Right lobe split liver transplantation versus whole liver transplantation in adult recipients: A systematic review and meta‐analysis

Abstract

Split liver transplantation (SLT) has proven to be an effective technique to reduce the mortality of children on the waiting list, but whether creating 2 split grafts from 1 standard-criteria whole liver would compromise outcomes of adult recipients remains uncertain. We conducted this meta-analysis to compare outcomes of right lobe SLT and whole liver transplantation (WLT) in adult patients. PubMed, Embase, and the Cochrane Library were searched for relevant articles published before December 2014. Outcomes assessed were patient survival (PS), graft survival (GS), and major surgical complications after transplantation. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to synthesize the results. Seventeen studies with a total of 48,457 patients met the full inclusion criteria. PS and GS rates were all found to be equivalent between SLT and WLT recipients. However, SLT was associated with higher rates of overall biliary complications (OR 5 1.66; 95% CI 5 1.29-2.15; P < 0.001), bile leaks (OR 5 4.30; 95% CI 5 2.97-6.23; P < 0.001), overall vascular complications (OR 5 1.81; 95% CI 5 1.29-2.53; P < 0.001), hepatic artery thromboses (OR 5 1.71; 95% CI 5 1.17-2.50; P 5 0.005), and outflow tract obstructions (OR 5 4.17; 95% CI 5 1.75-9.94; P 5 0.001). No significant difference was observed in incidences of biliary stricture, portal vein complications, postoperative bleeding requiring surgical treatments, primary nonfunction, and retransplantations. In subgroup analyses, biliary and vascular complications only increased after ex vivo SLT rather than in situ SLT, and SLT recipients had more retransplantations if they matched with WLT recipients in terms of urgent status. In conclusion, adult right lobe SLT was associated with increased biliary and vascular complications compared with WLT, but it did not show significant inferiority in PSs and GSs. Liver Full-size liver transplantation (LT) was first introduced by Starzl et al. 1 and has currently evolved as the optimal treatment modality for patients with endstage liver diseases. With an increasing number of patients requiring donor organs, the number of whole liver cadaveric grafts is progressively inadequate. Split liver transplantation (SLT) was initially described in 1988 by Pichlmayr et al., 2 which offered an attractive

Long‐term follow‐up after full‐split liver transplantation and its applicability in the recent transplant era

“…During study period, we performed overall 44 full‐split LTX. Follow‐up of our patients revealed a good short‐ and long‐term graft and patient survival, compared to patients with whole organ or conventional splitting LTX . Detailed outcome analysis revealed no significant influence of graft type (full‐left vs full‐right split) on graft or patient survival.…”

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

“…Finally, a good ERL/recipient match may be crucial for the success of SLT . Accordingly, our data suggest that ERLT in patients with low laboratory MELD may achieve outcomes similar to WLT.…”

“…In situ splitting would most certainly help to reduce the ischemia times . Also, it may help reduce some vascular and biliary complications as has recently been proposed . However, there are also significant disadvantages that contribute to the current situation within ET where almost exclusively the ex situ preparation is performed—most importantly, the missing infrastructure of the donor hospitals and the complexity of the organization of the organ procurement to which several teams from different countries have to travel with tight schedules.…”

“…However, also some technical issues favor the ex situ procedure, ie, the possibility for a complete inspection using angiography, cholangiography, or methylene blue instillation. A clear advantage of 1 technique over the other regarding graft or even patient survival has yet to be shown …”

Outcome following right‐extended split liver transplantation in the recent transplant era: Single‐center analysis of a German transplant center

“…Most studies of adults also show similar graft and patient survival following right‐extended split LTX compared to whole organ transplantation . However, some analyses indicate that patients receiving split liver grafts show a reduced outcome or a higher complication rate, especially regarding biliary complications . Over the past 20 years, donor age has increased, such that almost 50% of donors are now over 55 years of age.…”