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Optimizing graft preservation is key for ex-situ split grafts in pediatric liver transplantation (PSLT). Hypothermic Oxygenated Perfusion (HOPE) improves ischemia-reperfusion injury (IRI) and post-operative outcomes in adult LT. This study compares the use of HOPE in exsitu partial grafts to static cold storage ex-situ partial grafts (SCS-Split) and to the gold standard living donor liver transplantation (LDLT). All consecutive HOPE-Split, SCS-Split and LDLT performed between 2018–2023 for pediatric recipients were included. Postreperfusion syndrome (PRS, drop ≥30% in systolic arterial pressure) and reperfusion biopsies served as early indicators of IRI. We included 47 pediatric recipients (15 HOPESplit, 17 SCS-Split, and 15 LDLT). In comparison to SCS-Split, HOPE-Split had a significantly shorter cold ischemia time (CIT) (470min vs. 538 min; p =0.02), lower PRS rates (13.3% vs. 47.1%; p = 0.04) and a lower IRI score (3 vs. 4; p = 0.03). The overall IRI score (3 vs. 3; p = 0.28) and PRS (13.3% vs. 13.3%; p = 1) after HOPE-Split were comparable to LDLT, despite a longer CIT (470 min vs. 117 min; p < 0.001). Surgical complications, one-year graft, and recipient survival did not differ among the groups. In conclusion, HOPE-Split mitigates early IRI in pediatric recipients in comparison to SCSSplit, approaching the gold standard of LDLT. [ABSTRACT FROM AUTHOR]

Background: Split liver transplantation (SLT) increases graft availability, but it's safe and effective utilization is insufficiently documented. This study aimed to investigate the association between perioperative body composition abnormalities and outcomes in adult SLT. Materials and methods: Two hundred forty recipients who underwent SLT in three centers were enrolled in this retrospective cohort study. Body composition abnormalities including sarcopenia, myosteatosis, visceral obesity, and sarcopenic obesity were evaluated at baseline and 1 month after surgery using computed tomography. Their impact on outcomes including early allograft dysfunction, early complications, ICU stay, graft regeneration rate, and survival was analyzed. Results: Recipients with sarcopenia or myosteatosis had a higher risk of early allograft dysfunction, higher early complication rate, and longer length of ICU stay (all P< 0.05), while there was no difference in graft regeneration rate. Recipient and graft survival were significantly worse for recipients with body composition abnormalities (all P< 0.05). In multivariable Cox-regression analysis, sarcopenia [hazard ratio (HR)= 1.765, P= 0.015], myosteatosis (HR=2.066, P=0.002), and visceral obesity (HR= 1.863, P =0.008) were independently associated with shorter overall survival. Piling up of the three factors increased the mortality risk stepwise (P< 0.001). Recipients experienced skeletal muscle loss and muscle fat infiltration 1 month after surgery. Postoperative worsening sarcopenia (HR= 2.359, P= 0.009) and myosteatosis (HR=1.878, P =0.026) were also identified as independent risk factors for mortality. Conclusion: Sarcopenia, myosteatosis, and their progression negatively affect outcomes including early allograft dysfunction, early complications, ICU stay and survival after SLT. Systemic evaluation and dynamic monitoring of body composition are valuable. [ABSTRACT FROM AUTHOR]

With persistent breakthrough and maturity of surgical procedures and postoperative immunosuppressive therapy, the survival rate of liver transplant recipients and grafts has been significantly increased. The shortage of donor liver has become the main obstacle for clinical development of liver transplantation. How to expand the source of donor liver has become an urgent issue. Groundbreaking progresses have been made in the use of common marginal donor livers in clinical liver transplantation, such as elderly donor liver, steatosis donor liver, viral hepatitis donor liver and liver from donation after cardiac death. Nevertheless, multiple restrictions still exist regarding the use of marginal donor liver. Consequently, the definition of marginal donor liver and research progress in the application of common marginal donor livers were reviewed, and the opportunities and challenges of mariginal donoor liver were illustrated, aiming to provide reference for expanding the donor pool for clinical liver transplantation and bringing benefits to more patients with end-stage liver disease. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Transplantation is the only treatment for congenital and acquired liver malformations in the pediatric population. The most common are biliary atresia, A1 antitrypsin deficiency, Wilson's disease, metabolic diseases, acquired diseases complicated by cirrhosis and liver failure. In most cases, patients with biliary atresia require liver transplantation at an early age. In case of late diagnosis and inability to perform portoenterostomy (Kasai procedure), the only treatment option is transplantation at the age of ±1 year. The aim of study. Single-center case analysis of a child with biliary atresia demonstrates the current state of solving this problem in Ukraine with the absence of the possibility of family transplantation and shortage of donor organs. To study the potential development opportunities of SPLIT transplantation in this stage group. Analyze the possibilities of optimizing the process from diagnosis to transplantation with the aim of maximizing the preservation of the child's physical and intellectual development and reducing the impact of the disease on other organs and systems. Results. In our work we analyzed the experience of treating a patient with uncorrected biliary atresia with late diagnosis. Patient P, blood group A(I) Rh(+) boy, 1st pregnancy, born with weight 2500g, height 50 cm at 39 weeks. Pregnancy: physiologic delivery, Apgar score 9\9. Liver biopsy confirmed the diagnosis of biliary atresia with significant cirrhosis. On esophagogastroscopy: signs of incipient portal hypertension. Considering these data and the child's age (85 days), portoenterostomy as a method of treatment was not appropriate. A course of treatment was prescribed and liver transplantation was determined as the only method of treatment for the patient. Unfortunately, the examination of close relatives to determine the possibility of family donation did not give positive results. The donor was a 14-year-old boy, blood type I(O) Rh(+), with a congenital defect of the central nervous system. After prolonged treatment, the patient had a sudden hemorrhage. After brain death was declared, the parents gave their consent for organ transplantation to recipients on the waiting list. SPLIT transplantation was performed by dividing the donor organ for 2 recipients. The left lobe of the liver was transplanted to a patient with biliary atresia at the age of 1 year and 3 months. Three vascular anastomoses (caval, portal and arterial) were performed together with anastomoses between the bile duct and the intestinal tube of the child. The right hepatic lobe was similarly transplanted in an adult patient. The post-operative period was uneventful. Patients were successfully discharged and continue to receive immunosuppressive therapy on an outpatient basis. SPLIT transplantation is a successful way to solve the problem of donor organ shortage. Conclusions. 1. Liver transplantation is the main method of treatment for children with biliary atresia and other liver diseases due to dangerous complications that occur at an early age. 2. Split transplantation is a significant step in the development of Ukrainian transplantology, especially in the conditions of organ shortage. It allows to save the life of two patients in need of transplantation. 3. If the diagnosis is made that liver transplantation is the only method of treatment and the patient is placed on the waiting list, the patient must be under observation and the multidisciplinary team must prepare the patient for transplantation. 4. Transplantation must be performed before significant physical and intellectual irreversible changes. 5. The correct preparation of the patient, the optimalerm and method of transplantation, before lesions of other systems, directly affect the success and result of transplantation. [ABSTRACT FROM AUTHOR]

Mortality on the paediatric liver transplantation (pLT) waiting list (WL) is still an issue. We analysed the Italian pLT WL to evaluate the intention-to-treat (ITT) success rate and to identify factors influencing success. All children (<18 years) listed for pLT in Italy between 2002-2018 were included (Era 1 [2002–2007]: centre-based allocation; Era 2 [2008–2014]: national allocation; Era 3 [2015–2018]: national allocation+mandatory-split policy). A total of 1,424 patients (median age: 2.0 [IQR 1.0-9.0] years; median weight: 12.0 kg [IQR 7–27]) were listed for pLT. Median WL time was 2 days (IQR 1–5) for Status 1 and 44 days (IQR 15–120) for non-Status 1 patients; 1,302 children (91.4%) were transplanted (67.3% with split grafts), while 50 children (3.5%) dropped off the WL (2.5% death, 1.0% clinical deterioration). Predictive factors for receiving LT included Status 1 (hazard ratio [HR] 1.66, p = 0.001), Status 1B (HR 1.96, p = 0.016), Status 2A (HR 2.15, p = 0.024) and each 1-point increase in PELD/MELD score. Children with recipient's weight >25 kg, blood group O or awaiting pLT combined with other organs had less chance of being transplanted. ITT patient survival rates were 90.5% at 1 year and 87.5% at 5 years, remaining stable across eras. Risk factors for ITT survival were re-transplantation (HR 5.83, p < 0.001), Status 1 (HR 2.28, p = 0.006), Status 1B (HR 2.90, p = 0.014), Status 2A (HR 9.12, p < 0.001), recipient weight <6 kg (HR 4.53, p < 0.001) and low-volume activity (HR 4.38, p = 0.001). In Italy, continuous adaption of paediatric organ allocation policies via the introduction of national allocation, paediatric prioritisation rules and a mandatory-split policy have helped maximise the use of donors for paediatric candidates and to minimise WL mortality without compromising outcomes. Globally, paediatric liver transplant candidates still suffer from high mortality. Over recent decades, the continuous adaption of organ allocation policies in Italy has led to excellent outcomes for children awaiting liver transplantation. The mortality rate of paediatric liver transplant candidates has been minimised to almost zero, mainly using grafts from deceased donors. Paediatric prioritisation rules, national organ exchange organisation and a mandatory-split liver policy have resulted in a unique allocation model for paediatric liver transplant candidates and represent a landmark for the paediatric transplant community. [Display omitted] • In Italy paediatric liver transplant waiting list dropout rate is minimized to 3.5%. • Predictive factors of transplant are urgency, tumours, each added PELD/MELD point. • Survival risk factors are re-transplant, urgency, weight <6 kg, low-volume centre. • National mandatory-split liver policy increases paediatric liver transplant activity. • Paediatric priorisation and national organ allocation are needed to improve outcomes. [ABSTRACT FROM AUTHOR]

Inherited metabolic liver disease (IMLD) is a category of liver metabolic diseases caused by genetic disorders. The pathogenesis of IMLD is complex, which primarily comprises the accumulation of harmful metabolic substrates or products caused by specific enzyme defects and energy defects or abnormal deposition caused by abnormal metabolism of glucose, fat and other substances. In recent years, liver transplantation has played an increasingly critical role in the treatment of IMLD with the development of liver transplantation. At present, IMLD has become the second most important indication after biliary atresia in pediatric liver transplantation. Currently, IMLD patients receiving liver transplantation can be divided into two categories: the first category is IMLD complicated with liver disease; Category 2 patients have a normal liver structure but are deficient in related metabolic enzymes. It can not only replace the liver with abnormal structure and function, but also provide normal enzymes required for patients' metabolism, which may improve their quality of life and even save their lives. In this article, common feasible liver transplantation for IMLD, clinical prognosis and surgical procedures of liver transplantation for IMLD were reviewed, aiming to provide reference for liver transplantation for IMLD. [ABSTRACT FROM AUTHOR]

Optimizing graft preservation is key for ex-situ split grafts in pediatric liver transplantation (PSLT). Hypothermic Oxygenated Perfusion (HOPE) improves ischemia-reperfusion injury (IRI) and post-operative outcomes in adult LT. This study compares the use of HOPE in ex-situ partial grafts to static cold storage ex-situ partial grafts (SCS-Split) and to the gold standard living donor liver transplantation (LDLT). All consecutive HOPE-Split, SCS-Split and LDLT performed between 2018–2023 for pediatric recipients were included. Post‐reperfusion syndrome (PRS, drop ≥30% in systolic arterial pressure) and reperfusion biopsies served as early indicators of IRI. We included 47 pediatric recipients (15 HOPE-Split, 17 SCS-Split, and 15 LDLT). In comparison to SCS-Split, HOPE-Split had a significantly shorter cold ischemia time (CIT) (470min vs. 538 min; p =0.02), lower PRS rates (13.3% vs. 47.1%; p = 0.04) and a lower IRI score (3 vs. 4; p = 0.03). The overall IRI score (3 vs. 3; p = 0.28) and PRS (13.3% vs. 13.3%; p = 1) after HOPE-Split were comparable to LDLT, despite a longer CIT (470 min vs. 117 min; p < 0.001). Surgical complications, one-year graft, and recipient survival did not differ among the groups. In conclusion, HOPE-Split mitigates early IRI in pediatric recipients in comparison to SCS-Split, approaching the gold standard of LDLT.

Background: Split and living donor liver transplantations are both key surgical strategies for development of pediatric liver transplant programs. Often, however, teams tend to prioritize only one preferentially. Methods: In the context of a very active national split liver graft allocation program (Italy), retrospective study of 226 consecutive pediatric first isolated liver transplants performed by a single team using organs from both deceased and living donors. Clinical characterisitics and outcome were compared. Results: In the context of a steadily slowly decreasing split graft offer, living donation activity steadily increased. Deceased and living donation accounted for 52.6% and 47.4% of transplantations, respectively. Both strategies were equally used for transplanting patients up to 30 kg of weight, while deceased donors were predominantly used for older recipients. Technical variants represented 86% of all transplants, with 183 conisting of left lateral segment grafts (76 split liver grafts and 107 left grafts from living donors). Outcome of both surgical strategies was similar, with excellent outcomes at early, mid‐, and long‐term. Conclusions: Splitting livers of deceased donors and using living donation were complementary and non‐competitive strategies for developping pediatric liver transplant activity. Implementing both activities in parallell allowed to maintain stable the number of annual transplant in Italy and allowed to reach superior outcomes. This analysis provides evidence that living donation plays a role in Italy despite an existing very active "mandatory‐split" national policy. [ABSTRACT FROM AUTHOR]

Background: End‐stage liver disease (ESLD) and end‐stage renal disease (ESRD) are prevalent diseases for which the definitive treatment is transplantation. With limited organ supply, strategies to maximize organ availability has led to increasing rates of split liver transplantations for ESLD patients. Therefore, simultaneous split liver and kidney transplantations (SSLK) for patients with ESLD and ESRD could represent a treatment option for comorbid patients. However, current practice and outcomes after SSLK are unknown. Methods: We aim to report national trends and our experience with patients undergoing SSLK. We performed a retrospective review of the United Network for Organ Sharing (UNOS) Standard Transplant Analysis and Research file from January 2011–April 2022. Descriptive analysis of preoperative characteristics, postoperative outcomes and actuarial graft and patient survivals are reported. Results: National review of the UNOS transplant registry from 2011–2021 of adult patients undergoing initial transplantation via SSLK demonstrates that this procedure remains uncommon, with only 76 such cases captured in that time. Nevertheless, survival rates at 1, 3, and 5 years remains robust, at 94%, 92%, and 90% for patients overall, 90%, 88%, 88%, for the liver graft, and 93%, 91%, 88% for the kidney graft, respectively. Review of a single center experience with three such patients from 2019–2021 has shown a safe, enduring transplant option with no graft complications seen. Conclusions: SSLK is both safe and a feasible option to optimize organ supply while allowing recipients to receive quality liver and kidney grafts and should be considered more often by transplant centers going forward. [ABSTRACT FROM AUTHOR]

Objective To investigate the diagnosis and treatment strategy of the portal vein complications in children undergoing split liver transplantation. Methods The clinical data of 88 pediatric recipients who underwent split liver transplantation were retrospectively analyzed. Intraoperative anastomosis at the bifurcating site of the portal vein or donor iliac vein bypass anastomosis was performed depending on the internal diameter and development of the recipient's portal vein. A normalized portal venous blood stream monitoring was performed during the perioperative stage. After operation, heparin sodium was used to bridge warfarin for anticoagulation therapy. After portal vein stenosis or thrombosis was identified with enhanced CT or portography, managements including embolectomy, systemic anticoagulation interventional thrombus removal, balloon dilatation and/or stenting were performed. Results Among the 88 recipients, a total of 10 children were diagnosed with portal vein complications, of which 4 cases were diagnosed with portal vein stenosis at 1 d, 2 months, 8 months, and 11 months after surgery, and 6 cases were diagnosed with portal vein thrombosis at intraoperative, 2 d, 3 d (n=2), 6 d, and 11 months after surgery, respectively. One patient with portal vein stenosis and one patient with portal vein thrombosis died perioperatively. The fatality related to portal vein complications was 2% (2/88). Of the remaining 8 patients, 1 underwent systemic anticoagulation, 2 underwent portal venous embolectomy, 1 underwent interventional balloon dilatation, and 4 underwent interventional balloon dilatation plus stenting. No portal venous related symptoms were detected during postoperative long term follow up, and the retested portal venous blood stream parameters were normal. Conclusions The normalized intra- and post-operative portal venous blood stream monitoring is a useful tool for the early detection of portal vein complications, the early utilization of useful managements such as intraoperative portal venous embolectomy, interventional balloon dilatation and stenting may effectively treat the portal vein complications, thus minimizing the portal vein complication related graft loss and recipient death. [ABSTRACT FROM AUTHOR]

In July 2017, a policy to increase the use of segmental grafts (SGs) was implemented at our institution. The aim was to compare changes in waitlist activity after implementation of this policy. A single-center, retrospective study. Pediatric patients on the liver waiting list between January 2015 and December 2019 were screened. Patients were classified as receiving a liver transplant (LT) before (Period 1) or after (Period 2) policy changes. Primary end points were transplant rates and time to transplant. Sixty five first LT performed on 65 patients were included. Twenty nine LT were performed during Period 1 and 36 during Period 2. More than half (55%) of LT in Period 2 were SG, compared to 10.3% in Period 1 (P < 0.001). Forty nine and 56 pediatric candidates on the waiting list accounted for 38.78 and 24.48 person-years during Period 1 and Period 2, respectively. Transplant rates per 100 person-years on the waiting list increased from 85.09 during Period 1 to 187.87 in Period 2 (Rate ratio: 2.20; P < 0.001). Median time to receive a LT decreased from 229 d in Period 1 to 75 d during Period 2 (P = 0.013). One-year patient survival rates were 96.6% in Period 1 and 95.7% in Period 2. One-year graft survival rates were 89.7% and 88% in Period 1 and Period 2, respectively. A policy to increase the use of SG was associated with significantly higher transplant rates and lower waiting times. Implementation of this policy can be done successfully with no observed negative impact on patient and graft survival. [Display omitted] [ABSTRACT FROM AUTHOR]

Background: Biliary atresia (BA) remains the number one indication for paediatric liver transplantation (LT) worldwide but is an uncommon indication for older LT recipients. The impact of recent donor allocation changes, pervasive organ shortage and evolving LT practices on the BA LT population is unknown. Methods: We identified patients who underwent LT between January 2010 and December 2021 using the UNOS database. We compared clinical outcomes between patients with BA and those with non‐BA cholestatic liver disease. Groups were stratified by age, <12 years (allocated via PELD system) and ≥12 years (allocated via MELD system). Waitlist outcomes were compared using competing‐risk regression analysis, graft survival rates were compared using Kaplan–Meier time‐to‐event analysis and Cox proportional hazards modelling provided adjusted estimates. Results: There were 2754 BA LT waitlist additions and 2206 BA LTs (1937 <12 years [younger], 269 ≥12 years [older]). There were no differences in waitlist mortality between BA and non‐BA cholestatic patients. Among BA LT recipients, there were 441 (20.0%) living‐donor liver transplantations (LDLT) and 611 (27.7%) split deceased‐donor LTs. Five‐year graft survival was significantly higher among BA versus non‐BA cholestatic patients in the older group (88.3% vs. 79.5%, p <.01) but not younger group (89.3% vs. 89.5%). Among BA LT recipients, improved graft outcomes were associated with LDLT (vs. split LT: HR: 2, 95% CI: 1.03–3.91) and higher transplant volume (volume >100 vs. <40 BA LTs: HR: 3.41, 95% CI: 1.87–6.2). Conclusion: Liver transplant outcomes among BA patients are excellent, with LDLT and higher transplant centre volume associated with optimal graft outcomes. [ABSTRACT FROM AUTHOR]

Split liver transplantation is an essential means which expand the donor pool currently and the two livers obtained after splitting are marginal donor livers. The adoption of Static Cold Storage during allocation and preservation leads to a higher cold ischemia time, thus increasing the occurrence of related postoperative complications, which limits the further development of split-liver transplantation. Mechanical perfusion as a complement to split liver transplantation can minimize the damage to the marginal donor liver during preservation and reduce the occurrence of ischemia-reperfusion. At present, mechanical perfusion has achieved better efficacy in other types of marginal donor liver transplantation such as DCD, elderly donor liver, fatty liver, and so on. In recent years, mechanical perfusion has also shown great potential for application in split-liver transplantation, and limited clinical studies have shown outstanding therapeutic effects. Therefore, this paper will summarize the research progress and mechanisms related to the application of mechanical perfusion in split liver transplantation in order to promote the application of mechanical perfusion in split liver transplantation and reduce the damage of the organ during preservation. [ABSTRACT FROM AUTHOR]

Background: The most effective treatment for end-stage liver diseases is liver transplantation, which is impeded by the shortage of donor livers. Split liver transplantation (SLT) is important for addressing the donor liver shortage. However, full-right full-left SLT for two adult recipients is globally rarely conducted. This study aimed to investigate the clinical outcomes of this technique. Methods: We retrospectively analyzed the clinical data of 22 recipients who underwent full-right full-left SLT at Shulan (Hangzhou) Hospital between January, 2021 and September, 2022. The graft-to-recipient weight ratio (GRWR), cold ischemia time, operation time, length of the anhepatic phase, intraoperative blood loss, and red blood cell transfusion amount were all analyzed. The differences in liver function recovery after transplantation were compared between the left and right hemiliver groups. The postoperative complications and prognosis of the recipients were also analyzed. Results: The livers of 11 donors were transplanted into 22 adult recipients. The GRWR ranged from 1.16–1.65%, the cold ischemia time was 282.86 ± 134.87 min, the operation time was 371.32 ± 75.36 min, the anhepatic phase lasted 60.73 ± 19.00 min, the intraoperative blood loss was 759.09 ± 316.84 mL, and the red blood cell transfusion amount was 695.45 ± 393.67 mL. No significant difference in the levels of liver function markers, total bilirubin, aspartate aminotransferase, or alanine aminotransferase between left and right hemiliver groups at 1, 3, 5, 7, 14, and 28 d postoperatively was observed (both p > 0.05). One recipient developed bile leakage 10 d after transplantation, which improved with endoscopic retrograde cholangiopancreatography-guided nasobiliary drainage and stent placement. Another developed portal vein thrombosis 12 d after transplantation and underwent portal vein thrombectomy and stenting to restore portal vein blood flow. A color Doppler ultrasound performed 2 d after transplantation revealed hepatic artery thrombosis in one patient, and thrombolytic therapy was administered to restore hepatic artery blood flow. The liver function of other patients recovered quickly after transplantation. Conclusions: Full-right full-left SLT for two adult patients is an efficient way to increase the donor pool. It is safe and feasible with careful donor and recipient selection. Transplant hospitals with highly experienced surgeons in SLT are recommended to promote using full-right full-left SLT for two adult recipients. [ABSTRACT FROM AUTHOR]

Background: The intraoperative identification of a bile leak after liver transplantation can be challenging, especially when using technical variant grafts. Possible sources of leakage include the sometimes multiple biliary anastomoses or orphan ducts leading to cut surface leak. Preoperative imaging is often unable to precisely identify the location of the leak. Indocyanine green (ICG) fluorescence imaging has been utilized in adult hepatobiliary and transplant surgery, but not for the management of postoperative biliary complications. Methods: We present a case where ICG fluorescence imaging was used to identify a cut surface bile leak after pediatric split liver transplantation. Results: A 5‐year‐old girl with methylmalonic acidemia underwent a left lobe split liver transplantation. A single Roux‐en‐Y choledochojejunostomy was performed. Nine days after transplant, bile was noted in the surgical drain. Imaging confirmed the patency of the hepatic artery and the absence of intraabdominal collection. A hepatobiliary iminodiacetic acid scan showed the majority of radiotracer was excreted through the surgical drain. The patient was explored surgically: 4.5× loupe magnification did not allow for the localization of the leak. ICG was administered intravenously, after which a cut surface bile leak could be identified and repaired. There was no recurrence of bile leak after repair. Eighteen months after transplant, the patient is alive and well and has not suffered from any additional biliary complications. Conclusion: Indocyanine green constitutes an additional tool in the arsenal of measures available to facilitate the intraoperative detection and management of bile leaks occurring after pediatric technical variant graft transplant. [ABSTRACT FROM AUTHOR]

Abstract Background Liver transplantation is one of the most effective treatments for end-stage liver disease. Split liver transplantation (SLT) can effectively improve the utilization efficiency of grafts. However, split liver transplantation still faces shortcomings and is not widely used in surgery. How to improve the effective transplantation volume of split liver transplantation and promote the postoperative recovery of patients has important clinical significance. Methods In our study, the donor’s liver was split into the extended right graft and left lateral sector, and the IV segment occur ischemia. To guarantee the functional graft size, and avoid complications, we reconstructed the IV segment portal vein and left portal vein. And we analyzed the operation time, intraoperative bleeding, liver function, and postoperative complications. Results In our research, 14 patients underwent IV segment portal vein reconstruction, and 8 patients did not undergo vascular reconstruction. We found that the ischemic area of the IV segment decreased significantly after IV segment portal vein reconstruction. We found that there was no significant difference in operation time and postoperative complications between the patients of the groups. There were significant differences in ALT on the 1st day and albumin on the 6th day after the operation. Conclusion It indicates that IV segment reconstruction in SLT surgery can alleviate the graft ischemic and promote the recovery of liver function after the operation. And, IV segment reconstruction as a novel operating procedure may be widely used in SLT.

Introduction: Split liver transplantation (SLT) emerged due to its potential to contribute to the organ pool and reduce organ shortage. However, SLT is technically challenging and has been associated with higher rates of postoperative complications leading to concerns about graft and patient survival. Moreover, there are few studies on matched‐pair adult recipients of SLT and whole‐liver transplant (WLT), with conflicting results. Methods: This retrospective study analyze outcomes among adults who underwent SLT at our institution from 2010 to 2019. A 1:1 propensity score matching analysis was performed based on important donor and recipient variables. Baseline characteristics and postoperative outcomes were analyzed and compared between groups. Actuarial graft and patient survival were analyzed by KM curves. Results: Out of 592 adults receiving a LT in our institution, 21 SLT adult recipients were identified and matched with 21 adults undergoing WLT. As expected donor age was significantly lower in SLT recipients (16 (15–22) vs. 32 (17–47), P =.012). Additional donor characteristics, including anthropometrics, and ischemic times were similar between groups. Baseline recipient characteristics and postoperative outcomes, including length of stay, vascular complications, biliary complications, and re‐transplantation were comparable between SLT and WLT recipients. Graft (95/95/95 vs. 100/94/94, P =.98) and patient (100/100/100 vs. 100/94/94, P =.30) survival at 1‐, 3‐, 5‐years, were similar between the SLT‐ and WLT group, respectively. Conclusion: Split liver transplantation has the potential to increase the availability of organs for adult recipients without compromising individual outcomes. [ABSTRACT FROM AUTHOR]

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]

Introduction: Surgical site infections (SSI) are a significant cause of morbidity in liver transplant recipients, and the current data in the pediatric population are limited. The goal of this study was to identify the incidence, classification, risk factors, and outcomes of SSIs among children undergoing liver transplantation (LT). Methods: A single‐center, retrospective descriptive analysis was performed of patients age ≤18 years undergoing LT between September 2007 and April 2017. SSI identified within the first 30 days were analyzed. Primary endpoints included incidence, classification, risk factors, and outcomes associated with SSIs. Results: We included 86 patients, eight patients (9.3%) developed SSIs. Among segmental grafts (SG) recipients, 7/61 (11.4%) developed SSI. Among whole grafts recipients, 1/25 (4%) developed SSI. SSIs were associated with the presence of biliary complications (35% vs. 3%, p <.01; odds ratios 24, 95% CI: 3.41‐487.37, p<.01). There were no differences in long term graft or patient survival associated with SSI. Patients who developed SSI were more likely to undergo reoperation (50% vs. 16.7%, p =.045) and had an increased total number of hospital days in the first 60 days post‐transplant (30.5 vs. 12.5 days, p =.001). Conclusions: SSIs after pediatric LT was less frequent than what has been previously reported in literature. SSIs were associated with the presence of biliary complications without an increase in mortality. SG had an increased rate of biliary complications without an association to SSIs but, considering its positive impact on organ shortage barriers, should not be a deterrent to the utilization of SGs. [ABSTRACT FROM AUTHOR]

Objective To investigate the anatomical classification of left intrahepatic bile duct (LHD) and the pattern of bile duct reconstruction during pediatric split liver transplantation and their relationship with postoperative biliary complications. Methods Clinical data of 75 pediatric recipients undergoing split liver transplantation were analyzed retrospectively. Before splitting the donor liver, iopromide injection was used for retrograde cholangiography through the common bile duct. According to the patterns of intrahepatic bile ducts in the second, third and fourth segments, the anatomical classification of LHD of the donor liver was determined. The biliary reconstruction regimens for different classification types of LHD were summarized. The incidence and treatment of biliary complications after pediatric split liver transplantation were analyzed. Results Among 75 donor livers, the anatomical classification of LHD included 57 cases (76%) of type Ⅰ, 9 cases (12%) of type Ⅱ, 4 cases (5%) of type Ⅲ and 5 cases (7%) of type Ⅳ LHD, respectively. Among 75 pediatric recipients, 69 cases (53 cases of type Ⅰ, 8 type Ⅱ, 4 type Ⅲ and 4 type Ⅳ ) underwent the left hepatic duct-jejunum Roux-en-Y anastomosis, 1 case received common bile duct-jejunum Roux-en-Y anastomosis (type Ⅳ), and 5 cases underwent the left hepatic duct-common bile duct end-to-end anastomosis (4 cases of typeⅠ and 1 type Ⅱ). Postoperative biliary complications occurred in 6 cases (8%), including 3 cases of biliary anastomotic stenosis, 2 cases of biliary anastomotic leakage and 1 case of bile leakage on the hepatic resection surface. Among 6 recipients, 4 cases were classified as type Ⅰ and 2 cases of type Ⅲ LHD. No significant difference was observed in the incidence of biliary complications between typical type and anatomical variant type of LHD (all P>0.05). Among 3 recipients with biliary anastomotic stenosis, 2 cases underwent percutaneous transhepatic cholangial and drainage (PTCD) and 1 case repeatedly received biliary-intestinal anastomosis. Two cases of biliary anastomotic leakage underwent PTCD and 1 case of bile leakage on the hepatic resection surface received local drainage. All 6 children survived after treatment. Conclusions Anatomical variation of LHD can be observed in 24% of donor livers, and type Ⅱ accounts for the highest proportion of 12%. Prior to donor liver splitting, routine cholangiography and fine biliary anastomosis may effectively lower the incidence of biliary complications. The incidence of postoperative biliary complications is not significantly associated with the anatomical classification of LHD. [ABSTRACT FROM AUTHOR]

Objective To introduce the simplified “All in one” hepatic vein reconstruction in right split liver transplantation, and to investigate the clinical indications, surgical procedures and clinical prognosis of this technique. Methods Clinical data of 2 recipients undergoing right split liver transplantation were retrospectively analyzed, and the simplified “All in one” hepatic vein reconstruction of right liver lobe was summarized and analyzed. In 2 cases, the right liver lobe was split in vivo. In case 1, the liver parenchyma was split until the first and second porta hepatis, and then the liver was obtained by whole-liver perfusion after cutting off the right hepatic duct, and the hepatic blood vessels were isolated ex vivo. In case 2, the left liver lobe was obtained during splitting in vivo and the right liver lobe was obtained after perfusion in vivo. During donor liver splitting in two cases, the common trunk of the middle hepatic vein was maintained in the left liver lobe, the S5 and S8 hepatic veins of the right liver lobe were reconstructed by the same donor iliac artery, and directly anastomosed with the gap between the left and middle hepatic veins of the inferior vena cava, thus reconstructing the integrity of the posterior inferior vena cava. Results The simplified “All in one” right hepatic vein reconstruction was adopted. The anhepatic phase of two recipients undergoing liver transplantation was 41 and 36 min. After the liver was incised open, the blood flow of the donor liver was normal, the iliac artery bypass was fully filled, liver congestion or swelling was not observed, and liver function was properly recovered after surgery. Two recipients were subject to postoperative follow-up for 23 and 10 months, respectively, No complications related to hepatic venous outflow tracts were noted, such as hepatic vein and inferior vena cava. Conclusions “All in one” hepatic vein reconstruction may simplify the procedures of hepatic venous outflow tract reconstruction, shorten the anhepatic phase and reduce the incidence of postoperative hepatic vein complications in complete right liver split transplantation. [ABSTRACT FROM AUTHOR]

Background: Several surgical strategies, including split donor transplantation and living donor transplantation, have been used to increase the donor liver pool. This report focuses on the effects of whole, split, and LDLT on recipient outcomes. Methods: We retrospectively analyzed the records of all patients with biliary atresia at Tianjin First Central Hospital between April 2013 and December 2019. Results: A total of 882 patients were included and divided into three groups by graft type, with 198 in the whole‐liver‐transplantation group, 78 in the split liver transplantation group, and 606 in the LDLT group. The median follow‐up time was 39 months, patient survival rates of three groups were 94.4%, 88.5%, and 95.0%, respectively, and graft survival rates were 90.2%, 83.3%, and 94.7%, respectively. We divided the split liver transplantation group into two subgroups according to the donor's age, and patient survival rates exhibited a significant difference only in the group whose donor age was over 45 years. The postoperative complication rates were significantly higher with respect to hepatic artery thrombosis, portal stenosis, and AR; and lower in hepatic venous stenosis, PTLDs, CMV virus, and EBV infection in the WLT group. Our multivariate model showed that donor age ≥45 years, RBC transfusion, pneumonia, and HAT were the independent predictors of allograft loss. Conclusions: The survival of split liver transplantation group was slightly lower. The types of complications are different from different graft types. Therefore, postoperative monitoring and treatment need to be adjusted according to the different graft types used. [ABSTRACT FROM AUTHOR]

In the context of shortage of donor livers, split liver transplantation has achieved the goal of "one donor liver for two recipients", which effectively alleviates the shortage of donor livers and has promising development prospect. With the advancement of liver transplant techniques, split liver transplantation may yield clinical prognosis equivalent to total liver transplantation. However, perioperative management of split liver transplantation still encounters multiple challenges, with demanding techniques requirement and high-risk postoperative complications. Besides, there is a possibility of dividing one high-quality donor liver into two marginal donor livers, which will affect the development of liver transplantation. In this article, perioperative management of split liver transplantation was discussed from the perspectives of preoperative evaluation, recipient management and postoperative complication management, aiming to provide reference for promoting the development of split liver transplantation and enhancing clinical prognosis of recipients after split liver transplantation. [ABSTRACT FROM AUTHOR]

Rationale and Objectives: This study aimed to evaluate whether Doppler ultrasonography (DUS) and contrast-enhanced ultrasonography (CEUS) within 3 days postoperative can identify 1-month graft failure after split liver transplantation (SLT)., Materials and Methods: A total of 58 consecutive patients who underwent SLT between February 2022 and September 2023 were included. The DUS and CEUS images and parameters within 3 days postoperatively were analyzed and recorded. The DUS parameters included peak systolic velocity (PSV), resistive index, and systolic acceleration time for the hepatic artery and PSV for the portal vein and hepatic vein. The CEUS qualitative analysis variables included the liver parenchyma enhancement pattern and the posterior enhancement attenuation. Logistic regression and Cox proportional hazard regression were used to evaluate the relationship between DUS/CEUS findings and 1-month graft failure., Results: Seven of the 58 liver grafts failed within 1 month. Poor CEUS enhancement (pattern Ⅱ/Ⅲ) was observed in five of seven patients (71.4%) of graft failure, whereas good contrast enhancement (pattern Ⅰ) was found in 47 of the 51 patients (92.1%) in the successful group on postoperative day 3. Multivariate logistic regression analysis revealed that 1-month graft failure was independently predicted by operative time (odds ratio [OR] = 3.79, 95% confidence interval [CI]: 1.27-11.29, p = .017) and CEUS enhancement pattern on postoperative day 3 (OR = 90.88, 95% CI: 2.77-2979.56, p = .011). Cox proportional hazard regression showed that operative time (hazard ratio [HR] = 1.6, 95% CI: 1.15-2.22, p = .005) and CEUS enhancement pattern on postoperative day 3 (HR = 11.947, 95% CI: 2.04-69.98, p = .006) were independent predictors for graft failure., Conclusion: Poor CEUS enhancement (pattern Ⅱ/Ⅲ) was associated with 1-month graft failure in SLT recipients. CEUS may serve as a noninvasive, valuable prognostic tool to predict clinical outcomes early after SLT., Competing Interests: Declaration of Competing Interest No conflict of interest exists in the submission of this manuscript., (Copyright © 2024 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.)

Background: Liver transplantation is one of the most effective treatments for end-stage liver disease. Split liver transplantation (SLT) can effectively improve the utilization efficiency of grafts. However, split liver transplantation still faces shortcomings and is not widely used in surgery. How to improve the effective transplantation volume of split liver transplantation and promote the postoperative recovery of patients has important clinical significance.Methods: In our study, the donor's liver was split into the extended right graft and left lateral sector, and the IV segment occur ischemia. To guarantee the functional graft size, and avoid complications, we reconstructed the IV segment portal vein and left portal vein. And we analyzed the operation time, intraoperative bleeding, liver function, and postoperative complications.Results: In our research, 14 patients underwent IV segment portal vein reconstruction, and 8 patients did not undergo vascular reconstruction. We found that the ischemic area of the IV segment decreased significantly after IV segment portal vein reconstruction. We found that there was no significant difference in operation time and postoperative complications between the patients of the groups. There were significant differences in ALT on the 1st day and albumin on the 6th day after the operation.Conclusion: It indicates that IV segment reconstruction in SLT surgery can alleviate the graft ischemic and promote the recovery of liver function after the operation. And, IV segment reconstruction as a novel operating procedure may be widely used in SLT. [ABSTRACT FROM AUTHOR]

Background: Ex vivo split liver transplantation in pediatric recipients has shown inferior results compared with whole grafts. One factor among others contributing to split grafts being considered as marginal is the prolonged static cold storage time related to ex vivo liver splitting. End ischemic hypothermic oxygenated perfusion is a validated strategy to improve outcomes of marginal whole grafts and may thus also benefit split liver grafts. Method: We present the first case of full left/full right split procedure performed during hypothermic oxygenated perfusion. Results: We present a standardized surgical two‐step approach where parenchymal transection was performed during end ischemic hypothermic oxygenated perfusion via the portal vein to shorten static cold storage duration. Both split grafts were successfully transplanted in a 4‐year‐old pediatric and a 38‐year‐old adult recipient. Despite high‐risk procedure (retransplantation), extended donor criteria including a prolonged cardiac arrest and high donor risk index (2,25), both grafts showed early recovery of hepatic function and low serum transaminase release. At 6 months, both recipients were alive with a normal liver biology and a functioning graft. Conclusion: Although challenging, full left/full right liver split procedure during end ischemic hypothermic oxygenated perfusion can be successfully performed and is a promising strategy to improve post‐transplant outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Split liver transplantation (SLT) enables two recipients to be transplanted using a single donor liver; typically, an adult and a child. Despite equivalent long‐term outcomes to whole grafts in selected adults, the use of these grafts in high‐risk adult recipients with high model for end‐stage liver disease (MELD) scores (≥30), a poor pre‐transplant clinical status (ICU or hospital‐bound), acute liver failure or retransplantation remains controversial. Methods: We retrospectively analyzed all deceased donor adult liver transplants performed between July 2002 and November 2019 at a single high‐volume center and performed a propensity score‐matched analysis. A subgroup analysis was performed to assess utility of these grafts for high‐risk recipients. Results: A total of 1090 adult liver transplants were performed, including 155 SLT (14%). Graft survival at 1‐, 3‐ and 5‐years were comparable between recipients of split and whole liver grafts (82%, 79% and 74% vs. 86%, 81% and 77%, respectively, log rank P =.537), as was patient survival at 1‐, 3‐ and 5‐years. Recipients of split grafts were more likely to have biliary complications and hepatic artery thrombosis, but equivalent long‐term survival. Recipients with high MELD scores or a poor pre‐transplant clinical status had similar patient and graft survival and complication profiles irrespective of whether they received split or whole grafts. Conclusions: SLT is an important method for addressing donor shortages and provides comparable long‐term outcomes in adult recipients despite an increase in short‐term complications. SLT use in high‐risk recipients should be considered to allow for sickest‐first allocation policies. [ABSTRACT FROM AUTHOR]

Background: Erythropoietic protoporphyria (EPP) is a rare inherited disorder that causes the accumulation of protoporphyrin in the erythrocytes, skin, and liver. Severe protoporphyric hepatopathy results in liver failure, requiring both liver and bone marrow transplantation as a life‐saving procedure and to correct the underlying enzymatic defect, respectively. Case presentation: We report a 20‐year‐old man who underwent split liver transplantation using a right trisegment and caudate lobe graft for EPP‐induced liver failure, but succumbed to a deadly combination of early relapse of EPP and subsequent, intractable, late‐onset bile leakage from the cut surface of segment 4. EPP recurrence most likely created a high‐risk situation for bile leakage from the non‐communicating bile ducts of segment 4; therefore, this case shed light on the potential relationship between EPP recurrence and biliary complications. Conclusion: Physicians should recognize the potentially rapid and life‐threatening progression of protoporphyric hepatopathy that leads to liver failure. For young patients with EPP, LT and sequential BMT should thoroughly be considered by a multidisciplinary team as soon as hepatic reserve deterioration becomes evident. Split liver transplantation should preferably be avoided and appropriate post‐transplant management is critical before protoporphyrin depositions to the bile duct and hepatocyte causes irreversible damage to the liver graft. [ABSTRACT FROM AUTHOR]

Congenital factor X (FX) deficiency is a rare autosomal-recessive disease that induces bleeding disorder. Herein, we present the 10-year posttransplant course of a pediatric patient who underwent liver transplantation (LT) with portal vein (PV) stenting for correction of severe congenital FX deficiency, with focus on long-term maintenance of coagulation function and patency of PV stenting. A 17-month-old infant with recurrent hemorrhagic episodes due to FX deficiency underwent split LT using a left lateral section graft. The graft-recipient weight ratio was 2.2%. The graft implantation procedures were performed by following the standard pediatric split LT procedure. Nevertheless, a wall stent was inserted due to PV anastomotic stenosis on posttransplant day 1. Graft function recovered slowly because of partial parenchyma infarct, and the patient was discharged at 46 days after LT operation. The FX activity started to increase soon after LT and gradually normalized; the coagulation profiles have been maintained well for the past 10 years. The patient has been doing well for the past 10 years after LT without any episodes of abnormal bleeding. Due to the risk of vascular complications owed to PV stenting, life-long follow-up is mandatory with special attention until attainment of complete physical growth to adolescent and adulthood.

Abstract Background Risks for living-liver donors are lower in case of a left liver donation, however, due to lower graft volume, the risk for small-for-size situations in the recipients increases. This study aims to prevent small-for-size situations in recipients using an auxiliary two-staged partial resection liver transplantation (LTX) of living-donated left liver lobes. Case presentation Two patients received a two-stage auxiliary LTX using living-donated left liver lobes after left lateral liver resection. The native extended right liver was removed in a second operation after sufficient hypertrophy of the left liver graft had occurred. Neither donor developed postoperative complications. In both recipients, the graft volume increased by an average of 105% (329 ml to 641 ml), from a graft-to-body-weight ratio of 0.54 to 1.08 within 11 days after LTX, so that the remnant native right liver could be removed. No recipient developed small-for-size syndrome; graft function and overall condition is good in both recipients after a follow-up time of 25 months. Conclusions Auxiliary two-staged partial resection LTX using living-donor left lobes is technically feasible and can prevent small-for-size situation. This new technique can expand the potential living-donor pool and contributes to increase donor safety.

Currently, multiple difficulties exist in clinical liver transplantation, such as shortage of donor liver, increasing quantity of patients waiting for liver transplantation and lack of matching donors, etc. Some children and adult patients have little chance of undergoing liver transplantation, which also limits the development of liver transplantation. In this context, split liver transplantation emerges, in which 1 donor liver can be applied to 2 or even more recipients. It may effectively increase the utilization rate of donor liver and alleviate the shortage of donor liver. With the development of split liver transplantation, the survival rate of split liver transplantation is comparable to that of total liver transplantation. Multiple transplantation centers have routinely adopted split liver transplantation. In this article, the development of split liver transplantation, the selection and matching of donors and recipients, the split and reconstruction techniques of donor liver and postoperative complications were reviewed, aiming to provide reference for subsequent development of split liver transplantation in clinical practice and increase the chance of liver transplantation for more patients diagnosed with end-stage liver diseases. [ABSTRACT FROM AUTHOR]

In recent decade, pediatric liver transplantation has developed rapidly in China due to the improvement of surgical techniques and postoperative management, which has been applied from several domestic liver transplantation centers to more than 10 provinces, cities and autonomous regions. The annual quantity of pediatric liver transplantation has exceeded 1 000 for 3 consecutive years, ranking first across the world. The technique of pediatric liver transplantation has been gradually oriented to precision medicine. The development of pediatric liver transplantation mainly focuses on the "grafts". In this article, the development characteristics and trends of pediatric liver transplantation were elucidated from the perspectives of different types of liver transplantation that expanded the source of donor liver, including split liver transplantation, auxiliary liver transplantation, Domino liver transplantation and liver transplantation with hyper-reduced grafts, as well as the application of minimally invasive surgical and microsurgical anastomosis techniques in pediatric liver transplantation, which represented by laparoscopic surgery and Da Vinci surgical system, aiming to provide reference for further improving the long-term survival rate of grafts and the quality of life of the recipients. [ABSTRACT FROM AUTHOR]

Liver transplantation remains a curative treatment for end-stage liver disease and some congenital metabolic abnormalities. While a growing demand for donor livers far exceeds the supply, waitlist mortality for liver transplant candidates remains critical. Lacking age/ size-matched organs results in a higher waitlist mortality in pediatric candidates than adults. More extended criteria donors and new transplant techniques are currently employed. And the feasibility and safety have been thoroughly evaluated. [ABSTRACT FROM AUTHOR]

Along with the increasing quantity of patients with end-stage liver diseases year by year, as an efficacious treatment, the safety and efficacy of liver transplantation are critical issues to be considered. In addition, liver transplant techniques have become a new research hot spot. In recent years, liver transplant techniques are constantly innovating and developing with the unremitting efforts of researchers. Researchers have successively developed multiple liver transplant techniques, such as split liver transplantation, ischemia-free liver transplantation, liver xenotransplantation, domino liver transplantation, delayed total hepatectomy combined with liver resection and segment Ⅱ - Ⅲ liver transplantation, heterotopic auxiliary liver transplantation on splenic fossa and magnetic anastomosis. It has laid a foundation for expanding the donor pool, improving clinical efficacy of liver transplantation and enhancing the quality of life of liver transplant recipients. In this article, the exploration, development, innovation and improvement of liver transplant techniques were reviewed and prospected, aiming to provide reference for clinical application of liver transplantation. [ABSTRACT FROM AUTHOR]

Summary: Full‐left‐full‐right split liver transplantation (FSLT) for adult recipients, may increase the availability of liver grafts, reduce waitlist time, and benefit recipients with below‐average body weight. However, FSLT may lead to impaired graft and patient survival. This study aims to assess outcomes after FSLT. Five databases were searched to identify studies concerning FSLT. Incidences of complications, graft‐ and patient survival were assessed. Discrete data were pooled with random‐effect models. Graft and patient survival after FSLT were compared with whole liver transplantation (WLT) according to the inverse variance method. Vascular complications were reported in 25/273 patients after FSLT (Pooled proportion: 6.9%, 95%CI: 3.1–10.7%, I2: 36%). Biliary complications were reported in 84/308 patients after FSLT (Pooled proportion: 25.6%, 95%CI: 19–32%, I2: 44%). Pooled proportions of graft and patient survival after 3 years follow‐up were 72.8% (95%CI: 67.2–78.5, n = 231) and 77.3% (95%CI: 66.7–85.8, n = 331), respectively. Compared with WLT, FSLT was associated with increased graft loss (pooled HR: 2.12, 95%CI: 1.24–3.61, P = 0.006, n = 189) and patient mortality (pooled HR: 1.81, 95%CI: 1.17–2.81, P = 0.008, n = 289). FSLT was associated with high incidences of vascular and biliary complications. Nevertheless, long‐term patient and graft survival appear acceptable and justify transplant benefit in selected patients. [ABSTRACT FROM AUTHOR]

Background : The present study intended to investigate the allocation status of pediatric deceased donor liver allografts. We analyzed the incidence of pediatric deceased donors in the Korean Network for Organ Sharing (KONOS) database and single-institutional status of liver transplantation (LT) using pediatric donors. Methods : We assessed the nationwide incidence of pediatric donors aged ≤15 years and conducted single-center analysis of LT using pediatric donors. Results : Between 2010 and 2019, pediatric donors aged ≤15 years accounted for 171 out of 4,395 donors (3.9%) in the KONOS database and 31 out of 640 liver donors (4.8%) in Asan Medical Center (AMC) database. In AMC, 11 (35.5%) and 20 (64.5%) grafts were allocated to pediatric recipients aged ≤15 years and adult recipients aged ≥19 years, respectively. All nine livers from donors aged ≤5 years were implanted in pediatric recipients aged ≤5 years. From 21 donors aged ≥9 years, 16 whole liver grafts and four split extended right liver grafts were implanted in 20 adult recipients and two split left lateral section grafts were implanted in two pediatric recipients. Four split liver grafts were implanted in other institutions. The overall patient survival rates at 1, 3, and 5 years were 90.9%, 80.8%, and 80.8%, respectively in pediatric-to-pediatric LT group and 69.6%, 58.4%, and 58.4%, respectively in pediatric-to-adult LT group (P=0.21). Conclusions: More than half of the pediatric donor livers were allocated to adult patients. Recipient criteria for allocation of liver allografts from pediatric donors need revision for children on pediatric LT waitlist.

Background: Given the current organ shortage crisis, split liver transplantation (SLT) has emerged as a promising alternative for select end-stage liver disease patients., Aim: To introduce an ex-vivo liver graft splitting approach and evaluate its safety and feasibility in SLT., Methods: A retrospective analysis was conducted on the liver transplantation data from cases performed at our center between April 1, 2022, and May 31, 2023. The study included 25 SLT cases and 81 whole liver transplantation (WLT) cases. Total ex-vivo liver splitting was employed for SLT graft procurement in three steps. Patient outcomes were determined, including liver function parameters, postoperative complications, and perioperative mortality. Group comparisons for categorical variables were performed using the χ² -test., Results: In the study, postoperative complications in the 25 SLT cases included hepatic artery thrombosis ( n = 1) and pulmonary infections ( n = 3), with no perioperative mortality. In contrast, among the 81 patients who underwent WLT, complications included perioperative mortality ( n = 1), postoperative pulmonary infections ( n = 8), abdominal infection ( n = 1), hepatic artery thromboses ( n = 3), portal vein thrombosis ( n = 1), and intra-abdominal bleeding ( n = 5). Comparative analysis demonstrated significant differences in alanine aminotransferase (176.0 vs 73.5, P = 0.000) and aspartate aminotransferase (AST) (42.0 vs 29.0, P = 0.004) at 1 wk postoperatively, and in total bilirubin (11.8 vs 20.8, P = 0.003) and AST (41.5 vs 26.0, P = 0.014) at 2 wk postoperatively. However, the overall incidence of complications was comparable between the two groups ( P > 0.05)., Conclusion: Our findings suggest that the total ex-vivo liver graft splitting technique is a safe and feasible approach, especially under the expertise of an experienced transplant center. The approach developed by our center can serve as a valuable reference for other transplantation centers., Competing Interests: Conflict-of-interest statement: The authors have no conflicts of interests or disclosures to report., (©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.)

The technology of split liver transplantation is becoming increasingly mature with rapid development. During ex vivo splitting, the depletion of intracellular energy sources [such as adenosine triphosphate (ATP)] and other metabolic disorders may lead to cell damage and dysfunction, which will be aggravated by reperfusion injury of liver transplantation, clinically manifested as postoperative complications and transplantation failure. To further improve the quality of donor liver in ex vivo split liver transplantation, research teams at home and abroad apply machine perfusion to enhance the quality of donor liver. In this article, the research progresses worldwide on machine perfusion of donor liver in ex vivo split liver transplantation were reviewed, and the application and prospect of dual hypothermic oxygenated machine perfusion (D-HOPE) in ex vivo split liver transplantation were elucidated, aiming to provide reference for increasing the source of donor liver for ex vivo split liver transplantation and further resolving the current status of donor liver shortage. [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.

Background: Risks for living-liver donors are lower in case of a left liver donation, however, due to lower graft volume, the risk for small-for-size situations in the recipients increases. This study aims to prevent small-for-size situations in recipients using an auxiliary two-staged partial resection liver transplantation (LTX) of living-donated left liver lobes.Case Presentation: Two patients received a two-stage auxiliary LTX using living-donated left liver lobes after left lateral liver resection. The native extended right liver was removed in a second operation after sufficient hypertrophy of the left liver graft had occurred. Neither donor developed postoperative complications. In both recipients, the graft volume increased by an average of 105% (329 ml to 641 ml), from a graft-to-body-weight ratio of 0.54 to 1.08 within 11 days after LTX, so that the remnant native right liver could be removed. No recipient developed small-for-size syndrome; graft function and overall condition is good in both recipients after a follow-up time of 25 months.Conclusions: Auxiliary two-staged partial resection LTX using living-donor left lobes is technically feasible and can prevent small-for-size situation. This new technique can expand the potential living-donor pool and contributes to increase donor safety. [ABSTRACT FROM AUTHOR]

With the maturity of the technique of adult liver transplantation, pediatric liver transplantation has been gradually emerging in major liver transplantation centers throughout China. Pediatric liver transplantation differs from adult liver transplantation in terms of recipient selection, technical details, perioperative management, postoperative treatment and follow-up, etc. Multidisciplinary cooperation is required to continuously improve the clinical efficacy of pediatric liver transplantation. In this article, we reviewed the significance of multidisciplinary cooperation in achieving the optimal clinical efficacy of pediatric liver transplantation, in respect to the recipient selection and extrahepatic organ function evaluation, mastering the technical key points of different types, improving the quality of postoperative followup, and formulating clinical diagnosis and treatment strategies, etc. [ABSTRACT FROM AUTHOR]