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Background: Split liver transplantation (SLT) is a strategy to address organ shortage, but is a technically more demanding procedure than whole graft liver transplantation (LT). We aimed to determine the outcomes following SLT in adult recipients as well as to highlight the impact that having a pediatric LT program has on SLT implementation. Methods: All SLTs conducted at a single‐center from 2010 to 2019 were identified. Patient data was obtained through retrospective review of the electronic medical record. Kaplan–Meier analysis assessed primary outcomes of 1‐,3‐, and 5‐year graft and patient survival. Results: We identified 37 SLTs performed at our institution from 2010 to 2019. Twenty‐four donated livers resulted in 21 extended right lobes and 16 left lateral segments for adults and pediatrics recipients, respectively. Eighty‐one percent (30/37) of the SLTs were performed after introduction of the combined pediatric program in 2016. 13/24 donor livers were split with both grafts allocated and used at our institution and 92% occurred after introduction of the pediatric program. Graft survival rates at 1‐, 3‐, and 5‐years were 94% in adult recipients and 100% for all time periods in pediatric recipients. Actuarial post‐transplant patient survival was 100% at 1‐, 3‐, and 5‐years in both. Conclusions: The introduction of a pediatric liver transplantation program resulted in more than a fourfold increase in the number of SLTs performed at our center. Increase in allocation and use of both grafts at our institution was also seen. [ABSTRACT FROM AUTHOR]

Aim. To analyse the surgical aspects of performing a split liver transplantation in patients with end-stage liver disease.Key findings. Split liver transplantation (SLT) is a technique allowing two functional grafts to be obtained from one deceased donor to simultaneously save the lives of two recipients. The global clinical experience of SLT application currently comprises more than three decades. Criteria necessary for successful SLT were developed, based both on assessment of graft quality (age and anthropometric characteristics of the donor, laboratory parameters, ultrasound data, length of stay in intensive care, as well as macroscopic intraoperative assessment of the liver), and on the selection of recipients (primarily in accordance with the height-weight characteristics and the use of the GRWR [graftto-recipient weight ratio]). The use of these criteria allows the results to be achieved comparable to other types of liver transplantation (a whole liver from a deceased donor or liver fragments of an intravital donor). However, issues involved with of the optimal choice of surgical techniques remain to be solved, which include such key aspects as the anatomical method of separation (left lateral section and extended right lobe; anatomical left and right lobes of the liver), an optimal method of separation (ex situ or in situ) and others. The issues of logistics of the SLT application, including the principles of allocation of transplants, also remain significant. Ethical aspects are equally important, since, theoretically, the widespread introduction of the SLT technique may increase the risk of graft loss. The immediate and long-term SLT results require further study, which makes it possible to form a more objective opinion on the effectiveness of the technique.Conclusion. SLT shows good results both in the near and in the remote period. The key aspects of SLT performing are a deep understanding of the variant anatomy of the liver and a high level of knowledge of liver resection surgery. The active use of SLT allows the pool of donor organs to be increased, which is of great importance under the conditions of their permanent lack.

In 1988, Rudolf Pichlmayr pioneered split liver transplantation (SLT), enabling the transplantation of one donor liver into two recipients - one pediatric and one adult patient. In the same year, Henri Bismuth and colleagues performed the first full right/full left split procedure with two adult recipients. Both splitting techniques were rapidly adopted within the transplant community. However, a SLT is technically demanding, may cause increased perioperative complications, and may potentially transform an excellent deceased donor organ into two marginal quality grafts. Thus, crucial evaluation of donor organs suitable for splitting and careful screening of potential SLT recipients is warranted. Furthermore, the logistic background of the splitting procedure as well as the organ allocation policy must be adapted to further increase the number and the safety of SLT. Under defined circumstances, in selected patients and at experienced transplant centers, SLT outcomes can be similar to those obtained in full organ LT. Thus, SLT is an important tool to reduce the donor organ shortage and waitlist mortality, especially for pediatric patients and small adults. The present review gives an overview of technical aspects, current developments, and clinical outcomes of SLT., Competing Interests: Conflict-of-interest statement: The authors declare no conflicts of interest.