Split liver transplantation using extended right grafts: The natural history of segment 4 and its impact on early postoperative outcomes

Abstract

Split liver transplantation (SLT) using extended right grafts is associated with complications related to ischemia of hepatic segment 4 (S4), and these complications are associated with poor outcomes. We retrospectively analyzed 36 SLT recipients so that we could assess the association of radiological, biological, and clinical features with S4 ischemia. The overall survival rates were 84.2%, 84.2%, and 77.7% at 1, 3, and 5 years, respectively. The recipients were mostly male (24/36 or 67%) and had a median age of 52 years (range ¼ 13-63 years), a median body mass index of 22.9 kg/m 2 (range ¼ 17.3-29.8 kg/m 2 ), and a median graft-to-recipient weight ratio of 1.3% (range ¼ 0.9%-1.9%). S4-related complications were diagnosed in 22% of the patients (8/36) with a median delay of 22 days (range ¼ 10-30 days). Secondary arterial complications were seen in 3 of these patients and led to significantly decreased graft survival in comparison with the graft survival of patients without complications (50.0% versus 85.6%, P ¼ 0.017). Patients developing S4-related complications had significantly elevated aspartate aminotransferase (AST) levels (>1000 IU/L) on postoperative day (POD) 1 and elevated gammaglutamyl transpeptidase (GGT) levels (>300 IU/L) on PODs 7 and 10 (P < 0.05). These AST and GGT elevations conferred a significantly high risk of developing these complications (odds ratio ¼ 42, 95% confidence interval ¼ 4-475, P < 0.05). The ischemic volume of S4 was extremely variable (0%-95%) and did not correlate with S4-related complications. In conclusion, our results suggest that S4-related complications are risk factors for worse graft survival, and the development of these complications can be anticipated by the early identification of a specific biological profile and a routine radiological examination. Liver Transpl 18:413-422,

To split or not to split: That is the question

“…In this issue of Liver Transplantation , Sepulveda et al1 from France report their results for a series of 36 split liver transplants in adults. They describe the complications suffered by adult recipients of a right lobe and segment IV [S4; ie, an extended right graft (ERG)] after the division of an organ, with the segment II‐III portion being transplanted into a child.…”

Splitting livers: Trans‐hilar or trans‐umbilical division? Technical aspects and comparative outcomes

“…It is also deprived of its arterial supply in most cases, and in a good number of cases, the biliary drainage may be altered as well, as has been shown previously. This potentially seriously compromises the vitality of that segment, and its fate has been well described in previous reports in the following terms: a need for a secondary segmentectomy ; 22% of the cases were with related complications within the first month including two related deaths ; and 66% of the cases with signs of Segment IV hypoperfusion at a computerized scan . With these facts, and the lack of anatomical evidence to the contrary, the concept of augmenting the mass of a right split liver graft, by retaining Segment IV (“extended” right split graft ), and justifying the retaining of Segment IV with the right side, is difficult to support. On the contrary, retaining part of the Segment IV mass within the LSG can successfully help enlarging the graft when the LLS is rather small in size; simply by shifting the line of division to the right, through Segment IV (TH) and creating a Segment II–III–IV LSG, allows for procuring more mass for the graft, with no changes in the surgical approach (Fig.…”

Current status of deceased donor split liver transplantation in Japan

“…Although bile leakage occurred from the insertion site of external biliary stent tube in two ERL recipients in this series, the occurrence of bile leakage in ERL grafts is generally related to the viability of segment 4 (S4). The blood supply to S4, which mostly comes from the left vasculatures, may be sacrificed during the splitting procedure and may increase the risk of parenchymal necrosis and bile leakage with an incidence of approximately 20 to 30% . The S4‐related complications may be directly associated with high rates of graft loss and mortality .…”

“…The blood supply to S4, which mostly comes from the left vasculatures, may be sacrificed during the splitting procedure and may increase the risk of parenchymal necrosis and bile leakage with an incidence of approximately 20 to 30% . The S4‐related complications may be directly associated with high rates of graft loss and mortality . S4‐related complications may be prevented by precise identification of the arterial supply to S4 and the reconstruction of the S4 artery in the recipient operation .…”