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New Strategies in Split Liver Transplantation

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 Center David Geffen School of Medicine at UCLA. Reduced-sized orthotopic liver graft in

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New Strategies in Split Liver Transplantation

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  1. 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 Center David Geffen School of Medicine at UCLA

  2. Reduced-sized orthotopic liver graft in hepatic transplantation in children H. Bismuth, M.D.,andD. Houssin, M.D.,Villejuif, France Because of the rarity of child donors, in cases of adult donors room requirement for the liver graft is a major technical obstacle to liver transplantation in children. To overcome this difficulty in a child, the authors performed an orthotopic transplantation with an adult liver that had been reduced to the left lobe. The absence of technically-related complications suggests that this procedure might facilitate the performance of liver transplantation in children. From the Unite de Chirurgie hepato-biliaire and Groupe de Recherche de chirurgie hepatique INSERM U17, Hopital Paul Brousse, Villejuif, France Surgery 1984

  3. 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

  4. Progress of Split Liver Transplantation • 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

  5. Outcomes of Conventional Split Liver Transplantation * Pediatric

  6. LD SLT Split Versus LDLT in the U.S. Merion RM, Am J Transpl 2004

  7. Adjusted† Relative Risk of Graft Failure for Living Donor Recipients UNOS - 1998-2001 (N=16,595) 2.0 * P <0.05 * 1.59 * 1.47 1.5 1.00 1.0 REF 0.5 Whole Cadaveric Partial/Split Cadaveric Living †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

  8. Predicted Lifetimes After SLT 100 pediatric SLT - 3.7 adult whole - 5.8* 100 80 80 adult SLT - 5.2 60 pediatric wait list 60 adult wait list 40 40 20 20 0 12 24 0 12 24 * months/first 2 years post-transplant Merion RM et al, Am J Transpl 2004

  9. Adult to Adult Split Liver Transplantation Rationale • 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

  10. Adult to Adult Split Liver Transplantation • Outcomes and predictors • donor and recipient matching • Techniques • Technical challenges

  11. ANNALS OF SURGERY Vol. 224, No. 6, 737-748 1996 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

  12. Adult to Adult Split Liver Transplantation Azoulay D, et al Ann Surg 2001

  13. Adult to Adult Split Liver Transplantation Azoulay D, et al Ann Surg 2001

  14. Factors Affecting Survival After ASLT • Univariately • recipient status • graft steatosis, donor GGT • GRWR <1% • ICU and hospital stay • Multivariately • recipient status • graft steatosis • ICU and hospital stay Azoulay D, et al Ann Surg 2001

  15. Adult to Adult Split Liver Transplantation Humar A, et al Am J Transpl 2001

  16. Adult-to-Adult Split Liver Transplantation Published or Presented Series Year Author N %Pt %Grft %Compl 2002 Zamir 6 83% 83% N/A 2002 Goss 8 100% 100% N/A 2001 Humar 12 83% 83% 58% 2001 Azoulay 34 81% 75% 24% 2001 Broering 12 93% 85% N/A 2001 Andorno 10 100% 80% N/A 2001 Colledan 8 87% 63% 75% 2000 Gundlach 4 100% 100% N/A

  17. Adult to Adult Split Liver Transplantation • Outcomes and predictors • donor and recipient matching • Techniques • in situ • ex situ • Technical challenges

  18. RHV IRHV IVC

  19. Right hepatic duct division by sharp dissection CBD RHA

  20. CBD RHA RPV

  21. RL RPV RHA CBD

  22. In Situ Splitting of the Liver I-IV V-VIII CBD celiac MPV Humar A, et al. Liver Transpl 2002

  23. In Situ Splitting of the Liver Sommacale, et al. Transplantation 2002

  24. Ex Situ Splitting of the Liver • Back bench cholangiography and arteriography • Hilar dissection: • Celiac axis to left graft • portal trunk usually to left • Main 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

  25. MHV portal trunk celiac axis CBD IVC Alternative Cutting Lines in Ex Situ Splitting Azoulay D, et al. Arch Surg 2001

  26. Adult to Adult Split Liver Transplantation • Outcomes and predictors • donor and recipient matching • Techniques • Technical challenges • small for size syndrome • bile duct

  27. Technical Challenges in ASLT “Small for Size Syndrome” portal inflow versus venous outflow GRWR Avoid sick recipients Optimize outflow Reduce inflow

  28. Venous Drainage Patterns of Right Lobe Posterior Segments RHV MHV IRHV Type I 38.6 % RHV large IRHV absent / <0.5 cm Nakamura S and Tsuzuki T, Surg Gyn & Obst; 1981

  29. Venous Drainage Patterns of Right Lobe Posterior Segments RHV RHV MHV MHV 6 6 IRHV IRHV Type II 37.3 % Type III 24.1 % RHV medium small IRHV 0.5 - 1cm 1- 1.5 cm Nakamura S and Tsuzuki T, Surg, Gyn & Obst 1981

  30. Venous Drainage Patterns of Right Lobe Anterior Segments RHV 8 MHV 5 RHV small - medium MHV Large proximal tributary

  31. Dominant MHV Drainage of Right Lobe 5 6 LHV MHV 7 MHV 8 RHV

  32. Right versus Extended Right Lobe Grafts RHV MHV 4 5 IVC

  33. MHV Outflow Reconstruction in Right Hemigrafts RHV MHV MHV RHV IVC IRHV IVC Ghobrial et al., Liver Transpl 2001

  34. Venous Outflow Reconstruction in Right Lobe Grafts

  35. Optimization of Venous Outflow in Right Lobe Grafts Humar A, et al. Liver Transpl 2004

  36. LBD RBD Vessel loop Split-Cava Technique to Optimize Venous Outflow of Both Hemiliver Grafts Gundalch et al, Liver Transplantation; 2000

  37. Split-Cava Technique to Optimize Venous Outflow of Both Hemiliver Grafts IVC LHV RHV MHV Gundalch et al, Liver Transplantation; 2000

  38. 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

  39. MHV Splitting in Left/Right Split for Two Adults Broering et al, Liver Transplantation; 2000

  40. Inflow Reduction in Small for Size Grafts Small-for-size partial liver graft In an adult recipient; a new transplant technique Olivier Boillot, Bertrand Delafosse, Isabelle Mechet, Catherine Boucaud, Michel Pouyet Liver Transplant Unit, Edouard Herriot Hospital, Lyon, France Boillot et al, Lancet; 2002

  41. 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

  42. Bile Duct Anatomy in Donors TWO DUCTS 28 cases (60.9 %) ONE DUCT 16 cases (34.8 %) THREE DUCTS 2 cases (4.3 %)

  43. Bile Duct Visualization During Split Liver Preparation Balzan Silvio, Liver Transpl 2004

  44. Conclusions • 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

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