Higher retransplantation rate following extended right split‐liver transplantation: An analysis from the eurotransplant liver follow‐up registry

Abstract

We read with interest the article by Andrassy et al. in Liver Transplantation on the Eurotransplant experience with extended right graft (ERG) split-liver transplantation (SLT). (1) In that series, an ex situ split was usually performed in pediatric centers, shipping ERGs to adult centers, resulting in prolonged cold ischemia time (CIT), which is identified as a significant risk factor for graft failure. These results suggested reconsidering what is the best SLT allocation policy.The Italian SLT experience started in the mid-1990s, and an in situ technique was chosen from the beginning. The SLT program was initially promoted in northern Italy and then implemented nationally, involving both pediatric and adult transplant centers, reaching >300 split-liver procedures in a few years (2) and rapidly decreasing the pediatric wait-list times and mortality. (3) Donor age, CIT, retransplantation, United Network for Organ Sharing (UNOS) I-IIA status, and center volume were early ERG risk factors, (2) whereas in the long term, these were donor age,

Is there an ethical obligation to split every donor liver? Scarce resources, medical factors, and ethical reasoning

“…In one study, recipients of left‐lateral splits (segments 2 and 3) had better outcomes than patients who had received right‐extended lobes (segments 1 and 4‐8) or full‐right (segments 5‐8) or full‐left (segments 1‐4) splits . A retrospective study that compared WLT to the transplantation of right‐extended lobes showed similar survival rates, although the latter were linked to a higher risk for retransplantation . In contrast, recipients of full‐left splits showed more complications in a study that compared full‐left and full‐right SLT …”

“…Specific split liver programs, for example, in northern Italy, have shown that a split liver rate of more than 20% can be achieved . Following these positive results, Italy has opted for a national policy that demands that every liver from adult donors aged ≥50 years is to be evaluated for SLT …”

“…27 Following these positive results, Italy has opted for a national policy that demands that every liver from adult donors aged ≥50 years is to be evaluated for SLT. 30 The information above might give rise to question why it is not the case that every liver deemed suitable for SLT is split, at least as long as children are waiting for a donor liver. Prioritization of children is commonly used to justify SLT as very few whole grafts are available for them.…”

“…27 A retrospective study that compared WLT to the transplantation of right-extended lobes showed similar survival rates, although the latter were linked to a higher risk for retransplantation. 1,30 In contrast, recipients of full-left splits showed more complications in a study that compared full-left and full-right SLT. 17 The outcome of complex surgical interventions largely depends on surgical precision and the training of the attending surgeons-a correlation that also applies to the outcome of SLT.…”