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New Strategies in Split Liver Transplantation
R. Mark Ghobrial M.D., Ph.D.Professor of Surgery
Division of Liver and Pancreas Transplantation
The Dumont-UCLA Transplant CenterDavid Geffen School of Medicine at UCLA
Reduced-sized orthotopic liver graft in hepatic transplantation in children
H. Bismuth, M.D., and D. Houssin, M.D., Villejuif, France
Because of the rarity of child donors, in cases of adult donors room requirement for theliver graft is a major technical obstacle to liver transplantation in children. Toovercome this difficulty in a child, the authors performed an orthotopic transplantationwith an adult liver that had been reduced to the left lobe. The absence oftechnically-related complications suggests that this procedure might facilitate theperformance of liver transplantation in children.
From the Unite de Chirurgie hepato-biliaire and Groupe de Recherche de chirurgie hepatiqueINSERM U17, Hopital Paul Brousse, Villejuif, France
Surgery 1984
Transplantation einer spenderbeber auf zwei empfanger(splitting-transplantation): eine neue methode in der weiterentwicklung der lebersegment transplantation.
Pichlmayr R, Ringe B, Gubernatis G.
Klinik fur Abdominal- und Transplantationschirurgie der Medizinischen Hochschule Hannover, Kostanty-Gutschow-StraBe 8, D-3000 Hannover 61
Langenbecks Arch Chir 1988
• First attempt by Pichlmayr et al., 1988• Second split performed by Bismuth et al., 1989 • First series by Broelsch et al., 1990• SLT in Europe, De Ville De Goyet, 1995• In situ modification of ex situ, Rogiers 1995• King’s College Experience, Rela 1998
Progress of Split Liver Transplantation
Outcomes of Conventional Split Liver Transplantation
Author Year Technique N Pt Sr % Gt Sr %
Reyes 2000 Ex / In situ 54 85 72
Spada 2000 In situ 39 84 76
Ghobrial 2000 In situ 110 79 -
Kilic 2001 In situ 24 100 96
Sauer 2001 - 36 93 87
Deshpande* 2002 Ex situ 80 94 90
Girdelli* 2003 In situ 90 91 83
Yersiz 2003 In situ 163 78 68
Broering 2004 Ex / In situ 245 83 75
* Pediatric
0
100
200
300
400
500
600
1995 1996 1997 1998 1999 2000 2001 2002
Split Versus LDLT in the U.S.
LDSLT
Merion RM, Am J Transpl 2004
1.00
1.471.59
0.5
1.0
1.5
2.0
Whole Cadaveric Partial/Split Cadaveric Living
REF
* P <0.05*
*
Adjusted† Relative Risk of Graft Failure for Living Donor Recipients
UNOS - 1998-2001 (N=16,595)
†Adjusted for recipient age, race, ethnicity, sex, and diagnosis; donor age, race, and sex; recipient medical urgency status, creatinine, bilirubin, medical condition, on life support, on dialysis, on ventilator, and NYHA functional status at transplant; ABO compatibility
0 12 24 0 12 24
20
40
60
80
100
20
40
60
80
100pediatric SLT - 3.7
pediatric wait list
adult whole - 5.8*
adult wait list
Merion RM et al, Am J Transpl 2004
Predicted Lifetimes After SLT
adult SLT - 5.2
* months/first 2 years post-transplant
• Rising demands for liver organs and increased wait list deaths
• Overcomes concerns of living donor safety
• Increases the total number of grafts
• Prolongs lifetimes of SLT recipients
Adult to Adult Split Liver Transplantation
Rationale
Adult to Adult Split Liver Transplantation
• Outcomes and predictorsdonor and recipient matching
• Techniques
• Technical challenges
ANNALS OF SURGERYVol. 224, No. 6, 737-7481996 Lippincott-Raven Publishers
Split-Liver Transplantation The Paul Brousse Policy
Daniel Azoulay, M.D., Ibrahim Astarcioglu, M.D., Henri Bismuth, M.D., F.A.C.S. (Hon),Denis Castaing, M.D., Pietro Majno, M.D., F.R.C.S., Rene Adam, M.D., and Marc Johann, M.D.
From the Hepatobiliary Surgery and Liver Transplant Center, Hopital Paul Brousse, Universite Paris Sud, Villejuif, France
Adult to Adult Split Liver Transplantation
Characteristic RL Recip (17) LL Recip (17) P
Recip Wt (kg) 72 (35-97) 50 (40-83) 0.003
Donor/Recip WR 1.06 (0.8-2.2) 1.55 (1.1-2.1) 0.02
GRWR 1.6 (1-3.3) 1.0 (0.7-1.7) 0.004
CIT (min) 678 515 NS
Pt Srv (1 yr) 74% 87% NS
Gft Srv (1 yr) 74% 75% NS
Azoulay D, et al Ann Surg 2001
Adult to Adult Split Liver Transplantation
Complications RLG LLG P
PNF 0 3 0.07
Bleeding 1 0 NS
HAT 2 NS
PVT 0 2 NS
Biliary 3 4 NS
Venous outflow 0 0 NS
Azoulay D, et al Ann Surg 2001
Factors Affecting Survival After ASLT
Azoulay D, et al Ann Surg 2001
• Univariatelyrecipient statusgraft steatosis, donor GGTGRWR <1%ICU and hospital stay
• Multivariatelyrecipient statusgraft steatosisICU and hospital stay
Adult to Adult Split Liver Transplantation
Humar A, et al Am J Transpl 2001
Characteristic RL Recip (6) LL Recip (6)
Donor age (yrs) 19.7 19.7
Donor weight (kg) 89 79
Recip age 46 37
Recip weight 89 60
GRWR 0.88% 0.86%
UNIOS status 2B 2B
Pt and Grft Sr 83.3% 83.3%
Adult-to-Adult Split Liver Transplantation
Year Author N %Pt %Grft %Compl
2002 Zamir 6 83% 83% N/A2002 Goss 8 100% 100% N/A2001 Humar 12 83% 83% 58%2001 Azoulay 34 81% 75% 24%2001 Broering 12 93% 85% N/A2001 Andorno 10 100% 80% N/A2001 Colledan 8 87% 63% 75%2000 Gundlach 4 100% 100% N/A
Published or Presented Series
Adult to Adult Split Liver Transplantation
• Outcomes and predictorsdonor and recipient matching
• Techniquesin situex situ
• Technical challenges
IVCIVC IRHVIRHVRHVRHV
Right hepatic duct divisionRight hepatic duct divisionby sharp dissectionby sharp dissection
RHARHA
CBDCBD
RHARHACBDCBD
RPVRPV
RHARHA RPVRPV
CBDCBD
RLRL
In Situ Splitting of the Liver
V-VIII I-IV
celiacceliacCBDCBD
MPVMPV
Humar A, et al. Liver Transpl 2002
In Situ Splitting of the Liver
Sommacale, et al. Transplantation 2002
Ex Situ Splitting of the Liver
• Back bench cholangiography and arteriography• Hilar dissection:
Celiac axis to left graftportal trunk usually to leftMain bile duct to right side
• Parenchymal transection“straight along middle of segment IV”MHV usually to right side
• Management of cut surface of liver
Azoulay D, et al. Arch Surg 2001
Azoulay D, et al. Arch Surg 2001
Alternative Cutting Lines in Ex Situ Splitting
celiac axisportal trunk
IVC
CBD
MHV
Adult to Adult Split Liver Transplantation
• Outcomes and predictorsdonor and recipient matching
• Techniques
• Technical challengessmall for size syndromebile duct
Technical Challenges in ASLT
“Small for Size Syndrome”portal inflow versus venous outflow
GRWRAvoid sick recipientsOptimize outflowReduce inflow
Nakamura S and Tsuzuki T, Surg Gyn & Obst; 1981
Venous Drainage Patterns of Right Lobe Posterior Segments
Type I 38.6 %
RHV largeIRHV absent / <0.5 cm
RHV
IRHV
MHV
Nakamura S and Tsuzuki T, Surg, Gyn & Obst 1981
Venous Drainage Patterns of Right Lobe Posterior Segments
RHV medium smallIRHV 0.5 - 1cm 1- 1.5 cm
Type III 24.1 %
RHV
IRHV
MHV
RHV
IRHV
MHV
Type II 37.3 %
6 6
Venous Drainage Patterns of Right Lobe Anterior Segments
RHV
MHV
RHV small - medium MHV Large proximal tributary
5
8
56
7
MHV
Dominant MHV Drainage of Right Lobe
LHV
RHV8
MHV
Right versus Extended Right Lobe Grafts
RHVRHV
MHV
5
IVC
4
MHV Outflow Reconstruction in Right Hemigrafts
MHV
RHV
IRHV
Ghobrial et al., Liver Transpl 2001
IVCIVC
IVCIVC
RHVMHV
Venous Outflow Reconstruction in Right Lobe Grafts
Optimization of Venous Outflow in Right Lobe Grafts
Humar A, et al. Liver Transpl 2004
Vessel loop
LBDLBDRBDRBD
Gundalch et al, Liver Transplantation; 2000
Split-Cava Technique to Optimize Venous Outflow of Both Hemiliver Grafts
Gundalch et al, Liver Transplantation; 2000
Split-Cava Technique to Optimize Venous Outflow of Both Hemiliver Grafts
IVC
MHVMHV
LHVLHVRHVRHV
Split-Cava Technique
• Solves the issue of minor hepatic veins draining into the retrohepatic IVC
• Does not resolve the MHV issue, especially when there is dominant MHV drainage of the right lobe
Broering et al, Liver Transplantation; 2000
MHV Splitting in Left/Right Split for Two Adults
Small-for-size partial liver graft In an adult recipient; a newtransplant technique
Olivier Boillot, Bertrand Delafosse, Isabelle Mechet, Catherine Boucaud, Michel Pouyet
Liver Transplant Unit, Edouard Herriot Hospital,Lyon, France
Boillot et al, Lancet; 2002
Inflow Reduction in Small for Size Grafts
Biliary Complications in SLT
• Incidence of 10-25%
• Tends higher in ex situ splits
• Ischemia of the bile ducts with extensive dissection
• Variant biliary anatomy
TWO DUCTS 28 cases (60.9 %)
ONE DUCT16 cases (34.8 %) THREE DUCTS
2 cases (4.3 %)
Bile Duct Anatomy in Donors
Balzan Silvio, Liver Transpl 2004
Bile Duct Visualization During SplitLiver Preparation
• AASLT is the logical approach for expansion of the adult donor pool
• Successful splitting requires precise matching of split donor livers with adequately sized recipients
• Technical advances that overcome SFSS are critical to successful future implementation of the procedure
Conclusions