Split-Liver Transplantation for Two Adult Recipients: Feasibility and Long-Term Outcomes

Abstract

ObjectiveTo identify the outcomes and risks of split-liver transplantation (SLT) for two adult recipients to determine the feasibility of more widespread use of this procedure to increase the graft pool for adults. Summary Background DataThe shortage of cadaver liver grafts for adults is increasing. Using livers from donors defined as optimal, the authors have been developing techniques for SLT for two adult recipients at their center. MethodsFrom July 1993 to December 1999, 34 adults have undergone SLT with grafts from optimal donors prepared by ex situ split (n ϭ 30) or in situ split (n ϭ 4), and 88 adults received optimal whole-liver grafts that were not split. Four split-grafts were transplanted at other centers. The outcomes of transplantation with right and left split-liver grafts were compared with those of whole-liver transplants. The main end points were patient and graft survival at 1 and 2 years and the incidence and types of complications. ResultsFor whole-liver, right and left split-liver grafts, respectively, patient survival rates were 88%, 74%, and 88% at 1 year and 85%, 74%, and 64% at 2 years. Graft survival rates were 88%, 74%, and 75% at 1 year and 85%, 74%, and 43% at 2 years. Patient survival was adversely affected by graft steatosis and recipients inpatient status before transplantation. Graft survival was adversely affected by steatosis and a graft-torecipient body weight ratio of less than 1%. Primary nonfunction occurred in three left split-liver grafts. The rates of arterial (6%) and biliary (22%) complications were similar to published data from conventional transplantation for an adult and a child. SLT for two adults increased the number of recipients by 62% compared with whole-liver transplantation and was logistically possible in 16 of the 104 (15%) optimal cadaver donors. ConclusionsSplit-liver transplantation for two adults is technically feasible. Outcomes and complication rates can be improved by rigid selection criteria for donors and recipients, particularly for the smaller left graft, and possibly also by in situ splitting in cadaver donors. Wider use will require changes in the procedures for graft allocation and coordination between centers experienced in the techniques.The gap between the supply of livers for transplantation and the demand continues to widen as new indications are added, with adult potential recipients accounting for more than 95% of waiting list deaths.1 The development of new guidelines for accepting potential recipients has been recommended to limit this proportion, ensuring that available organs go to patients whose condition has not deteriorated during the waiting time and who are more likely to enjoy longer-term survival.2 However, we believe that there is still scope for increasing the graft pool for adults through splitliver transplantation (SLT).Split-liver procedures that divide a cadaver organ into a small left graft for a child and a larger right graft for an adult have reduced the graft shortage for children 3 and could even eliminate the nee...

Split-Liver Transplantation: A Review

“…Similar patterns of complications emerged from the ASTS survey data and the Paris group, with vascular complications being more frequent in right lobe grafts and biliary complications more frequent in left lobe grafts (56). Graft survival is higher in right lobe SLT recipients with a similar incidence of primary nonfunction and recipient death in each group (60).…”

“…The incidence of biliary complications was 22% with a 15% incidence of arterial complications and one reported primary nonfunction. A later series comparing 1-and 2-year SLT patient and graft survival to adults receiving cadaver whole-organ transplantation over the same time period demonstrated right-and left-SLT graft 1-year recipient survival of 74% vs. 88%, respectively, with 1-year graft survival of 74% for right-SLT vs. 75% for left-SLT recipients (56). Graft complications were not uniformly distributed with a significantly higher incidence of biliary complications observed in left grafts and a higher incidence of arterial complications reported in right grafts (56).…”

“…A later series comparing 1-and 2-year SLT patient and graft survival to adults receiving cadaver whole-organ transplantation over the same time period demonstrated right-and left-SLT graft 1-year recipient survival of 74% vs. 88%, respectively, with 1-year graft survival of 74% for right-SLT vs. 75% for left-SLT recipients (56). Graft complications were not uniformly distributed with a significantly higher incidence of biliary complications observed in left grafts and a higher incidence of arterial complications reported in right grafts (56). While no significant difference between whole-organ and SLT recipient 1-year survival was identified, the increased incidence of complications observed in SLT grafts contributed to a significantly decreased incidence of graft survival at Azoulay 1996 27 79% 78% 37% n = graft number, recipient = recipient survival, graft = graft survival, comp = reported overall complication rate, N/A = data not reported.…”

“…The Paul Brousse group has reported the largest series on adult/adult SLT (22,56,64). In 1996, Bismuth reported 1-year patient and graft survival of 79% and 78%, respectively, on 27 SLT grafts, with the routine application of ex vivo SLT increasing overall graft availability at their center by 28% (22).…”

“…Adequate graft mass has been extensively explored in living donor liver transplantation with minimal graft thresholds advocated (48)(49)(50)(51)(52); however, these data are not directly applicable to SLT as parenchyma quality, and immediate function of living donor grafts exceeds that of cadavers (27,53,54). Our preference is a graft mass of at least 1% recipient body weight; however, grafts less than 0.8% recipient body weight have been utilized with success (30,55,56).…”