Reuters Health Information (2013-05-15): Outcomes of split liver transplantation "excellent"
Outcomes of split liver transplantation "excellent"
Last Updated: 2013-05-15 10:20:10 -0400 (Reuters Health)
NEW YORK (Reuters Health) - Outcomes of split liver transplantation in both pediatric and adult patients are "excellent" and match those of whole liver transplantation, surgeons at Washington University School of Medicine in St. Louis say.
"We recommend escalation of the use of split liver transplants to expand the donor pool for cadaveric liver transplantation," Dr. Maria B. Majella Doyle and colleagues wrote online May 1 in the Journal of the American College of Surgeons.
They note that in the late 1980s and early 1990s, split-liver transplant outcomes were poor, and as a result there wasn't much enthusiasm for the procedure. But interest in the technique re-emerged when more favorable results were reported in the mid and late 1990s.
In the majority of split-liver cases, one recipient is an adult and the other is a child.
The St. Louis team reviewed their experience with split liver transplantation between 1995 and 2012. They say they achieved "excellent outcomes in adult and pediatric recipients using carefully selected donors for liver splitting."
Yet during the 17-year study period, only 53 of 1,261 (4.2%) patients received split liver grafts from cadaveric donors.
Patient and graft survival in the 23 adult recipients of split grafts was 95% at one year and 89% at five and 10 years and was similar to that of whole organ recipients (p=0.15).
Eighteen of the grafts were right trisegment grafts, four were right lobes and one was a left lobe. Four of the adults required hepatic artery reconstruction, five required a caval-venous patch and five needed Roux-en-Y reconstruction of the bile duct. No venous conduits were needed.
Patient survival in the 30 children who received split liver grafts was 97% at one year and 80% at five and 10 years, similar to children who received whole livers (93%, 88% and 85%, respectively; p=0.60).
One-, five, and 10-year graft survival rates were 93%, 77%, and 77% in the pediatric split liver recipients, and 88%, 84% and 81% in the pediatric whole liver recipients.
Complications in the pediatric cases included bile leak in five, and hepatic arterial thrombosis, bowel perforation and bleeding in two cases each. Three children required retransplantation.
This retrospective single center review demonstrates that "increasing organ yield by splitting livers in carefully selected donors is a safe strategy," the researchers say. "No differences were seen in either patient or graft survival in either the pediatric or the adult recipients when comparing split graft recipients with whole organ recipients. The morbidity was also similar in all groups."
Yet, only 4% of all liver transplants at their center were split grafts, "highlighting the potential for increased use of this approach." It's been estimated that roughly 20% of all deceased donors meet criteria for split liver use, "yet less than 1% of total liver transplants in the US are from split livers," the researchers say. "Therefore, there is a large disparity between the potential for splitting and actual splitting that occurs."
Dr. Parsia A. Vagefi, a transplant surgeon at Massachusetts General Hospital, Boston, who wasn't involved in the study, told Reuters Health, this publication provides "more evidence that you can have good outcomes with split liver transplantation."
He noted that the results are predominantly "in splits between a child and an adult. Luckily, there aren't a lot of children waiting for liver transplants. The real future is how do we make splitting applicable for two adults, which is a much more technically challenging procedure and hasn't been done as frequently but it is something that we still need to develop."
Transplant surgeons in Italy have tried to approach that goal in an organized fashion, developing and applying a computerized algorithm in selected donors for two adult recipients -- and their results point to the difficulties involved. In March of this year, they reported on 12 years of data from the seven collaborative centers, in a paper in Annals of Surgery. The rate of grade III and IV complications was 64.1%, and the five-year survival rate was 63.3%, compared to 83.1% in recipients of whole livers. The authors of the report say splitting a liver for use in two adults "should be considered a surgical option for selected smaller-sized adults only in experimental clinical studies in experienced centers."
Dr. Doyle and colleagues note that the donor liver split procedure and two subsequent complex liver transplantations are challenging and require "a center with a high level of experience; splitting of the liver is not only an advanced hepatobiliary procedure, but issues of vascular sharing and reconstruction add additional complexity. So, expertise in complex hepatic resection technique is essential. Better outcomes have been reported in centers with high volumes."
"We believe that the decision to split should not only depend on local expertise but, to improve the use of this limit resource, collaborative networks should be established in order to maximize the liver splitting and consolidate suitable allocation," the authors conclude.
J Am Coll Surg 2013.
Ann Surg 2013.