Is There Still a Need for Living-related Liver Transplantation in Children?

Abstract

ObjectiveTo assess and compare the value of split-liver transplantation (SLT) and living-related liver transplantation (LRT). Summary Background DataThe concept of SLT results from the development of reducedsize 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. MethodsOutcomes 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. ResultsAfter 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. ConclusionsThe 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.Living-related liver transplantation (LRT) and split-liver transplantation (SLT) are surgical strategies that have led to a reduction in the pretransplant death rate in children from 20% to nearly 0%.1-5 LRT provides a graft of excellent quality by minimizing the cold ischemic time. Primary nonfunction (PNF) after LRT is rare. In addition, this procedure is elective and thus allows flexibility in choosing the optimal time for transplantation with regard to the recipient's clinical status. Because of these advantages, worldwide long-term results of LRT are equal or even superior to those obtained with cadaveric full-size or reduced-size techniques. The actual 1-year graft and patient survival rate after LRT exceeds 80%.6 -10 The expansion of LRT for adult recipients reflects the great expectations of this procedure despite the higher risks for the donor associated with major hepatectomy.Split-liver transplantation (SLT) is technically comparable to LRT. However, as in other cadaveric procedures, it is theoretically susceptible to potential negative effects resulting from...

Split-Liver Transplantation: A Review

“…The 32% incidence of left lateral segment graft complications reported by the ASTS survey is similar to data from individual centers, as is the classification of complications, with biliary complications being most common (29), followed by a 5-9% incidence of vascular complications (29,62,63). Right trisegment graft data were also similar between the ASTS survey and the single-center reports with respect to the incidence and nature of complications (Table 1).…”

“…This has renewed interest in increased application of traditional adult/pediatric SLT and performance of adult/adult SLT. A decade of experience with left lateral segment grafts has demonstrated that SLT applied to pediatric recipients yields excellent outcomes with significant decreases in pediatric wait-list times, wait-list morbidity, and lower utilization of living-donation at centers that routinely implement these techniques (27,29,74). Published comparisons between children receiving split and living donor left lateral segment grafts confirm comparable benefits from split liver grafts (27) (53).…”

“…Two series examined adult right trisegment recipients by comparing SLT recipients with adults receiving cadaver whole-organs during the same time period (27) or via case-matched controls (29). In each study, 1-year patient survival was comparable between SLT right trisegment and whole-organ recipients.…”

“…With this commitment, SLT accounts for approximately 10% of adult and 40% of pediatric grafts at UCLA (27), but only 2% of all transplants performed nationally over the past decade (28). Split-liver transplantation and living donation are complementary, not competitive, strategies for expansion of the donor pool; however, as SLT preserves the benefits of pediatric living-donor liver transplantation without incurring donor risk (20,27,29), it is the authors' procedure of choice.…”

Survival among pediatric liver transplant recipients: Impact of segmental grafts

“…Others have published equivalent graft survival rates between CAD and technical variant cadaveric grafts, as well as between split and living related grafts. 19,20 These single-center reports reflect the results that can be obtained in highly experienced centers. The findings in this study are based on a national average, and as such reflect a broad practice pattern.…”