Extended right liver grafts obtained by an ex situ split can be used safely for primary and secondary transplantation with acceptable biliary morbidity

Abstract

Split liver transplantation (SLT) is clearly beneficial for pediatric recipients. However, the increased risk of biliary complications in adult recipients of SLT in comparison with whole liver transplantation (WLT) remains controversial. The objective of this study was to investigate the incidence and clinical outcome of biliary complications in an SLT group using split extended right grafts (ERGs) after ex situ splitting in comparison with WLT in adults. The retrospectively collected data for 80 consecutive liver transplants using ERGs after ex situ splitting between 1998 and 2007 were compared with the data for 80 liver transplants using whole liver grafts in a matched-pair analysis paired by the donor age, recipient age, indications, Model for End-Stage Liver Disease score, and high-urgency status. The cold ischemic time was significantly longer in the SLT group (P ϭ 0.006). As expected, bile leakage from the transected surface occurred only in the SLT group (15%) without any mortality or graft loss. The incidence of all other early or late biliary complications (eg, anastomotic leakage and stenosis) was not different between SLT and WLT. The 1-and 5-year patient and graft survival rates showed no statistical difference between SLT and WLT [83.2% and 82.0% versus 88.5% and 79.8% (P ϭ 0.92) and 70.8% and 67.5% versus 83.6% and 70.0% (P ϭ 0.16), respectively]. In conclusion, ERGs can be used safely without any increased mortality and with acceptable morbidity, and they should also be considered for retransplantation. The significantly longer cold ischemic time in the SLT group indicates the potential for improved results and should thus be considered in the design of allocation policies. Liver Transpl 15:730-737, 2009. © 2009 AASLD. Received August 28, 2008 accepted December 22, 2008. In 1988, the first description of successful split liver transplantation (SLT) using a left lateral graft (LLG) for a pediatric recipient and the remnant extended right graft (ERG) for an adult recipient was reported by our institution.1 Since then, with increasing experience and improvement of the surgical technique, the significant potential of SLT became apparent, and this modality soon became common practice.2-5 SLT demonstrated great merit for very small children who were otherwise very unlikely find a suitable donor of a full size liver graft. Living-related liver donation of LLGs for pediatric recipients was introduced later into the repertoire of liver transplant techniques 6 and is now a well-established method with the disadvantage of the inherent risks for the healthy living donor. Therefore, SLT still has a place in pediatric and adult liver transplantation.

Spontaneous hepatitis B surface antigen seroclearance confers appreciably high rates except in patients with relapse of hepatitis

“…In our study, the cold ischemia time was not correlated with the development of S4‐related complications. The median cold ischemia time was found to be comparable to that of previous studies 33, 35. In our series, we demonstrated that S4‐related complications were directly associated with high rates of graft loss (50%) and mortality (8.3%).…”

“…In a radiological study of living donors, Yeh et al34 highlighted the importance of biliary tree vascularization and demonstrated that the distance between the second‐order biliary branch and the corresponding hepatic artery was a predictor of biliary leaks. Takebe et al35 identified cholestatic disease as a significant risk factor for bile leakage from the cut surface but could not offer a satisfactory explanation for this observation. Goss et al36 highlighted the devascularization of biliary convergence and graft rewarming during back‐table procedures as important risk factors in the development of ischemia/reperfusion injury and biliary complications.…”

Biliary Complications After Liver Transplantation: Old Problems and New Challenges

“…The risk of bile leaks from the cutsurface is higher than after LDLT; e.g. in the Hanover experience 15% cut surface leaks were observed (87). Most cut surface leaks have a favourable managed either by percutaneous drainage or surgical revision (87).…”

“…in the Hanover experience 15% cut surface leaks were observed (87). Most cut surface leaks have a favourable managed either by percutaneous drainage or surgical revision (87). Although available evidence is sparse, some authors recommend routine use of fibrin glue or fibrin-collagen sponges for prophylaxis of cut-surface leaks (88).…”

“…Although available evidence is sparse, some authors recommend routine use of fibrin glue or fibrin-collagen sponges for prophylaxis of cut-surface leaks (88). Due to devascularization of the hilar plate in split grafts, bile duct necrosis is observed in up to 5% of cases, which requires surgical revision or even retransplantation (87).…”