Skip to main content
PMC home page
Annals of Surgery logoLink to Annals of Surgery
. 1999 Mar;229(3):313–321. doi: 10.1097/00000658-199903000-00003

Split liver transplantation.

R W Busuttil 1, J A Goss 1
PMCID: PMC1191695  PMID: 10077042

Abstract

OBJECTIVE: This study reviews the indications, technical aspects, and experience with ex vivo and in situ split liver transplantation. BACKGROUND: The shortage of cadaveric donor livers is the most significant factor inhibiting further application of liver transplantation for patients with end-stage liver disease. Pediatric recipients, although they represent only 15% to 20% of the liver transplant registrants, suffer the greatest from the scarcity of size-matched cadaveric organs. Split liver transplantation provides an ideal means to expand the donor pool for both children and adults. METHODS: This review describes the evolution of split liver transplantation from reduced liver transplantation and living-related liver transplantation. The two types of split liver transplantation, ex vivo and in situ, are compared and contrasted, including the technique, selection of patients for each procedure, and the most current results. RESULTS: Ex vivo splitting of the liver is performed on the bench after removal from the cadaver. It is usually divided into two grafts: segments 2 and 3 for children, and segments 4 to 8 for adults. Since 1990, 349 ex vivo grafts have been reported. Until recently, graft and patient survival rates have been lower and postoperative complication rates higher in ex vivo split grafts than in whole organ cadaveric transplantation. Further, the use of ex vivo split grafts has been relegated to the elective adult patient because of the high incidence of graft dysfunction (right graft) when placed in an emergent patient. Reasons for the poor function of ex vivo splits except in elective patients have focused on graft damage due to prolonged cold ischemia times and rewarming during the long benching procedure. In situ liver splitting is accomplished in a manner identical to the living donor procurement. This technique for liver splitting results in the same graft types as in the ex vivo technique. However, graft and patient survival rates reported for in situ split livers have exceeded 85% and 90%, respectively, with a lower incidence of postoperative complications, including biliary and reoperation for bleeding. These improved results have also been observed in the urgent patient. CONCLUSION: Splitting of the cadaveric liver expands the donor pool of organs and may eliminate the need for living-related donation for children. Recent experience with the ex vivo technique, if applied to elective patients, results in patient and graft survival rates comparable to whole-organ transplantation, although postoperative complication rates are higher. In situ splitting provides two grafts of optimal quality that can be applied to the entire spectrum of transplant recipients: it is the method of choice for expanding the cadaver liver donor pool.

Full text

PDF
313

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Azoulay D., Astarcioglu I., Bismuth H., Castaing D., Majno P., Adam R., Johann M. Split-liver transplantation. The Paul Brousse policy. Ann Surg. 1996 Dec;224(6):737–748. doi: 10.1097/00000658-199612000-00009. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Bismuth H., Houssin D. Reduced-sized orthotopic liver graft in hepatic transplantation in children. Surgery. 1984 Mar;95(3):367–370. [PubMed] [Google Scholar]
  3. Bismuth H., Morino M., Castaing D., Gillon M. C., Descorps Declere A., Saliba F., Samuel D. Emergency orthotopic liver transplantation in two patients using one donor liver. Br J Surg. 1989 Jul;76(7):722–724. doi: 10.1002/bjs.1800760723. [DOI] [PubMed] [Google Scholar]
  4. Broelsch C. E., Emond J. C., Thistlethwaite J. R., Rouch D. A., Whitington P. F., Lichtor J. L. Liver transplantation with reduced-size donor organs. Transplantation. 1988 Mar;45(3):519–524. doi: 10.1097/00007890-198803000-00003. [DOI] [PubMed] [Google Scholar]
  5. Broelsch C. E., Emond J. C., Whitington P. F., Thistlethwaite J. R., Baker A. L., Lichtor J. L. Application of reduced-size liver transplants as split grafts, auxiliary orthotopic grafts, and living related segmental transplants. Ann Surg. 1990 Sep;212(3):368–377. doi: 10.1097/00000658-199009000-00015. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Busuttil R. W., Shaked A., Millis J. M., Jurim O., Colquhoun S. D., Shackleton C. R., Nuesse B. J., Csete M., Goldstein L. I., McDiarmid S. V. One thousand liver transplants. The lessons learned. Ann Surg. 1994 May;219(5):490–499. doi: 10.1097/00000658-199405000-00007. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Emond J. C., Heffron T. G., Whitington P. F., Broelsch C. E. Reconstruction of the hepatic vein in reduced size hepatic transplantation. Surg Gynecol Obstet. 1993 Jan;176(1):11–17. [PubMed] [Google Scholar]
  8. Emond J. C., Whitington P. F., Thistlethwaite J. R., Alonso E. M., Broelsch C. E. Reduced-size orthotopic liver transplantation: use in the management of children with chronic liver disease. Hepatology. 1989 Nov;10(5):867–872. doi: 10.1002/hep.1840100520. [DOI] [PubMed] [Google Scholar]
  9. Emond J. C., Whitington P. F., Thistlethwaite J. R., Cherqui D., Alonso E. A., Woodle I. S., Vogelbach P., Busse-Henry S. M., Zucker A. R., Broelsch C. E. Transplantation of two patients with one liver. Analysis of a preliminary experience with 'split-liver' grafting. Ann Surg. 1990 Jul;212(1):14–22. doi: 10.1097/00000658-199007000-00003. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Goss J. A., Yersiz H., Shackleton C. R., Seu P., Smith C. V., Markowitz J. S., Farmer D. G., Ghobrial R. M., Markmann J. F., Arnaout W. S. In situ splitting of the cadaveric liver for transplantation. Transplantation. 1997 Sep 27;64(6):871–877. doi: 10.1097/00007890-199709270-00014. [DOI] [PubMed] [Google Scholar]
  11. Hashikura Y., Makuuchi M., Kawasaki S., Matsunami H., Ikegami T., Nakazawa Y., Kiyosawa K., Ichida T. Successful living-related partial liver transplantation to an adult patient. Lancet. 1994 May 14;343(8907):1233–1234. doi: 10.1016/s0140-6736(94)92450-3. [DOI] [PubMed] [Google Scholar]
  12. Hertl M., Chartrand P. B., West D. D., Harvey P. R., Strasberg S. M. The effects of hepatic preservation at 0 degrees C compared to 5 degrees C: influence of antiproteases and periodic flushing. Cryobiology. 1994 Oct;31(5):434–440. doi: 10.1006/cryo.1994.1053. [DOI] [PubMed] [Google Scholar]
  13. Houssin D., Soubrane O., Boillot O., Dousset B., Ozier Y., Devictor D., Bernard O., Chapuis Y. Orthotopic liver transplantation with a reduced-size graft: an ideal compromise in pediatrics? Surgery. 1992 May;111(5):532–542. [PubMed] [Google Scholar]
  14. Howard T. K., Klintmalm G. B., Cofer J. B., Husberg B. S., Goldstein R. M., Gonwa T. A. The influence of preservation injury on rejection in the hepatic transplant recipient. Transplantation. 1990 Jan;49(1):103–107. doi: 10.1097/00007890-199001000-00023. [DOI] [PubMed] [Google Scholar]
  15. Inomoto T., Nishizawa F., Sasaki H., Terajima H., Shirakata Y., Miyamoto S., Nagata I., Fujimoto M., Moriyasu F., Tanaka K. Experiences of 120 microsurgical reconstructions of hepatic artery in living related liver transplantation. Surgery. 1996 Jan;119(1):20–26. doi: 10.1016/s0039-6060(96)80208-x. [DOI] [PubMed] [Google Scholar]
  16. Kalayoglu M., D'Alessandro A. M., Knechtle S. J., Hoffmann R. M., Pirsch J. D., Judd R. H., Armbrust M., Spaith E., Pilli G., Young C. J. Preliminary experience with split liver transplantation. J Am Coll Surg. 1996 May;182(5):381–387. [PubMed] [Google Scholar]
  17. Kawasaki S., Makuuchi M., Matsunami H., Hashikura Y., Ikegami T., Nakazawa Y., Chisuwa H., Terada M., Miyagawa S. Living related liver transplantation in adults. Ann Surg. 1998 Feb;227(2):269–274. doi: 10.1097/00000658-199802000-00017. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Langnas A. N., Marujo W. C., Inagaki M., Stratta R. J., Wood R. P., Shaw B. W., Jr The results of reduced-size liver transplantation, including split livers, in patients with end-stage liver disease. Transplantation. 1992 Feb;53(2):387–391. doi: 10.1097/00007890-199202010-00023. [DOI] [PubMed] [Google Scholar]
  19. Langnas A. N., Marujo W. C., Inagaki M., Stratta R. J., Wood R. P., Shaw B. W., Jr The results of reduced-size liver transplantation, including split livers, in patients with end-stage liver disease. Transplantation. 1992 Feb;53(2):387–391. doi: 10.1097/00007890-199202010-00023. [DOI] [PubMed] [Google Scholar]
  20. Lo C. M., Fan S. T., Chan J. K., Wei W., Lo R. J., Lai C. L. Minimum graft volume for successful adult-to-adult living donor liver transplantation for fulminant hepatic failure. Transplantation. 1996 Sep 15;62(5):696–698. doi: 10.1097/00007890-199609150-00029. [DOI] [PubMed] [Google Scholar]
  21. Otte J. B. Is it right to develop living related liver transplantation? Do reduced and split livers not suffice to cover the needs? Transpl Int. 1995;8(1):69–73. doi: 10.1007/BF00366716. [DOI] [PubMed] [Google Scholar]
  22. Otte J. B., de Ville de Goyet J., Alberti D., Balladur P., de Hemptinne B. The concept and technique of the split liver in clinical transplantation. Surgery. 1990 Jun;107(6):605–612. [PubMed] [Google Scholar]
  23. Pichlmayr R., Ringe B., Gubernatis G., Hauss J., Bunzendahl H. Transplantation einer Spenderleber auf zwei Empfänger (Splitting-Transplantation)--Eine neue Methode in der Weiterentwicklung der Lebersegmenttransplantation. Langenbecks Arch Chir. 1988;373(2):127–130. [PubMed] [Google Scholar]
  24. Raia S., Nery J. R., Mies S. Liver transplantation from live donors. Lancet. 1989 Aug 26;2(8661):497–497. doi: 10.1016/s0140-6736(89)92101-6. [DOI] [PubMed] [Google Scholar]
  25. Rat P., Paris P., Friedman S., Favre J. P. Split-liver orthotopic liver transplantation: how to divide the portal pedicle. Surgery. 1992 Sep;112(3):522–526. [PubMed] [Google Scholar]
  26. Rela M., Vougas V., Muiesan P., Vilca-Melendez H., Smyrniotis V., Gibbs P., Karani J., Williams R., Heaton N. Split liver transplantation: King's College Hospital experience. Ann Surg. 1998 Feb;227(2):282–288. doi: 10.1097/00000658-199802000-00019. [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Rogiers X., Malago M., Habib N., Knoefel W. T., Pothmann W., Burdelski M., Meyer-Moldenhauer W. H., Broelsch C. E. In situ splitting of the liver in the heart-beating cadaveric organ donor for transplantation in two recipients. Transplantation. 1995 Apr 27;59(8):1081–1083. [PubMed] [Google Scholar]
  28. Rogiers X., Malagó M., Gawad K., Jauch K. W., Olausson M., Knoefel W. T., Gundlach M., Bassas A., Fischer L., Sterneck M. In situ splitting of cadaveric livers. The ultimate expansion of a limited donor pool. Ann Surg. 1996 Sep;224(3):331–341. doi: 10.1097/00000658-199609000-00009. [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Saad S., Tanaka K., Inomata Y., Uemoto S., Ozaki N., Okajima H., Egawa H., Yamaoka Y. Portal vein reconstruction in pediatric liver transplantation from living donors. Ann Surg. 1998 Feb;227(2):275–281. doi: 10.1097/00000658-199802000-00018. [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Strong R. W., Lynch S. V., Ong T. H., Matsunami H., Koido Y., Balderson G. A. Successful liver transplantation from a living donor to her son. N Engl J Med. 1990 May 24;322(21):1505–1507. doi: 10.1056/NEJM199005243222106. [DOI] [PubMed] [Google Scholar]
  31. Superina R. A., Strasberg S. M., Greig P. D., Langer B. Early experience with reduced-size liver transplants. J Pediatr Surg. 1990 Nov;25(11):1157–1161. doi: 10.1016/0022-3468(90)90753-v. [DOI] [PubMed] [Google Scholar]
  32. Takada M., Nadeau K. C., Shaw G. D., Marquette K. A., Tilney N. L. The cytokine-adhesion molecule cascade in ischemia/reperfusion injury of the rat kidney. Inhibition by a soluble P-selectin ligand. J Clin Invest. 1997 Jun 1;99(11):2682–2690. doi: 10.1172/JCI119457. [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Tanaka K., Uemoto S., Tokunaga Y., Fujita S., Sano K., Nishizawa T., Sawada H., Shirahase I., Kim H. J., Yamaoka Y. Surgical techniques and innovations in living related liver transplantation. Ann Surg. 1993 Jan;217(1):82–91. doi: 10.1097/00000658-199301000-00014. [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. de Ville de Goyet J. Split liver transplantation in Europe--1988 to 1993. Transplantation. 1995 May 27;59(10):1371–1376. doi: 10.1097/00007890-199505270-00002. [DOI] [PubMed] [Google Scholar]

Articles from Annals of Surgery are provided here courtesy of Lippincott, Williams, and Wilkins

RESOURCES