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.

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