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• W2079662386 abstract "In 1984, with mortality on the pediatric liver transplant waiting list reaching 25% at major centers, Bismuth et al.1 described the first partial liver transplant of a large graft into a small child. Their report was later confirmed by Broelsch and others,2 with success equal to or better than that of cadaveric whole liver transplantation in children. Yet although the waiting time for pediatric livers was shortened, the practice of discarding the right hemiliver shifted the cost to the adult waiting list. A/A SLT, adult-to-adult split liver transplantation; CIT, cold ischemia time; GRWR, graft-to-recipient weight ratio; LLS, left lateral segment; MELD, Model for End-Stage Liver Disease; SLT, split liver transplantation; TIPS, transjugular intrahepatic portosystemic shunt. In 1989, Bismuth et al.3 and Pichlmayr et al.4 simultaneously reported the first instances of split liver transplantation (SLT), in which adult/child pairs received grafts from a single cadaveric donor.3, 4 After initial enthusiasm, however, discouraging outcomes of SLT versus cadaveric whole liver transplantation and living donor liver transplantation caused interest to fall.5, 6 With technical refinements from experience in living donor liver transplantation and a better understanding of partial graft failure, SLT was reinvestigated in the late 1990s. The University of Hamburg in 19967 and the University of California–Los Angeles8 in 1997 reported adult and pediatric graft/patient survival comparable to that with whole liver transplantation. Although splitting a liver between an adult and a child is known to be effective, data on SLT between 2 adults [adult-to-adult split liver transplantation (A/A SLT)] are scarce. The first A/A SLT was described by Bismuth et al.4 in 1989. Only a few reports followed the first one, reflecting the challenge of the procedure. In the largest series, by Azoulay et al.,9 patient survival and graft survival with right-lobe grafts were comparable to those with whole liver transplantation. Left-lobe grafts had a higher risk of primary nonfunction, mostly related to size inadequacy, but patient survival was comparable to survival in whole liver recipients (patients with primary nonfunction underwent retransplantation), and this led the authors to conclude that SLT between adults is technically feasible. In the first North American series of 12 A/A SLT procedures,10 patient and graft survival at 9 months was 89% for right-lobe grafts versus 78% for left-lobe grafts. Biliary complications were a frequent cause of morbidity (27%), followed by an 11% incidence of vascular complications that resulted in 2 deaths. Complications were observed in 26% of left-graft SLT recipients and 22% of right-graft SLT recipients. Renz et al.11 observed a similar pattern in their series: more frequent vascular complications in right-lobe grafts, more frequent biliary complications in left-lobe grafts, higher graft survival in right-lobe recipients, and rates of primary nonfunction and recipient death similar to those reported by others. In this issue of Liver Transplantation, 2 articles draw very different conclusions about A/A SLT. Giacomoni et al.12 found “compelling evidence of a poorer reliability of SLT for 2 adults.” Heaton et al.,13 on the other hand, advise that we proceed with A/A SLT in combination with living donor liver grafts, when possible, to improve outcomes. In the report by Giacomoni et al.,12 1-year survival was 69% for SLT recipients versus 87% in a control group of whole-graft recipients. Five of the 16 SLT patients died of early allograft dysfunction before they could undergo retransplantation. Retransplantation, however, is crucial in making SLT a justifiable procedure with reasonable survival,9 especially in the early learning phase of a living donor or split liver program. As the Adult to Adult Living Donor Liver Transplantation study has confirmed, outcomes improve dramatically after a learning curve of 20 procedures.14 Most likely, the authors' SLT survival rate, which is inconsistent with outcomes in other reports, would improve as they gained experience with patient selection and operative technique. Patient selection for A/A SLT is of paramount concern. In partial liver grafts, high portal flow is thought to produce intrasinusoidal damage in 2 ways: first by the direct effect of high portal pressure on sinusoids and second from indirect changes in HA flow (that is, vasoconstriction subsequent to decreased adenosine concentration and hepatic artery buffer response). Patients with hyperdynamic splanchnic flow [such as those who require a transjugular intrahepatic portosystemic shunt (TIPS)], large body habitus (for whom the probability of receiving a relatively small graft is high), or a high Model for End-Stage Liver Disease (MELD) score are more likely to fail with partial grafts. In the Milan group, 2 patients had a TIPS, 1 patient had a MELD score of 35, and on at least 2 occasions, the graft-to-recipient weight ratio (GRWR) was less than 0.8. In fact, median body weights for the recipients of right and left lobes were nearly identical. It is impossible to tell from the article whether these risk factors were concentrated in 1 or 2 patients or distributed among many recipients, yet the decision to transplant a patient with a TIPS, a GRWR less than 0.8, or a MELD of 35 carries a high risk of failure in our opinion. Furthermore, as reported by the Adult to Adult Living Donor Liver Transplantation study, one of the most significant risk factors for graft failure is the cold ischemia time (CIT).15 Whether because of logistical or technical issues, the average CIT in the Milan patients was nearly 7 hours, with at least 2 grafts having a CIT greater than 12 hours. Two left-lobe grafts were lost to outflow obstruction. These complications can be minimized or eliminated by the equal splitting of the donor cava between left and right grafts.16 With this extra venous tissue (not available in living donor grafts), a large patch venoplasty can be fashioned on the anterior wall of the recipient cava for the left lobe or on the right anterior wall for the right lobe. This technique ensures proper orientation and preserves all short or accessory hepatic veins, best ensuring perfect outflow. Sophisticated parenchymal transection devices are rarely available in the setting of the split liver donor operation. Our preferred technique for the parenchymal transection is the bloodless crush technique, which simply consists of the Kelly crush technique in the context of a bloodless field resulting from intermittent inflow occlusion. We control small branches with cautery, medium branches with clips, and large branches with ties. The benefits of intermittent inflow occlusion include decreased intraoperative blood loss, meticulous handling of vital structures in a bloodless field in which even small biliary branches are identified and properly sealed, and, ultimately, improved graft function in the recipient.17 This technique should be used from the outset, not just in cases with severe bleeding, to prevent severe bleeding to the extent possible. Other refinements of arterial and biliary reconstruction are also important. We have found it extremely useful to use the inferior mesenteric artery as an arterial extension graft when the celiac, common, and proper hepatic arteries are not available. It is a perfect size match for either the left or right hepatic artery, and we routinely procure this graft during the split donor operation. Bile leaks from left-lobe reconstructions are troublesome. Preservation of segment 1 with the left-lobe graft does not add much parenchymal volume but preserves a vital arterial plexus to the pars transversa of the left hepatic duct that helps prevent ischemically induced leaks or strictures.18 By combining all these technical refinements with an extensive learning curve in split and living donor grafting gained previously at another institution, we were able to minimize graft failure and avoid patient death in our own small A/A SLT series at the Cleveland Clinic. Of the 8 patients who underwent SLT in the last 4 years, all 8 are still alive, and 7 grafts are still functioning. The only graft loss was in an adult patient with fulminant hepatic failure after a right-lobe SLT from a 7-year-old child. The GRWR was only 0.7%, and the recipient was in extremis. This patient was promptly retransplanted with a whole organ graft. In the other 7 cases, the GRWR ranged from 1.2 to 2.5. Four of the 8 grafts required an outflow modification (the vena cava split technique was used for 2 grafts and reconstruction of V5 and V8 was performed for the other 2 grafts). An arterial interposition was performed in the back-table in 3 patients, and in 5 of the 8 patients, we were able to perform a duct-to-duct biliary reconstruction, which we believe is key in preventing posttransplant biliary leaks and sepsis. All 7 patients have excellent graft function, and only 2 of the 8 patients developed a complication (a biliary stricture in one and postoperative intra-abdominal bleeding in the other). Although the aforementioned refinements are important, the easiest and most effective way of improving graft function and reducing complications is increasing the actual graft size and maximizing GRWR. Heaton et al.13 suggest a novel approach to this problem: combining the established techniques of both SLT and left lateral segment (LLS) donation from living donors. By the adoption of the dual-graft technique pioneered by Lee et al.,19 it would be possible, in their opinion, to combine an LLS from a split liver with an LLS procured from a living donor or from another split liver. Such a dual-graft procedure would lower morbidity and mortality risks for the living donors and would provide more adequate volume for the recipient by reducing the risk of small-for-size syndrome and graft failure. The authors suggest that the allocation algorithm for a split liver should be as follows: a right extended graft should be offered to an adult and an LLS should be offered first to a pediatric recipient. If a pediatric recipient is not available, the LLS should then be offered to a recipient with a living donor ready and able to provide the additional LLS. If there is no recipient with a potential living door, then the split liver LLS should be offered, if possible, together with an LLS from another split liver (although this last option seems highly improbable). In Lee et al.'s original report,19 a single recipient received a left lobe from a living donor and an LLS from a split cadaveric liver. Chen et al.20 described a similar case in which a recipient received a right lobe from a living donor liver and an LLS from a split liver. This strategy has the potential to increase the numbers of both SLTs and living donor liver transplants. In fact, the West has a larger pool of cadaveric donors that could potentially yield the split graft to couple with the LLS from a living donor. In addition to its indisputable logistical difficulties, this approach is fraught with other challenges. In the United States, for instance, organ allocation is driven mainly by medical urgency. The sickest patient is offered the first suitable donor. With this policy, it is difficult if not impossible to offer only a partial graft to a very sick recipient or to bypass the sick recipient even for the chance to transplant 2 recipients of less urgency who are more suitable for partial grafting. Furthermore, the use of dual LLS grafts may still not provide adequate graft volume to meet a safe threshold of a GRWR > 1. Despite these practical concerns, the split/living dual-graft technique may carry the promise of rejuvenating living donor transplant activity, which has been heavily affected in the last half-decade by donor safety concerns. It has already been established that left-lobe living donation is characterized by lower morbidity and mortality rates, and LLS donation is characterized by even lower rates.21 The left lobe usually represents 30% to 40% of the entire parenchyma. This explains both the lower complication rate in left-lobe donors and the difficulty in obtaining an adequate mass of functional parenchyma to meet recipient metabolic demands. Combining a left-lobe living donation with an LLS from a split liver would provide a more adequate graft volume and still significantly reduce the risk for the living donor. Alternatively, the split grafts could be partitioned just to the left of the middle hepatic vein. The right-lobe graft with the middle hepatic vein, as shown by the Hong Kong group,22 is adequate for most adult recipients. The larger left lobe, even without the middle hepatic vein, could be paired with an LLS from the living donor, and this would provide even more options. Other permutations that maximize the primacy of living donor safety as well as transplant possibilities are likely to emerge. In such circumstances, the combined dual-lobe living donor/SLT concept described by Heaton et al.13 would transform a marginal living donor graft into an excellent alternative to whole liver transplantation. We continue to believe that A/A SLT is a viable option in highly selected situations. We believe that it is best to set an actual graft size threshold for split grafts larger than that used in standard living donor grafting; possibly a GRWR > 1 would be appropriate for SLT. This would counterbalance some of the uncontrollable variables such as donor instability and inability to strictly limit CIT. This threshold would indeed limit the number of candidates for left-lobe grafts. By the addition of a small piece from a living donor as proposed by Heaton et al.,13 this threshold would be overcome at minimal risk to the living donor. We look forward to a time when both SLT and living donation, separately or in tandem, have transitioned from an embryonic phase into a routine and effective way of reducing the organ shortage." @default.
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• W2079662386 title "Split liver transplantation: Will it ever yield grafts for two adults?" @default.
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