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Split for Two Adults: What Is the Real Feasibility?
Split for Two Adults: What Is the Real Feasibility? J.M. Ramia, A. Mansilla, J. Villar, M.A. Cabrera, D. Garrote, and J.A. Ferron ABSTRACT Introduction. A split liver for two adults is a good theoretical option but the number of cases is low. We have tried to assess the feasibility of this technique. Materials and Methods. From April 2002 to April 2004, we evaluated 81 donors of which only 59 (72.8%) were used for transplantation of which 10 were grafted in other centers (pediatric or emergency code). Among the 49 donors the criteria for splitting were: ages ⬎14 and ⬍50 years, weight ⬎70 and ⬍100 kg, less than 3 days in the intensive care unit (ICU), hemodynamic stability, Na⫹ ⬍ 160 mg/L, liver enzymes elevated no more than twofold, no macroscopic steatosis, and procurement in our hospital. Results. The mean donor age was 50.7 years (range: 16 to 77) of whom 25 were men (51%). The mean weight was 65.7 kg (range: 50 to 100) and days of ICU stay, 3 (range: 1 to 23). Six grafts (12%) were split. The reasons for not splitting were: age (n ⫽ 26 [53%]), weight (n ⫽ 17 [34.7%]), UCI ⬎3 days (n ⫽ 9 [18.3%]), Na⫹ ⬎ 160 (n ⫽ 1 [2%]), blood liver test elevated (n ⫽ 5 [10.2%]), steatosis (n ⫽ 6 [12.2%]), and procurement outside our center (n ⫽ 20 [40.8%]). The donors not suitable for splitting had: only one criteria (n ⫽ 12 [24.4%]; 2 (n ⫽ 23 [46.9%], 3 (n ⫽ 6 [12.2%]) or 4 (n ⫽ 2 [4.1%]). If we had had two suitable recipients, we could performed six more liver transplantations (12.2% increase). Conclusions. The theoretical feasibility of a split liver for two adults is 12.2%, but the actual probability is lower because of lack of two adequate candidates.
S
PAIN HAS THE HIGHEST donor rate in the world, but we do not have enough grafts to perform the number of liver transplantations needed in our country. Surgeons are trying to obtain more grafts using complex solutions: domino, split, on living donor. Split for two adults is a good theoretical solution to reduce the waiting list. Splits have been performed with good results for a pediatric and adult patient, but its utility for two adults is controversial,1 because the results especially with left lobe are worse compared with a whole cadaveric organ. Since there are few studies to determine the real feasibility of split grafts, we have sought to estimate the theoretical, number of cases that could have been performed with our donors.
than 3 days in intensive care unit (ICU); hemodynamic stability; Na⫹ ⬍ 160 mg/L, liver enzymes no more than twice normal; no macroscopic steatosis; and procurement in our hospital.
RESULTS
MATERIALS AND METHODS
The mean donor age was 50.7 years (range: 16 to 77), to among whom 25 were men (51%). The overall mean weight was 65.7 kg (range: 50 to 100), the donors blood groups were: A (n ⫽ 21), O (n ⫽ 24) B (n ⫽ 2), AB (n ⫽ 2). The mean ICU stay was 3 days (range: 1 to 23). The liver blood supply was free of anatomic variations in 42 cases (85.7%), among which six grafts (12%) were suitable for splitting. The theoretical reason for no splitting was: inadequate age (n ⫽ 26 [53%]), weight ⬍70 kg (n ⫽ 17 [34.7%]), ICU stay ⬎3 days (n ⫽ 9 [18.3%]), Na⫹ ⬎ 160 mg/L (n ⫽ 1 [2%]), abnormal liver blood test (n ⫽ 5 [10.2%]), macroscopic steatosis (n ⫽ 6 [12.2%]), and procurement outside our
In the period between April 2002 to April 2004, we evaluated 81 donors, among whom 59 (72.8%) were useful for transplantation. Ten of these grafts were performed in other centers (pediatric or emergency code), so we had 49 donors. Accepted criteria for splitting were: ⬎14 and ⬍50 years; weight ⬎70 and ⬍100 kg; less
From the Unidad de Trasplante Hepático, Hospital Virgen de las Nieves, Granada, Spain. Address reprint requests to J.M. Ramia, C/Buensuceso 6, 4°D Granada 18002, Spain. E-mail: [email protected]
© 2005 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/05/$–see front matter doi:10.1016/j.transproceed.2005.10.067
Transplantation Proceedings, 37, 3855–3856 (2005)
3855
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hospital (n ⫽ 20 p [40.8%]). The donors not suitable for splitting had: only one criterion (n ⫽ 12 [24.4%]), or 2 (n ⫽ 23 [46.9%]), or 3 (n ⫽ 6 [12.2%]), or 4 (n ⫽ 2 [4.1%]) criteria. If we had had two suitable recipients, we could have performed six more liver transplantations (12.2% increase). DISCUSSION
The main parameters to evaluate before performing a split for two adults are: donor parameters, intraoperative parameters (macroscopic view, hemodynamic stability, and anatomical variations), logistic parameters (surgeon experience and hospital), and recipient characteristics (weight and height, clinical status).2– 4 There is no international consensus about the donor criteria adequate for performing a split procedure. The main donor characteristics in the literature are: weight, steatosis, age, days in ICU, and liver blood tests.2– 6 The minimum weight for a split is 70 kg, the liver weight from whom is about 1500 g with 850 g in the right and 650 g in the left liver.2 This weight allows a left lobe liver transplantation for a recipient of 65 kg or less without the risk of a smallfor-size syndrome.5,6 But some groups perform liver splitting with slim donors. There is no upper cutoff, but probably patients over 100 kg or body mass index ⬎28 should be excluded due the well-known relationship between overweight and steatosis.2 Macroscopic steatosis is a exclusion criteria for a split. There is no consensus about age, the usual cutoff is 50 years,2,4 but some groups have increased it to 60 years, if the donor has a good previous health status.5 But only a 2.4% increase of splits is obtained by increasing the age cutoff to 60 years.2 Hemodynamic stability is mandatory to perform a split procedure2: a donor with a previous arrest or hypotension may be excluded.2 A prolonged stay in the ICU correlates with liver injury or risk of infection, which is why we only
RAMIA, MANSILLA, VILLAR ET AL
use donors with a short ICU stay (less than 3 days) for splits.2 Only a 1.4% increase of splits is obtained when we increase the cutoff to 5 days.2 Normal serum sodium and liver blood test, are mandatory to perform a split. Liver from donors without these criteria are likely to engender unacceptable results. In our study, consistent with other reports,2,3 the rate of possible splits was about 10%. But this theoretical rate is probably too high, because the procedure requires no severe anatomical variations in the donor; two adequate recipients (especially a low-weight recipient); and a large team experienced in splits. The proposed solution is to share split livers with another team in your regional area or country. So probably the real rate of splits is between 5% and 8%. The main question is whether in countries with a high rate of donation it is justified to perform a split, when you know that the results especially with the left lobe are worse. Only a cost-effective study will answer this question, but meanwhile liver transplant groups will seek to obtain more grafts with splits and with other technical options. REFERENCES 1. Marcos A: Split liver transplantation. Liver Transplantation 6:707, 2000 2. Toso C, Ris F, Mentha G, et al: Potential impact of in situ liver splitting on the number of available grafts. Transplantation 74:222, 2002 3. Poncet G, Dumortier J, Choucair A, et al: Split liver transplantation in two adult recipients. Gastroenterol Clin Biol 26:578, 2002 4. Schlitt HJ: Which liver is splittable? In Rogiers X, Bismuth H, Busuttil RW, et al (eds): Split Liver Transplantation. Alemania: Springer; 2002, p 63 5. Azoulay D, Castaing D, Adam R, et al: Split liver transplantation for two adults recipients: feasibility and long term outcomes. Ann Surg 233:565, 2001 6. Yerziz H, Renz JF, Farmer DG, et al: One hundred in situ split liver transplantation: a single center experience. Ann Surg 238:496, 2003
S
PAIN HAS THE HIGHEST donor rate in the world, but we do not have enough grafts to perform the number of liver transplantations needed in our country. Surgeons are trying to obtain more grafts using complex solutions: domino, split, on living donor. Split for two adults is a good theoretical solution to reduce the waiting list. Splits have been performed with good results for a pediatric and adult patient, but its utility for two adults is controversial,1 because the results especially with left lobe are worse compared with a whole cadaveric organ. Since there are few studies to determine the real feasibility of split grafts, we have sought to estimate the theoretical, number of cases that could have been performed with our donors.
than 3 days in intensive care unit (ICU); hemodynamic stability; Na⫹ ⬍ 160 mg/L, liver enzymes no more than twice normal; no macroscopic steatosis; and procurement in our hospital.
RESULTS
MATERIALS AND METHODS
The mean donor age was 50.7 years (range: 16 to 77), to among whom 25 were men (51%). The overall mean weight was 65.7 kg (range: 50 to 100), the donors blood groups were: A (n ⫽ 21), O (n ⫽ 24) B (n ⫽ 2), AB (n ⫽ 2). The mean ICU stay was 3 days (range: 1 to 23). The liver blood supply was free of anatomic variations in 42 cases (85.7%), among which six grafts (12%) were suitable for splitting. The theoretical reason for no splitting was: inadequate age (n ⫽ 26 [53%]), weight ⬍70 kg (n ⫽ 17 [34.7%]), ICU stay ⬎3 days (n ⫽ 9 [18.3%]), Na⫹ ⬎ 160 mg/L (n ⫽ 1 [2%]), abnormal liver blood test (n ⫽ 5 [10.2%]), macroscopic steatosis (n ⫽ 6 [12.2%]), and procurement outside our
In the period between April 2002 to April 2004, we evaluated 81 donors, among whom 59 (72.8%) were useful for transplantation. Ten of these grafts were performed in other centers (pediatric or emergency code), so we had 49 donors. Accepted criteria for splitting were: ⬎14 and ⬍50 years; weight ⬎70 and ⬍100 kg; less
From the Unidad de Trasplante Hepático, Hospital Virgen de las Nieves, Granada, Spain. Address reprint requests to J.M. Ramia, C/Buensuceso 6, 4°D Granada 18002, Spain. E-mail: [email protected]
© 2005 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/05/$–see front matter doi:10.1016/j.transproceed.2005.10.067
Transplantation Proceedings, 37, 3855–3856 (2005)
3855
3856
hospital (n ⫽ 20 p [40.8%]). The donors not suitable for splitting had: only one criterion (n ⫽ 12 [24.4%]), or 2 (n ⫽ 23 [46.9%]), or 3 (n ⫽ 6 [12.2%]), or 4 (n ⫽ 2 [4.1%]) criteria. If we had had two suitable recipients, we could have performed six more liver transplantations (12.2% increase). DISCUSSION
The main parameters to evaluate before performing a split for two adults are: donor parameters, intraoperative parameters (macroscopic view, hemodynamic stability, and anatomical variations), logistic parameters (surgeon experience and hospital), and recipient characteristics (weight and height, clinical status).2– 4 There is no international consensus about the donor criteria adequate for performing a split procedure. The main donor characteristics in the literature are: weight, steatosis, age, days in ICU, and liver blood tests.2– 6 The minimum weight for a split is 70 kg, the liver weight from whom is about 1500 g with 850 g in the right and 650 g in the left liver.2 This weight allows a left lobe liver transplantation for a recipient of 65 kg or less without the risk of a smallfor-size syndrome.5,6 But some groups perform liver splitting with slim donors. There is no upper cutoff, but probably patients over 100 kg or body mass index ⬎28 should be excluded due the well-known relationship between overweight and steatosis.2 Macroscopic steatosis is a exclusion criteria for a split. There is no consensus about age, the usual cutoff is 50 years,2,4 but some groups have increased it to 60 years, if the donor has a good previous health status.5 But only a 2.4% increase of splits is obtained by increasing the age cutoff to 60 years.2 Hemodynamic stability is mandatory to perform a split procedure2: a donor with a previous arrest or hypotension may be excluded.2 A prolonged stay in the ICU correlates with liver injury or risk of infection, which is why we only
RAMIA, MANSILLA, VILLAR ET AL
use donors with a short ICU stay (less than 3 days) for splits.2 Only a 1.4% increase of splits is obtained when we increase the cutoff to 5 days.2 Normal serum sodium and liver blood test, are mandatory to perform a split. Liver from donors without these criteria are likely to engender unacceptable results. In our study, consistent with other reports,2,3 the rate of possible splits was about 10%. But this theoretical rate is probably too high, because the procedure requires no severe anatomical variations in the donor; two adequate recipients (especially a low-weight recipient); and a large team experienced in splits. The proposed solution is to share split livers with another team in your regional area or country. So probably the real rate of splits is between 5% and 8%. The main question is whether in countries with a high rate of donation it is justified to perform a split, when you know that the results especially with the left lobe are worse. Only a cost-effective study will answer this question, but meanwhile liver transplant groups will seek to obtain more grafts with splits and with other technical options. REFERENCES 1. Marcos A: Split liver transplantation. Liver Transplantation 6:707, 2000 2. Toso C, Ris F, Mentha G, et al: Potential impact of in situ liver splitting on the number of available grafts. Transplantation 74:222, 2002 3. Poncet G, Dumortier J, Choucair A, et al: Split liver transplantation in two adult recipients. Gastroenterol Clin Biol 26:578, 2002 4. Schlitt HJ: Which liver is splittable? In Rogiers X, Bismuth H, Busuttil RW, et al (eds): Split Liver Transplantation. Alemania: Springer; 2002, p 63 5. Azoulay D, Castaing D, Adam R, et al: Split liver transplantation for two adults recipients: feasibility and long term outcomes. Ann Surg 233:565, 2001 6. Yerziz H, Renz JF, Farmer DG, et al: One hundred in situ split liver transplantation: a single center experience. Ann Surg 238:496, 2003