Split Liver Transplantation Using Hemiliver Graft in the MELD Era: A Single Center Experience in the United States

Abstract

Under the ''sickest first'' Model for End-Stage Liver Disease (MELD) allocation, livers amenable to splitting are most often allocated to patients unsuitable for split liver transplantation (SLT). Our experience with SLT using hemilivers was reviewed. From April 2004 to June 2012, we used 25 lobar grafts (10 left lobes and 15 right lobes) for adult-sized recipients. Twelve recipients were transplanted with primary offers, and 13 were transplanted with leftover grafts. Six grafts were shared with other centers. The data were compared with matched whole liver grafts (n ¼ 121). In 92% of donors, the livers were split in situ. Hemiliver recipients with severe portal hypertension had a greater graft-torecipient weight ratio than those without severe portal hypertension (1.96% vs. 1.40%, p < 0.05). Hemiliver recipients experienced biliary complications more frequently (32.0% vs. 10.7%, p ¼ 0.01); however, the 5-year graft survival for hemilivers was comparable to whole livers (80.0% vs. 81.5%, p ¼ 0.43). The secondary recipients with leftover grafts did not have increased incidences of graft failure (p ¼ 0.99) or surgical complications (p ¼ 0.43) compared to the primary recipients. In conclusion, while routine application is still controversial due to various challenges, hemiliver SLT can achieve excellent outcomes under the MELD allocation.Abbreviations: ALT, alanine aminotransferase; GRWR, graft-to-recipient weight ratio; MELD, Model for EndStage Liver Disease; SLT, split liver transplantation

Split liver transplantation: What’s unique?

“…The risk of graft failure is now similar between split and wholeliver recipients [54] . There are several challenges, and routine application of the hemiliver technique is still controversial, but can achieve excellent outcomes under the model for end stage liver disease allocation [8] . The 5year graft survival for hemilivers is comparable to whole livers [8] .…”

“…It may take an additional 1-2 h to perform cholangiogram, hilar dissection and parenchymal division. Cholangiogram can be performed to assess surgical splitability [8] . Contrast enhanced computed tomography could be used to perform a virtual resection and volume analysis.…”

“…The severity of portal hypertension can be assessed using a triphasic computer tomographic scan [9] . Liver grafts are then perfused and preserved with HistidineTryptophan Ketoglutarate solution (Custodiol Solution; Essential Pharmaceuticals, Newtown, PA) [8] . Excellent results have been reported with split livers.…”

“…Presently, in the United States, temporary portocaval shunt is routine practice in 29% of programs, and a low CVP technique is practiced in 54% of centers [25] . The liver weight can be estimated as 2% of donor's body weight, divided into approximate weights of 35% for the left lobe and 65% for the right lobe [8] . It is important to note that since smallforsize grafts require vigorous and immediate hepatocyte proliferation, regeneration is critically required for the success of SLT.…”

An Overview of Current Status, Recent Techniques and Challenges of Liver Transplantation

“…According to the report of Organ Procurement and Transplantation Network in January 2017, 14,450 patients were awaiting a liver transplant (Hashimoto et al, 2014). Many patients continue to die while awaiting a life-saving transplant.…”