Ann Surg 1990 Sep;212(3):368-75; discussion 375-7

Application of reduced-size liver transplants as split grafts, auxiliary
orthotopic grafts, and living related segmental transplants

Broelsch CE, Emond JC, Whitington PF, Thistlethwaite JR, Baker AL, Lichtor JL

Department of Surgery, University of Chicago Pritzker School of Medicine,
Illinois.

Abstract

The University of Chicago program in pediatric liver transplantation continues
actively to seek innovative surgical solutions to problems related to the
management of children with end-stage liver disease. Among the most important
problems facing these children is a shortage of donor organs, which results from
three factors in addition to the actual supply of pediatric donors: the
concentration of pediatric liver disease in the population younger than 2 years;
the necessity for a graft that is small enough; and the epidemiology of
accidents and other events that lead to organ donation. Transplantation using a
liver lobe as a graft overcomes size disparity and shifts the available supply
of organs from older donors to younger recipients. This work describes the
technical aspects of recent innovations in the use of liver lobes in pediatric
transplantation, simple reduced-size liver transplantation (RLT), split-liver
transplantation (SLT), orthotopic auxiliary liver grafting (ALT), and
transplantation using a living related donor (LRLT), and compares their results.
Since November 1986 a total of 61 procedures have been performed in which a
liver lobe was used as a graft: 26 RLT; 30 SLT, 25 in children and 5 in adults;
5 LRLT; and 1 ALT. Overall 62% of transplants performed in children have
involved using a liver lobe as a graft. The rates of complications are somewhat
higher than with whole-liver transplantation, but this may not be entirely the
result of the complex procedures. Split liver transplantation is associated with
the highest mortality and complication rates. Living related liver
transplantation has been associated with complications in donors and recipients,
but to date survival is 100%. Orthotopic auxiliary liver transplantation
effectively corrected the metabolic defect in one patient with ornithine
transcarbamylase deficiency. Overall the various modalities of using graft
reduction have resulted in postoperative results similar to those achieved with
full-size grafts, while pretransplantation mortality has been limited to less
than 2%. Thus the use of grafts as liver lobes accomplishes the goal of reducing
global mortality among children with end-stage liver disease, but at the cost of
increased surgical complexity and more postoperative complications.