Split-Liver Full-Left Full-Right: Proposal for an Operative Protocol

doi:10.1016/j.transproceed.2014.07.066

Transplantation Proceedings

Volume 46, Issue 7, September 2014, Pages 2279-2282

https://doi.org/10.1016/j.transproceed.2014.07.066 Get rights and content

Abstract

Introduction

Worldwide, organ shortage is a major limiting factor to transplantations. One possible way to face graft scarcity is splitting full livers into hemilivers; this procedure would allow transplantation in 2 adult recipients with the use of a single organ from a deceased donor.

Objective

The goal of this study was to describe an adult-to-adult split liver operative protocol and share it between centers interested in exploring this procedure.

Materials and Methods

A literature review was first conducted to elaborate on the present protocol; second, selection criteria for suitable deceased donors were identified. The technical aspects of performing the procurement were also analyzed; finally, the recipient selection criteria and the transplantation criteria were determined.

Results

The donor characteristics should be consistent with the following: age ≤55 years; weight ≥70 kg; body mass index <28 kg/m²; intensive care unit stay <7 days; sodium level <160 mEq/L if the intensive care unit stay is >2 days; maximum transaminase value 3 times normal; hemodynamic stability; negative for hepatitis B surface antigen, hepatitis C virus, and human immunodeficiency virus; macrosteatosis <20%; macroscopic adequacy; and absence of anatomic anomalies requiring complex reconstruction. The procurement hospital should provide the preoperative computed tomography scan, liver dissector, and the intraoperative ultrasound. Indication for in situ or ex situ splitting depends on the hepatic vein outflow anatomy. Graft-to-recipient weight ratio should be ≥1%, and the graft-to-recipient spleen size ratio should be ≥0.6. United Network for Organ Sharing status 1 and 2A recipients are excluded, as are patients with transjugular intrahepatic portosystemic shunts. Hemiliver transplants are performed as in living-donor liver transplantation, and portal hyperflow is corrected by splenic artery ligation, splenectomy, and portal infusion of vasoactive drugs.

Conclusions

The present protocol was proposed to test the validity of the full-left full-right split liver procedure. A retrospective analysis found that 130 transplantations were suitable for this procedure according to the present protocol in the period January 1, 2008, through December 31, 2011 (65 donors). We believe that these numbers could be greatly increased once this procedure is proven feasible and safe within the proposed criteria.

Section snippets

Materials and Methods

Four main analyses were conducted of the present protocol. First, we reviewed the literature on the full-left full-right split liver (FLFRSL) topic. Second, we focused on donor selection criteria; we identified the donor clinical characteristics as well as the procurement hospital characteristics mandatory to proceeding with the splitting procedure in the NITp setting. Third, we analyzed the technical possibilities to perform the procedure: the splitting can be done in situ or ex situ [6], [7],

Results

The protocol was structured into the 4 following main sections: donor selection criteria, “how to split,” recipient selection criteria, and the transplant itself.

Discussion

FLFRSL transplantation has been created to increase the number of grafts available, but no agreement by the scientific community has been reached regarding its efficacy. The main concerns in sharing 1 liver between 2 adults are related to technical difficulties and to the possibility of graft dysfunction and small for size syndrome (SFSS). Many technical solutions have been proposed to make FLFRSL transplantation feasible: we combined our experience in living-donor liver transplantation with

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Cited by (10)

Addressing the challenges of split liver transplantation through technical advances. A systematic review
2021, Transplantation Reviews
Citation Excerpt :
The LLSG procedure is performed similar to the recipient procedure for living donors with anastomosis of the left hepatic vein to recipient middle and left hepatic vein confluence, the left portal vein to the recipient portal vein trunk and the arterial trunk either to the recipient hepatic artery proper or aorta [25]. The left hemiliver recipient procedure is usually performed in the standard way as above but may require multiple biliary anastomoses [21]. The right hemiliver recipient procedure is performed similar to a living donor transplantation except that a standard duct-to-duct biliary anastomosis is usually possible [21].
Split liver transplantation addresses donor shortages by facilitating the transplant of two recipients using one donor liver. Some still consider these grafts inferior due to prolonged cold ischaemia time and at times difficult vascular reconstruction. Techniques such as in-situ splitting, machine perfusion and interposition grafts may address these challenges and thereby address these concerns. The aim of this review is to assess these technical advances in split liver transplantation, their utility and outcomes.
A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Keywords included ‘split liver transplantation’, ‘arterial reconstruction’, and ‘machine perfusion’. Data found was synthesised into sections including: methods of splitting, full-left full-right splitting, donor cholangiography, machine perfusion and arterial reconstruction.
A total of 78 articles met inclusion criteria after screening of 151 eligible articles. These were subdivided into the following categories: in-situ (25), ex-vivo (25), full-left full-right splitting (15), donor cholangiography (2), machine perfusion (6), and arterial reconstruction (5). The in-situ splitting technique reduces the cold ischaemia time compared to the ex-vivo technique which may improve graft quality and liver splitting during normothermic machine perfusion is a novel technique with the potential to incorporate the best aspects of both techniques. Interposition grafts are often required during split liver transplantation but have an increased risk of hepatic artery thrombosis.
Advancements in technique have allowed many of the unique challenges of split liver transplantation to be overcome. Overall, this supports the use of split liver transplantation in broader and riskier settings and we advocate for liver transplant surgeons to not hesitate in using these grafts liberally and expanding their recipient selection criteria.
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Despite the progressively increasing gap between patients waiting for liver transplant under the Model for End-stage Liver Disease MELD system and the availability of deceased donor organs, the use of right extended split liver grafts (RESLG) has not been accepted by all centers. In this study, we compared the results obtained using RESLG vs a group of matched whole liver graft (WLG) recipients at a single center in Latin America.
A single-center retrospective review performed between August 2009 and December 2015.
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RESLG allows expeditious transplantation for low MELD recipients. Its use should be expanded in Latin America and worldwide as a valid alternative to increase the donor pool as it has been used in other regions.
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37th Congress of the Italian Transplantation SocietyLiver transplantationSplit-Liver Full-Left Full-Right: Proposal for an Operative Protocol

Abstract

Introduction

Objective

Materials and Methods

Results

Conclusions

Section snippets

Materials and Methods

Results

Discussion

Am J Transplant

Am J Transplant

HPB (Oxford)

Liver Transpl

Hepatology

Am J Transplant

37th Congress of the Italian Transplantation Society
Liver transplantation
Split-Liver Full-Left Full-Right: Proposal for an Operative Protocol