Monday, September 12, 2011

Split Liver Transplant

The shortage of available organs was previously most acute for pediatric patients. Because of the small number of pediatric donors, the mortality rate among patients on the wait list was commonly high when only whole-organ transplantation was performed. In 1984, the introduction of reduced-liver transplant in which a portion of the adult liver was given to infants and children dramatically reduced this mortality rate. Over the past 20 years, the risk of death among patients on the pediatric weight list has substantially declined because of the ability to use these reduced-size grafts and because of the subsequent introduction of live-donor transplantation.

As most commonly performed, split-liver transplantation (SLT) involves the division of donor liver from a deceased adult between a pediatric recipient and an adult recipient to maximize the benefit of each available donor organ.

Split-liver transplantation takes advantage of the knowledge gained in reduced-liver transplantation to increase the organ supply by using the right lobe or tri-segmental graft that remains after the left lateral segment or left lobe is removed for a pediatric recipient. Split-liver transplantation has now been applied in all patient groups, including status 1 patients and patients requiring re-transplantation. In the young pediatric population, split-liver transplantation or reduced-liver transplantation has become an increasingly frequent procedure.
The goal of split-liver transplantation (SLT) is to produce 2 grafts with preserved vascular supply (i.e., portal vein, hepatic artery), venous drainage and bile duct. Anatomic variations (replaced arteries, biliary anomalies) are not considered to be a contraindication to liver splitting as long as both right and left-sided allografts have a complete set of vessels and biliary drainage. In most cases, the vena cava and the common bile duct are maintained with the right-sided allograft, and the left hepatic vein and left bile duct are divided for the left allograft.

Two approaches are available to generate split-liver allografts: ex vivo, in which the organ is removed from the donor and divided on the back table after the organ has been flushed and cooled, and in situ, in which the dissection and parenchymal division is performed in the donor while the organs are still being perfused.

Cooperation between different surgical teams is crucial, and the decision to proceed to in situ splitting should be based on the stability of the donor's condition and on the conditions of all waiting recipients. In general, acceptable outcomes can be achieved by using either approach.
Complications after split-liver transplantation (SLT) are similar to those of whole-organ liver transplantation. The rate of bile leaks may be slighted elevated because of the large cut surface, particularly in livers that are split into right and left lobes. Otherwise, the rate of delayed graft function and allograft non-function is not increased in properly selected split-liver grafts.

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