Ann Surg 1999 Mar;229(3):313-21

Split liver transplantation

Busuttil RW, Goss JA

Department of Surgery, The Dumont-UCLA Transplant Center, University of
California, Los Angeles School of Medicine, 90095-7054, USA.

Abstract

OBJECTIVE: This study reviews the indications, technical aspects, and experience
with ex vivo and in situ split liver transplantation. BACKGROUND: The shortage
of cadaveric donor livers is the most significant factor inhibiting further
application of liver transplantation for patients with end-stage liver disease.
Pediatric recipients, although they represent only 15% to 20% of the liver
transplant registrants, suffer the greatest from the scarcity of size-matched
cadaveric organs. Split liver transplantation provides an ideal means to expand
the donor pool for both children and adults. METHODS: This review describes the
evolution of split liver transplantation from reduced liver transplantation and
living-related liver transplantation. The two types of split liver
transplantation, ex vivo and in situ, are compared and contrasted, including the
technique, selection of patients for each procedure, and the most current
results. RESULTS: Ex vivo splitting of the liver is performed on the bench after
removal from the cadaver. It is usually divided into two grafts: segments 2 and
3 for children, and segments 4 to 8 for adults. Since 1990, 349 ex vivo grafts
have been reported. Until recently, graft and patient survival rates have been
lower and postoperative complication rates higher in ex vivo split grafts than
in whole organ cadaveric transplantation. Further, the use of ex vivo split
grafts has been relegated to the elective adult patient because of the high
incidence of graft dysfunction (right graft) when placed in an emergent patient.
Reasons for the poor function of ex vivo splits except in elective patients have
focused on graft damage due to prolonged cold ischemia times and rewarming
during the long benching procedure. In situ liver splitting is accomplished in a
manner identical to the living donor procurement. This technique for liver
splitting results in the same graft types as in the ex vivo technique. However,
graft and patient survival rates reported for in situ split livers have exceeded
85% and 90%, respectively, with a lower incidence of postoperative
complications, including biliary and reoperation for bleeding. These improved
results have also been observed in the urgent patient. CONCLUSION: Splitting of
the cadaveric liver expands the donor pool of organs and may eliminate the need
for living-related donation for children. Recent experience with the ex vivo
technique, if applied to elective patients, results in patient and graft
survival rates comparable to whole-organ transplantation, although postoperative
complication rates are higher. In situ splitting provides two grafts of optimal
quality that can be applied to the entire spectrum of transplant recipients: it
is the method of choice for expanding the cadaver liver donor pool