Addressing the challenges of split liver transplantation through technical advances. A systematic review

Lau, Ngee-Soon; Jacques, Andrew; McCaughan, Geoffrey W.; Crawford, Michael; Liu, Ken; Pulitano, Carlo

doi:10.1016/j.trre.2021.100627

Cited by 16 publications

(29 citation statements)

References 98 publications

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“…[ 1 ] In situ liver graft splitting during procurement has achieved the best posttransplantation outcomes but consists in a technically and logistically challenging procedure. [ 2 ] Consequently, ex situ liver splitting remains frequently performed. [ 3 ] As a result of technical aspects inherent to the ex situ split, these partial grafts have prolonged static cold storage time, which negatively impacts graft survival despite the use of optimal donors.…”

Section: Introductionmentioning

confidence: 99%

Liver transplantation of partial grafts after ex situ splitting during hypothermic oxygenated perfusion—The HOPE–Split pilot study

Rossignol

Muller

Hervieu

et al. 2022

Liver Transplantation

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Partial liver grafts from ex situ splitting are considered marginal due to prolonged static cold storage. The use of ex situ hypothermic oxygenated perfusion (HOPE) may offer a strategy to improve preservation of ex situ split grafts. In this single‐center pilot study, we prospectively performed ex situ liver splitting during HOPE (HOPE–Split) for adult and pediatric partial grafts over a 1‐year period (November 1, 2020 to December 1, 2021). The primary safety endpoint was based on the number of liver graft–related adverse events (LGRAEs) per recipient, including primary nonfunction, biliary complications, hepatic vascular complications, and early relaparotomies and was compared with consecutive single‐center standard ex situ split transplantations (Static–Split) performed from 2018 to 2020. Secondary endpoints included preservation characteristics and early outcomes. Sixteen consecutive HOPE–Split liver transplantations (8 HOPE–Split procedures) were included and compared with 24 Static–Splits. All HOPE–Split grafts were successfully transplanted, and no graft loss nor recipient death was encountered during the median follow‐up of 7.5 months (interquartile range, 5.5–12.5). Mean LGRAE per recipient was similar in both groups (0.31 ± 0.60 vs. 0.46 ± 0.83; p = 0.78) and split duration was not significantly increased for HOPE–Split (216 vs. 180 min; p = 0.45). HOPE–Split grafts underwent perfusion for a median of 125 min, which significantly shortened static cold storage (472 vs. 544 min; p = 0.001), whereas it prolonged total ex vivo preservation (595 vs. 544 min; p = 0.007) and reduced neutrophil infiltration on reperfusion biopsies (p = 0.04) compared with Static–Split. This clinical pilot study presents first feasibility and safety data for transplantation of partial liver grafts undergoing ex situ split during HOPE and suggests improved preservation compared with static ex situ splitting. These preliminary results will allow to set up large‐scale trials on the use of machine perfusion in pediatric and split‐liver transplantation.

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Section: Introductionmentioning

confidence: 99%

Liver transplantation of partial grafts after ex situ splitting during hypothermic oxygenated perfusion—The HOPE–Split pilot study

Rossignol

Muller

Hervieu

et al. 2022

Liver Transplantation

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“…Despite a SFSS requiring portal flow modulation by splenic artery ligation during the reintervention, biological parameters regarding hepatic function (transaminases release and factor V) normalized within 48h and no PNF nor vascular complication was encountered. We postulate that by reducing static cold storage and protecting from mitochondrial damage, HOPE may be beneficial in the setting of high‐risk recipient‐donor matching and difficult SLT scenarios 21,22 . Further larger studies are needed to confirm this hypothesis.…”

Section: Discussionmentioning

confidence: 94%

“…We postulate that by reducing static cold storage and protecting from mitochondrial damage, HOPE may be beneficial in the setting of high-risk recipient-donor matching and difficult SLT scenarios. 21,22 Further larger studies are needed to confirm this hypothesis.…”

Section: Discussionmentioning

confidence: 95%

Full left/full right liver graft ex situ split during hypothermic oxygenated perfusion

Rossignol

Muller

Mohkam

et al. 2022

Pediatric Transplantation

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Split liver transplantation (SLT) has been developed to increase the number of available liver grafts for pediatric recipients. Liver graft splitting can be performed in situ during procurement but remains performed ex situ due to logistical challenges, resulting in prolonged static cold storage (SCS) time. 1,2 This negatively impacts postoperative outcomes 2,3 and contributes to split liver grafts being considered as marginal grafts. 4 End ischemic ex vivo hypothermic oxygenated machine perfusion (HOPE) has been shown to reduce ischemia/reperfusion injury, shorten static cold storage time and improve post-liver

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“…The advantages of this technique are: a shorter cold ischemia time and the opportunity for accurate, hemostatic splitting of the liver parenchyma. The disadvantages are an increased donor surgery time and the need for transplant surgeons with hepatobiliary expertise to travel to the donor hospital 18 . We find that using the in‐situ technique is critical to minimize the cold ischemia time in a geographically large country like Australia where there can be large distances between donor and recipient hospitals.…”

Section: Discussionmentioning

confidence: 97%

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

Lau

Liu

et al. 2022

Clinical Transplantation

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Introduction: Split 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 pretransplant clinical status (ICU or hospital-bound), acute liver failure or retransplantation remains controversial. Methods:We 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.Results: A 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. Conclusions:SLT 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 sickestfirst allocation policies.

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Addressing the challenges of split liver transplantation through technical advances. A systematic review

Cited by 16 publications

References 98 publications

Liver transplantation of partial grafts after ex situ splitting during hypothermic oxygenated perfusion—The HOPE–Split pilot study

Liver transplantation of partial grafts after ex situ splitting during hypothermic oxygenated perfusion—The HOPE–Split pilot study

Full left/full right liver graft ex situ split during hypothermic oxygenated perfusion

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

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