Split liver transplantation: Current status and future trend
Corresponding Author
Lijin Zhao MD
Affiliated Hospital of Zunyi Medical University, Zunyi City, China
Correspondence
Lijin Zhao, Affiliated Hospital of Zunyi Medical University, 149 Dalian Road, Huichuan District, Zunyi City, Guizhou Province, China.
Email: [email protected]
Search for more papers by this authorZhihong Zheng
Affiliated Hospital of Zunyi Medical University, Zunyi City, China
Search for more papers by this authorCorresponding Author
Lijin Zhao MD
Affiliated Hospital of Zunyi Medical University, Zunyi City, China
Correspondence
Lijin Zhao, Affiliated Hospital of Zunyi Medical University, 149 Dalian Road, Huichuan District, Zunyi City, Guizhou Province, China.
Email: [email protected]
Search for more papers by this authorZhihong Zheng
Affiliated Hospital of Zunyi Medical University, Zunyi City, China
Search for more papers by this authorAbstract
Liver transplantation (LT) remains the most effective treatment for end-stage liver disease. However, there continues to be a severe shortage of liver donors worldwide, resulting in a significant disparity between the number of patients on the liver transplant waiting list and the available donor organs. Split liver transplantation (SLT) enables a single whole liver graft to be divided into two partial grafts, which can then be transplanted into two recipients. This approach expands the pool of available liver donors and reduces the waiting time for LT. Since its inception, SLT has undergone continuous development and research. As a complex variant of LT, SLT requires a high level of surgical expertise, and many aspects of SLT have not yet reached a consensus or clear definition within the transplantation community. In addition, it represents a smaller proportion among all LT techniques, which hampers the further development of SLT technology. This review concludes recent developments in SLT, offering a comprehensive summary of current practices regarding donor selection criteria, surgical techniques, and clinical outcomes. Its purpose is to serve as a reference for real clinical scenarios and explore potential future trends in SLT.
CONFLICT OF INTEREST STATEMENT
The authors have no competing interests to declare that are relevant to the content of this article.
REFERENCES
- 1Broering DC, Topp S, Schaefer U, et al. Split liver transplantation and risk to the adult recipient: analysis using matched pairs. J Am Coll Surg. 2002; 195(5): 648-657.
- 2Yersiz H, Renz JF, Farmer DG, Hisatake GM, McDiarmid SV, Busuttil RW. One hundred in situ split-liver transplantations: a single-center experience. Ann Surg. 2003; 238(4): 496-505. discussion 6–7.
- 3Merion RM, Rush SH, Dykstra DM, Goodrich N, Freeman RB Jr, Wolfe RA. Predicted lifetimes for adult and pediatric split liver versus adult whole liver transplant recipients. Am J Transplant. 2004; 4(11): 1792-1797.
- 4Wilms C, Walter J, Kaptein M, et al. Long-term outcome of split liver transplantation using right extended grafts in adulthood: a matched pair analysis. Ann Surg. 2006; 244(6): 865-872. discussion 72–3.
- 5Dababneh Y, Mousa OY. Liver transplantation. StatPearls. StatPearls Publishing LLC Copyright © 2023; 2023.
- 6Aqel B, Wijarnpreecha K, Pungpapong S, et al. Outcomes following liver transplantation from HCV-seropositive donors to HCV-seronegative recipients. J Hepatol. 2021; 74(4): 873-880.
- 7Pandya K, Sastry V, Panlilio MT, et al. Differential impact of extended criteria donors after brain death or circulatory death in adult liver transplantation. Liver Transpl. 2020; 26(12): 1603-1617.
- 8Sasaki K, Firl DJ, McVey JC, et al. Elevated risk of Split-liver grafts in adult liver transplantation: statistical artifact or nature of the beast? Liver Transpl. 2019; 25(5): 741-751.
- 9Ge J, Perito ER, Bucuvalas J, et al. Split liver transplantation is utilized infrequently and concentrated at few transplant centers in the United States. Am J Transplant. 2020; 20(4): 1116-1124.
- 10de Ville de Goyet J. Outcome of in-situ split liver transplantation in Italy over the last 25 years: an alternative analysis and personal view. J Hepatol. 2023; 80(5):e212-e3.
- 11Halac E, Dip M, Quiñonez E, et al. Split liver transplantation: report of right and left graft outcomes from a multicenter Argentinean group. Liver Transpl. 2016; 22(1): 63-70.
- 12Sakamoto S, Kasahara M, Ogura Y, Inomata Y, Uemoto S. Current status of deceased donor split liver transplantation in Japan. J Hepatobiliary Pancreat Sci. 2015; 22(12): 837-845.
- 13Aseni P, De Feo TM, De Carlis L, et al. A prospective policy development to increase split-liver transplantation for 2 adult recipients: results of a 12-year multicenter collaborative study. Ann Surg. 2014; 259(1): 157-165.
- 14Chan KM, Wang YC, Wu TH, et al. Encouraging Split liver transplantation for two adult recipients to mitigate the high incidence of wait-list mortality in the setting of extreme shortage of deceased donors. J Clin Med. 2019; 8(12):2095.
- 15Hashimoto K, Quintini C, Aucejo FN, et al. Split liver transplantation using Hemiliver graft in the MELD era: a single center experience in the United States. Am J Transplant. 2014; 14(9): 2072-2080.
- 16Lee WC, Chan KM, Chou HS, et al. Feasibility of split liver transplantation for 2 adults in the model of end-stage liver disease era. Ann Surg. 2013; 258(2): 306-311.
- 17Heaton N. Small-for-size liver syndrome after auxiliary and split liver transplantation: donor selection. Liver Transpl. 2003; 9(9): S26-S28.
- 18Sandroussi C, Crawford M, Lockwood DS, et al. Donor and recipient selection leads to good patient and graft outcomes for right lobe split transplantation versus whole graft liver transplantation in adult recipients. Liver Transpl. 2009; 15(11): 1586-1593.
- 19Dalzell C, Vargas PA, Soltys K, et al. Living donor liver transplantation vs. Split liver transplantation using left lateral segment grafts in pediatric recipients: an analysis of the UNOS database. Transpl Int. 2022; 36: 10437.
- 20Park GC, Hwang S, Song GW, et al. Prognosis of Split liver transplantation compared with whole liver transplantation in adult patients: single-center results under the Korean MELD score-based allocation policy. J Korean Med Sci. 2020; 35(37):e304.
- 21Wan P, Li Q, Zhang J, Xia Q. Right lobe split liver transplantation versus whole liver transplantation in adult recipients: a systematic review and meta-analysis. Liver Transpl. 2015; 21(7): 928-943.
- 22Bahador A, Salahi H, Nikeghbalian S, et al. Split liver transplantation in shiraz transplant center. Transplant Proc. 2009; 41(7): 2872-2874.
- 23Angelico R, Trapani S, Spada M, et al. A national mandatory-split liver policy: a report from the Italian experience. Am J Transplant. 2019; 19(7): 2029-2043.
- 24Angelico R, Nardi A, Adam R, et al. Outcomes of left split graft transplantation in Europe: report from the European liver transplant registry. Transpl Int. 2018; 31(7): 739-750.
- 25Operative surgical group BoSoCMA, transplantation group BoSoCMA. Chinese expert consensus on evaluation of donor and donor liver for split liver transplantation. 肝脏研究(英文) 2022; 6(2):59-65.
- 26Xu M, Dong C, Sun C, et al. Impact of donor age on short-term outcomes after pediatric split liver transplantation. Front Pediatr. 2023; 11: 1131629.
- 27 李川, 赖彦华. 劈离式肝移植围手术期管理. 器官移植 2022(005):013.
- 28Howard TK, Klintmalm GB, Cofer JB, Husberg BS, Goldstein RM, Gonwa TA. The influence of preservation injury on rejection in the hepatic transplant recipient. Transplantation. 1990; 49(1): 103-107.
- 29Takada M, Nadeau KC, Shaw GD, Marquette KA, Tilney NL. The cytokine-adhesion molecule cascade in ischemia/reperfusion injury of the rat kidney. Inhibition by a soluble P-selectin ligand. J Clin Invest. 1997; 99(11): 2682-2690.
- 30Andrassy J, Wolf S, Lauseker M, et al. Higher retransplantation rate following extended right split-liver transplantation: an analysis from the eurotransplant liver follow-up registry. Liver Transpl. 2018; 24(1): 26-34.
- 31Herden U, Fischer L, Koch M, Li J, Achilles EG, Nashan B. Outcome following right-extended split liver transplantation in the recent transplant era: single-center analysis of a German transplant center. Clin Transplant. 2018; 32(7):e13288.
- 32Gambaro SE, Romero P, Pedraza N, et al. Right extended Split liver transplantation compared with whole liver transplantation: lessons learned at a single Center in Latin America-Results from a match case-control study. Transplant Proc. 2017; 49(9): 2122-2128.
- 33Battula NR, Platto M, Anbarasan R, et al. Intention to Split policy: a successful strategy in a combined pediatric and adult liver transplant center. Ann Surg. 2017; 265(5): 1009-1015.
- 34Mabrouk Mourad M, Liossis C, Kumar S, et al. Vasculobiliary complications following adult right lobe split liver transplantation from the perspective of reconstruction techniques. Liver Transpl. 2015; 21(1): 63-71.
- 35Cherukuru R, Reddy MS, Shanmugam NP, et al. Feasibility and safety of Split-liver transplantation in a nascent framework of deceased donation. Liver Transpl. 2019; 25(3): 450-458.
- 36Vagefi PA, Parekh J, Ascher NL, Roberts JP, Freise CE. Outcomes with split liver transplantation in 106 recipients: the University of California, san Francisco, experience from 1993 to 2010. Arch Surg. 2011; 146(9): 1052-1059.
- 37Reyes J, Gerber D, Mazariegos GV, et al. Split-liver transplantation: a comparison of ex vivo and in situ techniques. J Pediatr Surg. 2000; 35(2): 283-289. discussion 9–90.
- 38Vagefi PA, Parekh J, Ascher NL, Roberts JP, Freise CE. Ex vivo split-liver transplantation: the true right/left split. HPB (Oxford). 2014; 16(3): 267-274.
- 39Hackl C, Schmidt KM, Süsal C, Döhler B, Zidek M, Schlitt HJ. Split liver transplantation: Current developments. World J Gastroenterol. 2018; 24(47): 5312-5321.
- 40Lau NS, Jacques A, McCaughan G, Crawford M, Liu K, Pulitano C. Addressing the challenges of split liver transplantation through technical advances. A systematic review. Transp Rev (Orlando). 2021; 35(3):100627.
- 41Chul Yoon K, Song S, Jwa EK, et al. Survival outcomes in Split compared with whole liver transplantation. Liver Transpl. 2018; 24(10): 1411-1424.
- 42Moussaoui D, Toso C, Nowacka A, et al. Early complications after liver transplantation in children and adults: are split grafts equal to each other and equal to whole livers? Pediatr Transplant. 2017; 21(4):e12908.
- 43Ross MW, Cescon M, Angelico R, et al. A matched pair analysis of multicenter longterm follow-up after split-liver transplantation with extended right grafts. Liver Transpl. 2017; 23(11): 1384-1395.
- 44Maggi U, De Feo TM, Andorno E, et al. Fifteen years and 382 extended right grafts from in situ split livers in a multicenter study: are these still extended criteria liver grafts? Liver Transpl. 2015; 21(4): 500-511.
- 45Doyle MB, Maynard E, Lin Y, et al. Outcomes with split liver transplantation are equivalent to those with whole organ transplantation. J Am Coll Surg. 2013; 217(1): 102-112. discussion 13–4.
- 46Jung DH, Hwang S, Song GW, et al. In situ Split liver transplantation for 2 adult recipients: a single-center experience. Ann Transplant. 2017; 22: 230-240.
- 47Cintorino D, Spada M, Gruttadauria S, et al. In situ split liver transplantation for adult and pediatric recipients: an answer to organ shortage. Transplant Proc. 2006; 38(4): 1096-1098.
- 48Baccarani U, Adani GL, Risaliti A, et al. Long-term results of in situ split-liver transplantation. Transplant Proc. 2005; 37(6): 2592-2594.
- 49Mogul DB, Luo X, Bowring MG, et al. Fifteen-year trends in pediatric liver transplants: Split, whole deceased, and living donor grafts. J Pediatr. 2018; 196:149–153.e2.
- 50Viganò L, Laurent A, Tayar C, et al. Outcomes in adult recipients of right-sided liver grafts in split-liver procedures. HPB (Oxford). 2010; 12(3): 195-203.
- 51Chen CL, de Villa VH. Split liver transplantation. Asian J Surg. 2002; 25(4): 285-290.
- 52Chan KM, Hung HC, Lee JC, et al. A review of split liver transplantation with full right/left hemi-liver grafts for 2 adult recipients. Medicine (Baltimore). 2021; 100(39):e27369.
- 53Couinaud C, Delmas A, Patel J. Le foie: etudes anatomiques et chirurgicales. Masson; 1957: 530 illus. p.
- 54Bismuth H. Surgical anatomy and anatomical surgery of the liver. World J Surg. 1982; 6(1): 3-9.
- 55Gridelli B, Spada M, Petz W, et al. Split-liver transplantation eliminates the need for living-donor liver transplantation in children with end-stage cholestatic liver disease. Transplantation. 2003; 75(8): 1197-1203.
- 56Broering DC, Mueller L, Ganschow R, et al. Is there still a need for living-related liver transplantation in children? Ann Surg. 2001; 234(6): 713-721. discussion 21–2.
- 57Zambelli M, Andorno E, De Carlis L, et al. Full-right-full-left split liver transplantation: the retrospective analysis of an early multicenter experience including graft sharing. Am J Transplant. 2012; 12(8): 2198-2210.
- 58Jain AK, Anand R, Lerret S, et al. Outcomes following liver transplantation in young infants: data from the SPLIT registry. Am J Transplant. 2021; 21(3): 1113-1127.
- 59Perito ER, Roll G, Dodge JL, Rhee S, Roberts JP. Split liver transplantation and pediatric waitlist mortality in the United States: potential for improvement. Transplantation. 2019; 103(3): 552-557.
- 60Lau NS, Liu K, McCaughan G, Crawford M, Pulitano C. Are split liver grafts a suitable option in high-risk liver transplant recipients? Curr Opin Organ Transplant. 2021; 26(6): 675-680.
- 61Vargas PA, Cullen JM, Dalzell C, et al. Increased use of split liver grafts in adult recipients following implementation of a pediatric liver transplant program. Pediatr Transplant. 2022; 26(8):e14159.
- 62Yu Z, Keskinocak P, Magliocca JF, Romero R, Sokol J. Split or whole liver transplantation? Utilization and posttransplant survival. Hepatol Commun. 2023; 7(9):e0225.
- 63Kong L, Lv T, Yang J, Jiang L, Yang J. Adult split liver transplantation: a PRISMA-compliant Chinese single-center retrospective case-control study. Medicine (Baltimore). 2020; 99(51):e23750.
- 64Gavriilidis P, Roberts KJ, Azoulay D. Right lobe split liver graft versus whole liver transplantation: a systematic review by updated traditional and cumulative meta-analysis. Dig Liver Dis. 2018; 50(12): 1274-1282.
- 65Cescon M, Grazi GL, Ravaioli M, et al. Conventional split liver transplantation for two adult recipients: a recent experience in a single European center. Transplantation. 2009; 88(9): 1117-1122.
- 66Perkins JD, Dick AA, Healey PJ, et al. New evidence supporting increased use of Split liver transplantation. Transplantation. 2020; 104(2): 299-307.
- 67Schrem H, Kleine M, Lankisch TO, et al. Long-term results after adult ex situ split liver transplantation since its introduction in 1987. World J Surg. 2014; 38(7): 1795-1806.
- 68Rogiers X, Sieders E. Split-liver transplantation: an underused resource in liver transplantation. Transplantation. 2008; 86(4): 493-499.
- 69Liu H, Li R, Fu J, He Q, Li J. Technical skills required in Split liver transplantation. Ann Transplant. 2016; 21: 408-415.
- 70Hashimoto K, Fujiki M, Quintini C, et al. Split liver transplantation in adults. World J Gastroenterol. 2016; 22(33): 7500-7506.
- 71Namgoong JM, Hwang S, Kim DY, et al. Pediatric split liver transplantation using a hyperreduced left lateral segment graft in an infant weighing 4 kg. Korean J Transplant. 2020; 34(3): 204-209.
- 72Lau NS, Ly M, Dennis C, et al. Liver splitting during normothermic machine perfusion: a novel method to combine the advantages of both in-situ and ex-vivo techniques. HPB (Oxford). 2023; 25(5): 543-555.
- 73Kathirvel M, Nasralla D, Iype S, et al. Salvage of a right-extended Split liver graft using ex situ Normothermic machine perfusion-a new therapeutic horizon. Transplantation. 2022; 106(6): e320-e321.
- 74Bismuth H, Morino M, Castaing D, et al. Emergency orthotopic liver transplantation in two patients using one donor liver. Br J Surg. 1989; 76(7): 722-724.
- 75Broering DC, Wilms C, Lenk C, et al. Technical refinements and results in full-right full-left splitting of the deceased donor liver. Ann Surg. 2005; 242(6): 802-812. discussion 12–3.
- 76Petrowsky H, Busuttil RW. Evolving surgical approaches in liver transplantation. Semin Liver Dis. 2009; 29(1): 121-133.
- 77Ferla F, Lauterio A, Di Sandro S, et al. Split-liver full-left full-right: proposal for an operative protocol. Transplant Proc. 2014; 46(7): 2279-2282.
- 78Azoulay D, Castaing D, Adam R, et al. Split-liver transplantation for two adult recipients: feasibility and long-term outcomes. Ann Surg. 2001; 233(4): 565-574.
- 79Cardillo M, De Fazio N, Pedotti P, et al. Split and whole liver transplantation outcomes: a comparative cohort study. Liver Transpl. 2006; 12(3): 402-410.
- 80Herden U, Fischer L, Sterneck M, Grabhorn E, Nashan B. Long-term follow-up after full-split liver transplantation and its applicability in the recent transplant era. Clin Transplant. 2018; 32(3):e13205.
- 81Zimmerman A, Flahive JM, Hertl M, Cosimi AB, Saidi RF. Outcomes of full-right-full-left Split liver transplantation in adults in the USA: a propensity-score matched analysis. Int J Organ Transplant Med. 2016; 7(2): 69-76.
- 82Humar A, Beissel J, Crotteau S, Kandaswamy R, Lake J, Payne W. Whole liver versus split liver versus living donor in the adult recipient: an analysis of outcomes by graft type. Transplantation. 2008; 85(10): 1420-1424.
- 83Adham M, Dumortier J, Abdelaal A, Sagnard P, Boucaud C, Boillot O. Does middle hepatic vein omission in a right split graft affect the outcome of liver transplantation? A comparative study of right split livers with and without the middle hepatic vein. Liver Transpl. 2007; 13(6): 829-837.
- 84Sneiders D, van Dijk ARM, Polak WG, Mirza DF, Perera M, Hartog H. Full-left-full-right split liver transplantation for adult recipients: a systematic review and meta-analysis. Transpl Int. 2021; 34(12): 2534-2546.
- 85Humar A, Ganesh S, Jorgensen D, et al. Adult living donor versus deceased donor liver transplant (LDLT versus DDLT) at a single center: time to change our paradigm for liver transplant. Ann Surg. 2019; 270(3): 444-451.
- 86Mabrut JY, Lesurtel M, Muller X, et al. Ex vivo liver splitting and hypothermic oxygenated machine perfusion: technical refinements of a promising preservation strategy in Split liver transplantation. Transplantation. 2021; 105(8): e89-e90.
- 87Muller X, Rossignol G, Mohkam K, Mabrut JY. Novel strategies in liver graft preservation - the French perspective. J Visc Surg. 2022; 159(5): 389-398.
- 88Ishii D, Matsuno N, Gochi M, et al. Beneficial effects of end-ischemic oxygenated machine perfusion preservation for split-liver transplantation in recovering graft function and reducing ischemia-reperfusion injury. Sci Rep. 2021; 11(1): 22608.
- 89Li H, Li B. Using small-for-size grafts in living donor liver transplantation recipients with high MELD scores should not be considered a contraindication. Dig Dis Sci. 2013; 58(11): 3374-3375.
- 90Chok K, Chan SC, Fung JY, et al. Survival outcomes of right-lobe living donor liver transplantation for patients with high model for end-stage liver disease scores. Hepatobiliary Pancreat Dis Int. 2013; 12(3): 256-262.
- 91Jiang L, Yan L, Tan Y, et al. Adult-to-adult right-lobe living donor liver transplantation in recipients with hepatitis B virus-related benign liver disease and high model end-stage liver disease scores. Surg Today. 2013; 43(9): 1039-1048.
- 92Strong RW, Lynch SV, Ong TH, Matsunami H, Koido Y, Balderson GA. Successful liver transplantation from a living donor to her son. N Engl J Med. 1990; 322(21): 1505-1507.
- 93Özden İ, Yavru HA, Durmaz Ö, et al. Complementary roles of cadaveric and living donor liver transplantation in acute liver failure. J Gastrointest Surg. 2021; 25(10): 2516-2523.
- 94Wu SD, Huang J, Fang JZ, et al. Efficacy of in-situ full-left/full-right split liver transplantation for adult recipients using the living donor liver transplantation technique:a single-center report of 25 cases. Zhonghua Wai Ke Za Zhi. 2022; 60(10): 906-914.
- 95Chung YK, Hwang S, Ahn CS, et al. Fates of retained hepatic segment IV and its prognostic impact in adult split liver transplantation using an extended right liver graft. Ann Surg Treat Res. 2021; 101(1): 37-48.
- 96Mogul DB, Luo X, Garonzik-Wang J, et al. Expansion of the liver donor supply through greater use of Split-liver transplantation: identifying optimal recipients. Liver Transpl. 2019; 25(1): 119-127.
- 97Lozanovski VJ, Döhler B, Weiss KH, Mehrabi A, Süsal C. The differential influence of cold ischemia time on outcome after liver transplantation for different indications-who is at risk? A collaborative transplant study report. Front Immunol. 2020; 11: 892.
- 98Nadalin S, Schaffer R, Fruehauf N. Split-liver transplantation in the high-MELD adult patient: are we being too cautious? Transpl Int. 2009; 22(7): 702-706.
- 99Sebagh M, Yilmaz F, Karam V, et al. Cadaveric full-size liver transplantation and the graft alternatives in adults: a comparative study from a single centre. J Hepatol. 2006; 44(1): 118-125.
- 100Azoulay D, Astarcioglu I, Bismuth H, et al. The Paul Brousse policy. Ann Surg. 1996; 224(6): 737-746. discussion 46–8.