Split liver transplantation

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 inhib iting further application of liver transplantation for patients with end-st age liver disease. Pediatric recipients, although they represent only 15% t o 20% of the liver transplant registrants, suffer the greatest from the sca rcity of size-matched cadaveric organs. Split liver transplantation provide s an ideal means to expand the donor pool for both children and adults. Methods This review describes the evolution of split liver transplantation from red uced liver transplantation and living-related liver transplantation. The tw o types of split liver transplantation, ex vivo and in situ, are compared a nd contrasted, including the technique, selection of patients for each proc edure, 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 c hildren, and segments 4 to 8 for adults, Since 1990, 349 ex vivo grafts hav e 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 th e high incidence of graft dysfunction (right graft) when placed in an emerg ent patient. Reasons for the poor function of ex vivo splits except in elec tive patients have focused on graft damage due to prolonged cold ischemia t imes and rewarming during the long benching procedure. In situ liver splitt ing is accomplished in a manner identical to the living donor procurement. This technique for liver splitting results in the same graft types as in th e 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 reoperatio n for bleeding. These improved results have also been observed in the urgen t patient. Conclusion Splitting of the cadaveric liver expands the donor pool of organs and may e liminate the need for living-related donation for children. Recent experien ce 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 pr ovides two grafts of optimal quality that can be applied to the entire spec trum of transplant recipients: it is the method of choice for expanding the cadaver liver donor pool.