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.

We read with great interest the paper by Kitajima et al. 1 The authors are to be congratulated for their innovations and safety record in addressing the shortage of size-matched organs in pediatric liver transplantation. Liver transplantation for neonates, small infants, and children less than 5 kg remains a challenge with high technical complication rates partly due to the "large-for-size" graft problem.The authors addressed this niche area and their excellent short-term and long-term results stand testimonial to their expertise. We would like to highlight some aspects of this study which will benefit from further clarification and also present our philosophy for managing large-for-size grafts in small children.Our primary concern with this study is the time scale of the study and the epochal spread of the two techniques compared here. The dataset spans a long period in time (2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015)(2016)(2017), and most of the non-anatomical reductions (NAR) happened before 2012. Intuitively, the authors with increasing expertise, moved onto the relatively more complex anatomical graft reductions (AR). This could lead to an "era effect," and the reduced complications and better outcomes in the recent group cannot be entirely ascribed to the new technique. A more equitable comparison would be a NAR versus AR grafts in the 2012-2017 period, which has, however, not been focused upon. In addition, the authors have not clarified their current indications for non-anatomical reduction. Do they believe that this simple means of reducing graft size is now redundant?In our program, we take a more nuanced and individualized approach to dealing with graft size in small infants. We believe that a graft-to-recipient weight ratio (GRWR) of greater than 4.0 does not always mandate graft reduction. 2,3 Multiple additional factors including the size of the child's abdominal cavity, the anteroposterior thickness of the graft, presence of ascites, sarcopenia, and quality of portal inflow have to be taken into account. In our center's experience of 216 left lateral segment (LLS) grafts over seven years (2010)(2011)(2012)(2013)(2014)(2015)(2016)(2017), 46 of our patients were transplanted with large-for-size grafts (GRWR of ≥4). However, only nine of these children needed graft reduction (Table 1). Using the authors' protocol, we would instead have had to perform 50 (37 + 13) reductions. Interestingly, four other children needed reduction, though their actual GRWR was <4.0. This again highlights the difficulty in having a rigid cutoff for graft reduction.We do concede that 23 of these 46 children needed partial abdominal closure. There was no additional morbidity in these children (compartment syndrome, ACR, or infectious complications) except the need of another operative procedure for delayed abdominal sheath closure. In children where the anterioposterior graft thickness is an issue, we have used anatomically reduced segment III grafts with in situ reduction using portal venous delineati...

No abstract

Leiomyosarcoma (LMS) of primary vascular origin is a rare entity with only potentially curative option being complete surgical resection; despite which the prognosis remains dismal. Tumour recurrence is very common, and the benefits of adjuvant therapy are undefined. A 39-year-old woman presented with 6 months’ history of abdominal pain, abdominal distension and pedal oedema. On evaluation, she was diagnosed to have chronic Budd-Chiari syndrome (BCS) secondary to a tumour arising from the inferior vena cava (IVC) on evaluation. Her liver decompensation included jaundice, gastrointestinal bleed and ascites. Following a detailed multidisciplinary team discussion, she underwent complete excision of the tumour along with a segment of the IVC with living donor liver transplantation. She remains disease-free 24 months following surgery. This is the first reported case of liver transplantation for IVC LMS causing chronic BCS.

Objective: To define benchmark values for adult-to-adult living-donor liver transplantation (LDLT). Background: LDLT utilizes living-donor hemiliver grafts to expand the donor pool and reduce waitlist mortality. While references have been established for donor hepatectomy, no such information exists for recipients to enable conclusive quality and comparative assessments. Methods: Patients undergoing LDLT were analyzed in 15 high-volume centers (≥10 cases/year) from three continents over 5 years (2016-2020), with a minimum follow-up of one year. Benchmark criteria included MELD ≤20, no portal vein thrombosis, no previous major abdominal surgery, no renal replacement therapy, no acute liver failure, and no ICU admission. Benchmark cutoffs were derived from the 75th-percentile of all centers’ medians. Results: Of 3636 patients, 1864 (51%) qualified as benchmark cases. Benchmark cutoffs including posttransplant dialysis (≤4%), primary nonfunction (≤0.9%), non-anastomotic strictures (≤0.2%), graft loss (≤7.7%), and redo-LT (≤3.6%) at 1-year were below the DDLT benchmarks. Bile leak (≤12.4%), hepatic artery thrombosis (≤5.1%), and CCI® (≤56) were above the DDLT benchmarks, while mortality (≤9.1%) was comparable. The right-hemiliver graft, compared to the left, was associated with a lower CCI® score (34 vs.21, P<0.001). Preservation of the MHV with the right-hemiliver graft had no impact neither on the recipient nor on the donor outcome. Asian centers outperformed other centers with CCI® score (21 vs.47, P<0.001), graft loss (3.0%vs.6.5%, P=0.002), and redo-LT rates (1.0%vs.2.5%, P=0.029). In contrast, non-benchmark low-volume centers displayed inferior outcomes such as bile leak (15.2%), hepatic artery thrombosis (15.2%), or redo-LT (6.5%). Conclusion: Benchmark LDLT offers a valuable alternative to reduce waitlist mortality. Exchange of expertise, public awareness and centralization policy are however mandatory to achieve benchmark outcomes worldwide.