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World J Gastroenterol. Sep 7, 2016; 22(33): 7500-7506
Published online Sep 7, 2016. doi: 10.3748/wjg.v22.i33.7500
Split liver transplantation in adults
Koji Hashimoto, Masato Fujiki, Cristiano Quintini, Federico N Aucejo, Teresa Diago Uso, Dympna M Kelly, Bijan Eghtesad, John J Fung, Charles M Miller
Koji Hashimoto, Masato Fujiki, Cristiano Quintini, Federico N Aucejo, Teresa Diago Uso, Dympna M Kelly, Bijan Eghtesad, John J Fung, Charles M Miller, Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH 44195, United States
Author contributions: All authors contributed equally to this work.
Conflict-of-interest statement: The authors declare no conflicts of interest or potential conflicts of interest for this article.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Koji Hashimoto, MD, PhD, Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Ave. Desk A-100, Cleveland, OH 44195, United States. hashimk@ccf.org
Telephone: +1-216-4450753 Fax: +1-216-4449375
Received: March 29, 2016
Peer-review started: April 4, 2016
First decision: May 12, 2016
Revised: May 30, 2016
Accepted: June 28, 2016
Article in press: June 28, 2016
Published online: September 7, 2016
Processing time: 159 Days and 2.1 Hours
Abstract

Split liver transplantation (SLT), while widely accepted in pediatrics, remains underutilized in adults. Advancements in surgical techniques and donor-recipient matching, however, have allowed expansion of SLT from utilization of the right trisegment graft to now include use of the hemiliver graft as well. Despite less favorable outcomes in the early experience, better outcomes have been reported by experienced centers and have further validated the feasibility of SLT. Importantly, more than two decades of experience have identified key requirements for successful SLT in adults. When these requirements are met, SLT can achieve outcomes equivalent to those achieved with other types of liver transplantation for adults. However, substantial challenges, such as surgical techniques, logistics, and ethics, persist as ongoing barriers to further expansion of this highly complex procedure. This review outlines the current state of SLT in adults, focusing on donor and recipient selection based on physiology, surgical techniques, surgical outcomes, and ethical issues.

Keywords: Split liver transplantation; Adults; Graft survival; Graft size; Donor and recipient selection; Surgical technique; Ethical issues

Core tip: Split liver transplantation (SLT) in adults is usually performed with the right trisegment graft or less frequently with the hemiliver graft. Both graft types require highly complex surgical techniques. Compared with the right trisegment graft, hemiliver SLT requires stricter donor and recipient selection to prevent graft dysfunction associated with size-mismatch. To achieve ideal graft-recipient paring, a clear understanding of surgical anatomy and recipient physiology is needed. With favorable circumstances, outcomes of adult SLT can be comparable to whole liver transplantation. The routine use of SLT, however, remains controversial due to various challenges, particularly under the current “sickest first” liver allocation policy.