Use Of Split Grafts Research Articles

Reducing Hospital Length of Stay and Hepatic Artery Thrombosis Rates for Children Receiving a Liver Transplant: A Single-Center Experience From 2000 to 2021.

Pediatric liver transplantation is a very resource-intensive therapy. This study aimed to identify the changes made between two epochs of management and analyze their influence on length of stay (LOS). Data from a single center were obtained from the liver transplant and Pediatric Intensive Care Unit (PICU) databases for 336 transplants (282 children) performed between 2000 and 2021. Transplants were analyzed in two epochs, before and after July 2012, representing a change in postoperative anticoagulation management. Differences in graft recipient demographics and perioperative management factors were compared between epochs. Multivariate regression was performed to identify the complications that correlated most strongly with hospital LOS. There was a difference in hospital LOS between Epoch 1 (Median = 31.7 days) and Epoch 2 (Median = 26.3 days) (p < 0.001), but not in PICU LOS (E1 Median = 7.3 days, E2 Median = 7.4 days; p = 0.792). Epoch 2 saw increased use of split grafts (60.6% of total), decreased pediatric end-stage liver disease (PELD) score at transplant (Average = 16.7; p < 0.001), decreased invasive ventilation time (Average = 4.48 days; p < 0.001), and decreased hepatic artery thrombosis (HAT) rates (E1 = 14.4%, E2 = 4.3%; p < 0.001) without an associated increase in bleeding rates. Hospital LOS has reduced in Epoch 2 due to refinements in intraoperative and postoperative management. There is increased emphasis on early extubation and increased use of noninvasive ventilatory techniques in Epoch 2. Split grafts have effectively expanded our graft donor pool and reduced transplant waitlist times.

Outcomes after Ex-vivo Liver Splitting during Hypothermic Oxygenated Perfusion - A Prospective Case Series

Introduction: Ex-vivo liver graft splitting in donation after brain death increases cold ischemia leading to inferior outcomes compared to whole grafts. Hypothermic Oxygenated Perfusion (HOPE) improves outcomes of marginal liver grafts and may also benefit split grafts. We present outcomes from the first case series of ex-vivo liver graft splitting during HOPE with subsequent transplantation. Method: In 2020, we developed HOPE-Split, an ex-vivo liver splitting technique with concurrent HOPE. We included all conventional ex-vivo liver splits performed from 2018-2020 at our center as comparison cohort. Results: During the study period, we performed 6 HOPE-Split procedures resulting in 12 successful liver transplantations in 6 pediatric and 6 adult recipients. During HOPE, both partial grafts were perfused for a mean 125min through a single portal cannula until respective recipient hepatectomies were completed. In comparison to the standard ex-vivo split, HOPE-Split grafts displayed significantly shorter static cold storage times (542min vs 470min, p =0,02) but comparable total ex-vivo preservation (543min vs 600min). Despite a higher donor risk in the HOPE-Split cohort (Donor Risk Index 1,9 vs 2,16, p=0,29), factor V normalization in the recipients was comparable to standard splits. No primary non function nor early vascular complications occurred and all 12 recipients present normal liver values after a mean follow-up of 4 months. Conclusions: Our preliminary results confirm feasibility of HOPE-Split and suggest improved preservation with reduced static cold storage in high-risk split grafts. Pending validation in a larger cohort, HOPE-Split may allow to improve outcomes and increase the use of split grafts.

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.

First simultaneous and synchronized split-liver transplantation involving two recipients and three surgeons in Costa Rica: A case report

BackgroundCosta Rica has a public health system based on social security, and its transplant program has limited resources. Therefore, when a whole liver is surgically split for transplantation, only one of the obtained grafts can be transplanted. In Costa Rica, there are only three surgeons with expertise and surgical training in liver transplantation with living-donor and split-liver transplantation (SLT) for both pediatric and adult patients. To overcome the existing limitations and the low organ donation rate, a strategy designed to maximize the use of split grafts for liver transplantation was created. This strategy involves the performance of two simultaneous and synchronized SLTs in parallel at two different hospitals. MethodsThis strategy was performed for the first time in May 2018. Simultaneously and synchronously, two SLTs were performed for a woman and a female infant; both patients underwent operations at the same time by only three transplant surgeons in two different hospitals. ResultsThis strategy allowed the performance of two SLTs without compromising the cold ischemia time (CIT) or reperfusion. The infant and woman had a CIT time of 4.5 and 6.0 h, respectively. At 16 months postoperatively, both patients had excellent quality of life and graft function. ConclusionThis first experience with the herein-described surgical and logistical strategy, although successful, requires institutional and governmental support so that the outcomes can be improved to maximize the benefit and opportunity of access for patients on the waiting list for liver transplantation in health systems of third-world countries with limited resources.

Where are we today in split liver transplantation?&lt;/ TI&gt;

Results of surgical innovations using partial liver grafts from deceased donors have improved the availability of transplantable organs. However, current data on outcomes after split liver transplantation (SLT) are conflicting. This article reviews the current state of SLT, focusing on long-term outcomes and predictors for patient and graft survival after SLT. The conventional SLT has been proven to be a durable life-saving procedure. Early results for full left-right SLT for two adults are promising but this technique had not showed efficacy for wide application. Predictors of diminished patient survival after SLT included the use of split grafts in critically ill recipients (model for end-stage liver disease score >30), retransplant patients, cold ischemia time more than 10 h, and the performance of SLT in low-volume liver transplant centers. Conventional SLT performed in specialized centers resulted in long-term survival outcomes comparable with whole-organ liver transplantation. Full left-right SLT for two adults remains experimental. Splitting of the liver is an effective approach to expand the donor pool and remains an untapped resource for patients in need of liver transplantation. Split graft-to-recipient pairing is crucial for optimal organ allocation and survival outcomes after liver transplantation.

Efforts to expand the donor pool for liver transplantation

Liver transplantation has become a victim of its own success in that there are no longer enough suitable livers for transplantation while at the same time the indications for transplantation increase. Efforts to expand the number of recipients who benefit from this life-saving procedure are being made, in particular through the use of split grafts and live donors. However, such grafts are associated with increased morbidity and mortality related to their reduced size.

Pediatric Liver Transplantation in Iran: A 9-Year Experience

Liver transplantation (OLT) is accepted as the standard therapy for end-stage liver disease. The current shortage of organ donors has led to the use of split grafts and living related donors to provide timely liver transplants for these children. Herein we have reported our experience with pediatric OLT over a 9-year period. We retrospectively studied 138 infants and children who underwent OLT from April 1999 to August 2008 including pretransplantation status, medical and surgical complications, and survival. There were 83 (60.1%) boys and 55 (39.9%) girls. The mean patient age was 9.1 +/- 5.6 years (range = 0.5-18) with a mean weight of 28.1 +/- 17.0 kg (range = 7-80). The main indications were Wilson's disease (20.3%); cryptogenic cirrhosis (16.7%); autoimmune cirrhosis (14.5%); biliary atresia (13.8%); tyrosinemia (9.4%); and progressive familial intrahepatic cholestasis (8.7%). We used living related donors in 54 (39.1%) and split livers in 20 (14.5%) cases with 64 (46.4%) patients receiving a whole liver from a deceased donor. The mean follow-up was 25.3 +/- 20.3 months (range = 1-100). The mortality rate was 27.5% with a 26.1% in-hospital mortality. The main causes of mortality were vascular complications (32.6%); primary nonfunction (19.6%); sepsis (17.4%); chronic rejection (17.4%); and biliary complications (6.5%). The mortality rate among patients under 10 kg (58.8%) was higher than that of patients over 10 kg (23.1%). Among those patients who were discharged from the hospital (73.9%), the most common cause of mortality was chronic rejection from noncompliance (n = 4), chronic rejection (n = 3 cases), or posttransplant lymphoproliferative disease (n = 2). Our results demonstrated that pediatric OLT is a feasible undertaking in Iran. The organ shortage in our area led to liberal use of living related and split-liver techniques. The overall results of pediatric OLT in Iran were acceptable.

Use of split-liver allografts does not impair pediatric recipient growth

The use of split-liver (SL) allografts continues to be an excellent option for many pediatric recipients. Patient and graft survival with this graft type are comparable to patient and graft survival with whole organ grafts. Quality-of-life issues, specifically growth, for SL recipients have not been compared to those of recipients of more conventional whole-organ recipients. Pediatric recipients of SL and whole allografts at 2 institutions were identified. Height, z score, and delta z score were calculated for all recipients for each year after transplant. Between 1995 and 2004, 201 pediatric liver transplants were analyzed. Data were collected on 39 split-graft recipients and 36 whole-size recipients. Only subjects 3 years or younger were included in the study. Growth retardation was present in all recipients at transplant. Height z score post split and whole-size transplant were not statistically different at 1- (P = 0.65), 2- (P = 0.13), and 3-year (P = 0.32) anniversaries, respectively. Catch-up growth was present only in recipients of split grafts. In conclusion, the use of split grafts as opposed to whole-size grafts revealed no significant differences in terms of linear growth. Our report indicates that split-liver transplantation does not impair recipient growth.

PEDIATRIC LIVER TRANSPLANTATION : FROM THE FULL-SIZE LIVER GRAFT(FS) TO THE REDUCED (RED), SPLIT AND LIVING RELATED LIVER TRANSPLANTATION(LRLT).

338 We updated our experience with innovative techniques since 1994. MATERIAL:Between 1984 and 1996,499 transplants were performed in 416 children (< 15 yr); main indications were biliary atresia (BA: n=286), metabolic diseases (MD: n=59) and acute liver failure (ALF: n=22). Of the 209 children transplanted in 1984-1990, age was < 1 yr in 26.8%; 1-3 year in 49.8%; 3-5 yr in 11% and > 5 yr in 12.4%. Weight was < 12 kilos in 60.5%. Of the first transplants,there were 109 FS,95 RED,5 split Of the 207 children transplanted in 1991-1996, age was < 1 yr in 24.6%; 1-3 yr in 41.5%; 3-5 yr in 16.9% and > 5 yr in 16.9%. Weight was < 12 kilos in 64%. Of the first transplants, there were 61 FS, 88 RED, 22 split and 40 LRLT. If not otherwise indicated, actuarial survival curves were calculated. RESULTS: Patient survival at 10 yr was 76.5% for the whole group, 78.5% for BA, 87.3% for MD and 72.7% for ALF. In 1984-1990, 5 yr patient survival was 73.6%. In 1991-1996, 5 yr patient survival was 85% (85.3% for BA, 95.2% for MD and 80% for ALF). In 1984-1996, 5 yr survival was 85% in 168 children who received an elective FS and 76% in 174 children who received an elective RED (first transplants; p:0.08). Overall 5 yr survival was 77.7% for 22 children who received a split as a first graft.Between 7/1993 and 10/1997, 53 LRLT were performed with 90% actual survival rate. A detailed analysis was made for 45 children listed for a LRLT and 79 children listed for a CAD transplant between 7/1993 and 3/1997. Mortality while waiting was 2% and 14.5% for LRLT and CAD respectively. Corresponding figures were 4.6% and 16.1% for retransplantation rate, 88% and 82% for actual post-transplant survival rate and 86% and 70% (p < 0.05) for overall actual survival rate from the date of registration. The 2 yr post-OLT survival in children < 1 yr was 88.8% and 80.3% in LRLT and CAD respectively. Patient survival rate was better for LRLT than for CAD, in every risk category but not significally different. CONCLUSIONS: 1. In our group, long term life expectancy is currently 85%, all indications included. 2. Expansion of the liver donor pool should rely on an increased use of SPLIT grafts and on LRLT in centers having a large experience with RED and SPLIT grafts. 3. Currently, LRLT provides the best results.