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The UCLA pediatric liver transplant experience utilizing in-situ splitting of the cadaveric liverBy John A. Goss, MD, and Ronald W. Busuttil, MD PhD C.L.A.S.S. Notes, Fall 1997 -- For close to 15 years orthotopic liver transplantation (OLT) has been established as the definitive therapy for patients with end-stage liver disease. During this evolutionary period, improved patient and graft survivals have been achieved and thus a natural expansion of the list of indications for the procedure has occurred. The full potential for liver replacement is far from being realized, however, due to the widening disparity between the number of potential recipients and a constant donor supply. This is clearly illustrated when considering that 7,279 patients were listed for hepatic transplantation in 1995 while only 3,922 donor livers were available. The donor shortage is particularly critical for children and small adults. Several novel approaches have been developed in an attempt to alleviate the organ shortage in children. These have primarily involved reduced-size allografts and living-related liver donation. The former, however, does not increase the scarce donor organ resource and the latter still has unresolved concerns about the safety of the living-donor. Split liver transplantation, in which an adult cadaveric liver is divided into two functioning allografts, not only overcomes the drawbacks of living-donor grafts but also increases the total number of donor organs. The concept of ex-vivo split-liver transplantation was introduced clinically in 1988 by Dr. Pichlmayr. While early reports described the feasibility of this technique, patient and graft survival rates were disappointing and associated with biliary complications, intra-abdominal hemorrhage, and primary nonfunction of the right graft. A modification of the ex-vivo technique is in-situ splitting of the liver. In-situ splitting of the liver is an extension of the techniques established for living-donor procurement and is applied to the heart-beating cadaveric donor. Dr. Rogiers, et al, initially described the in-situ splitting of the cadaveric donor liver and reported lower rates of biliary complications, intra-abdominal hemorrhage, and nonfunction of the right-sided liver allografts as compared to other series utilizing the ex-vivo split liver techniques. We first attempted in-situ split liver transplantation at UCLA in 1992, prior to our establishment of a living-donor liver transplant program. Our experience was not favorable. However, after successfully establishing a living-donor liver transplant program we once again began a split liver transplant program in July, 1996, using the in-situ methods which had been established in the living-donor procurement. Since that time we have selected 27 livers from hemodynamically stable donors with a median age and weight of 17 years (range 6 - 36 years) and 58 kg (range 24 - 76 kg), respectively for in-situ splitting. This splitting technique has been performed without technical complication and resulted in 27 right trisegmental and 27 left lateral segment grafts. These grafts have resulted in 49 transplants performed in 45 patients (22 adults and 23 children) with an age range of 4 months to 62 years and a weight range of 4.1 - 77 kg respectively. The most common etiology of end-stage liver disease in the pediatric population was congenital biliary atresia. At the time of transplantation, seven children were confined to the intensive care unit (United Network for Organ Sharing [UNOS] status 1), six patients were hospitalized (UNOS status 2), and 11 pediatric patients were awaiting liver transplantation at home (UNOS status 3). Of the 23 children undergoing in-situ split liver transplantation 22 are currently alive. The overall 6-month and 1-year actuarial patient survival rates were 96% and 96%, respectively; the 6-month and 1-year actuarial graft survival rates were 86% and 86%, respectively. Three of the pediatric recipients had to be retransplanted, 1 for hepatic artery thrombosis, 1 for primary nonfunction, and 1 for biopsy proven antibody-mediated allograft rejection. In-situ liver splitting has virtually eliminated the waiting time for small infants on our waiting list and has reduced our need to resort to living-donor liver transplantation. The average UNOS waiting period for liver transplantation in a child less than 1 year of age and 1-5 years of age outside UCLA is 197 and 128 days respectively. At UCLA these waiting times have been decreased to 24 days and 30 days respectively, since initiating our in-situ split liver transplant program. Only 3 living-donor liver transplants have been performed during this same time period (1 case for antibody-mediated rejection, 1 case for fulminant hepatic failure, and 1 case of biliary atresia with upper gastrointestinal bleeding). With these data in mind, in-situ splitting of the adult cadaveric
liver has become our technique of choice for pediatric transplantation.
It has enabled us to transplant children prior to them becoming
critically ill and allowed us to avoid hepatectomy on a family member. Dr. Goss is a transplant surgeon and assistant professor of surgery at the Dumont-UCLA Transplant Center and member of the CLASS Scientific Advisory Committee. Dr. Busuttil is Director, Dumont-UCLA Transplant Center and member of
the CLASS Scientific Advisory Committee.
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Children’s Liver Association for Support Services
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