status I (n=30, 16%), previous right upper abdominal surgery (n=32, 17.1%), caudate lobe encirclement of IVC (n=65, 32.2%), IVC (n=24, 11.9%), and splanchnic venous modification (n=58, 30.9%), transjugular intrahepatic portosystemic stent shunt (n=34, 16.8%), giant (>5 kg) liver tumor (n=6, 3%), septic necrosis of the caudate lobe (n=1, 0.5%), and previous cavocaval (n=13, 6.4%) or classical LT (n=5, 2.5%). IVC preservation, avoidance of IVC cross clamping and of VVB use were possible in 98.9%, 93%, and 99.5% of 183 primary LT and in 89.5%, 84.2%, and 89.5% of 19 re-LT. Temporary portocaval shunting was never applied. Perioperative mortality was 1.2%. There was no allotransfusion in 73 (36%) grafts and 45 (22%) patients were immediately extubated. Permanent hepatic vein and caval problems were encountered in three (1.5%) grafts. One patient needed stent placement to treat IVC stenosis. Actual 3- and 12-month patient survival for whole, re-LT, and right-lobe split LT groups were 94.7%, 94.1%, 94.7%, 88.2%, 94.1%, and 89%. Three-month graft survival rates for these groups were 92.6%, 94.7%, and 84.2%. LT with IVC preservation and without VVB use and portocaval shunting is possible in nearly all primary transplants and in the majority of re-LT.

Is there still a need for living-related liver transplantation in children?

To assess and compare the value of split-liver transplantation (SLT) and living-related liver transplantation (LRT). The concept of SLT results from the development of reduced-size transplantation. A further development of SLT, the in situ split technique, is derived from LRT, which itself marks the optimized outcome in terms of postoperative graft function and survival. The combination of SLT and LRT has abolished deaths on the waiting list, thus raising the question whether living donor liver transplantation is still necessary. Outcomes and postoperative liver function of 43 primary LRT patients were compared with those of 49 primary SLT patients (14 ex situ, 35 in situ) with known graft weight performed between April 1996 and December 2000. Survival rates were analyzed using the Kaplan-Meier method. After a median follow-up of 35 months, actual patient survival rates were 82% in the SLT group and 88% in the LRT group. Actual graft survival rates were 76% and 81%, respectively. The incidence of primary nonfunction was 12% in the SLT group and 2.3% in the LRT group. Liver function parameters (prothrombin time, factor V, bilirubin clearance) and surgical complication rates did not differ significantly. In the SLT group, mean cold ischemic time was longer than in the LRT group. Serum values of alanine aminotransferase during the first postoperative week were significantly higher in the SLT group. In the LRT group, there were more grafts with signs of fatty degeneration than in the SLT group. The short- and long-term outcomes after LRT and SLT did not differ significantly. To avoid the risk for the donor in LRT, SLT represents the first-line therapy in pediatric liver transplantation in countries where cadaveric organs are available. LRT provides a solution for urgent cases in which a cadaveric graft cannot be found in time or if the choice of the optimal time point for transplantation is vital.