Region 10 and In situ Split of the Deceased Donor Liver

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Region 10 and In situ Split of the Deceased Donor
Liver

• OSOTC Education Conference
• September 11, 2015

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History

• In late 1980s early 1990s, pediatric waiting
  list mortality significant
• Development of reduced size liver transplantation
• Both living donor (LDLT) and deceased donor split
  liver transplantation (DDSLT) evolved from
  reduced size liver transplantation
• Imbalance between recipients and available donors
  drove the innovation with the goal of reducing
  waiting list mortality while maximizing
  utilization of resources
• DDSLT 1989, LDLT 1991
• Outcomes following whole organ is best but given
  imbalance, alternative techniques must be employed

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Anatomic Liver segments
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Reduced Size Liver Transplantation
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Left Lateral Segment Extended Right Lobe Split
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Left Lobe Right Lobe Split
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In Situ Split Left Lateral Segment Dissection
Left Hepatic Vein
Middle Hepatic Vein
Left Portal Vein
Left Hepatic Artery
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Left Lateral Segment Graft
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Abdominal Position - LLS GRAFT
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Donor Criteria for Split Liver Consideration

• Age lt 40
• ICU Stay lt 5 days
• Liver biochemical profile within normal limits
• No more than 1 vasopressor agent
• Serum electrolytes within normal limits

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Who should get a Split segment? Pediatric
Recipient

• Donor Recipient Weight Ratio
• Left Lobe Graft 2-5 1
• Left Lateral Segment Graft - 6-10 1
• Disease Severity
• Status I
• PELDgt15
• Any patient for whom a reduced size graft is
  being considered

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Who should get a Split segment? Adolescent /
Adult Recipient

• Donor Recipient Weight Ratio
• Extended Right Lobe Graft
• Size match
• Right Lobe Graft
• Graft weight Recipient weight (GWRW)
• Living donor gt 0.8
• Deceased donor gt 1
• Recipient Disease Severity
• Lower MELD
• Less portal hypertension /hyperdynamic splanchnic
  circulation

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Where to Split?In situ versus Ex vivo

• In Situ
• Benefits
• Clearer sense of both grafts perfusion
• Cut surface controlled
• Less cold ischemia time
• Risks
• Longer donor OR time
• Potential risk of hemodynamic instability which
  could effect other organs

• Ex Vivo
• Benefits
• Shorter OR time
• Less risk to other organs
• Risks
• Perfusion of both grafts unknown
• Longer cold ischemia time
• Cut surface

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Operative Considerations

• Local OPO preparation
• Appropriate donor selection and organ allocation
• Communication with different donor teams timing
  and length of operation
• OR team
• Anesthesia aware with more blood available
• OR Equipment
• Essential Bovie, slush, patience
• Helpful Intra-op cholangiography, laparoscopic
  staplers, harmonic, argon beam, experienced scrub
  tech

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Allocation of Vessels and Biliary Tract

• Hepatic artery
• Portal vein
• Hepatic veins / Inferior vena cava
• Bile duct
• Vessels for reconstruction
• Iliac artery and vein
• Others - Inferior mesenteric and carotid artery

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Region 10 Allocation of Structures Working
agreement

• The center allocated organ decides vessel
  distribution
• Hepatic artery Celiac axis
• Portal vein - variable
• Bile duct left hepatic duct
• Hepatic veins / IVC
• LLS left hepatic vein
• Left Lobe - Vena cava

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Allocation of Hepatic Veins and IVC
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Split grafts - Complications

• Biliary tract
• Cut surface
• Major bile duct
• Vascular HAT/PVT
• Small for size
• Ascites
• Jaundice
• Failure to thrive

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In situ Split the UCLA experience

• Single Center experience where they mostly split
  with themselves
• 100 donors yielded 190 grafts transplanted into
  105 pediatric patients and 60 adults at UCLA, 25
  shared within region
• Compared outcomes with whole organs and living
  donor grafts for both LLS and right trisegs

Yersiz et al, Ann Surg, 2003
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In situ Split the UCLA experience
Yersiz et al, Ann Surg, 2003
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In situ Split the UCLA experience

• Amongst pediatric recipients, biliary and
  vascular complications similar between LLS, LD
  and whole organ recipients
• Amongst adult recipients, increased rate of
  biliary and vascular complications
• Mechanism to get pediatric recipients
  transplanted while still giving adults access to
  a slightly higher risk but viable alternative
• Reduce need for living donor transplantation

Yersiz et al, Ann Surg, 2003
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Annual Trend Split Liver Transplantation
Lee KW, Cameron AM, Maley WR et al. Am J Transpl
200881186-1196.
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SPLIT Registry Survival
Diamond IR, Fecteau A, Millis JM et al. Ann Surg.
2007246301-310.
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Factors affecting graft survival LLS Split Liver
Risk Factor Hazard Ratio (95) P value
Recipients Factors
Dx Tumor / No Tumor 1.904 (Tumor ) 0.03
Dialysis 1 wk of Tx 2.935 (Dialysis ) 0.004
Wt lt 6 vs gt 6 Kg 2.05 (lt6Kg) 0.001
Donor Factors
lt 30 vs gt 30 yrs 1.448 (Age gt 30) 0.041
CA post DBD 3.792 (cardiac arrest ) 0.001
Transplant Factors
CIT gt 6 hr 1.688 0.008
CIT gt 12 hrs 3.003 0.001
Pediatric Specific Ctr 1.0
No share vs share 1.666 vs 2.231 0.009
Lee KW, Cameron AM, Maley WR et al. Am J Transpl
200881186-1196.
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In situ Right LobeLeft Lobe split Cleveland
Clinic Experience

• Reviewed their experience using a rightleft lobe
  split comparing outcomes to whole organ
  recipients
• Excluded Right TrisegLLS in situ splits
• Sixteen donors 32 grafts
• 25 used at CCF, six by other programs in the
  region, 1 discarded for technical reasons

Hashimoto et al, AJT, 2014
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In situ split Hemi livers Cleveland Clinic
Experience
Hashimoto et al, AJT, 2014
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In situ split Hemi livers Cleveland Clinic
Experience

• Primary and secondary recipients with similar
  outcomes
• Biliary complications increased 32 versus 10.7
• Two cases of PNF salvaged by retransplantation

Hashimoto et al, AJT, 2014
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Meta-analysis of In situ split right lobe grafts

• Review encompassed all articles before December
  2014 time period
• PubMed, Embase and Cochrane Library search
• Seventeen studies with a total of 48457 patients
  utilized in analysis

Wan et al, Liver Transpl, 2015
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Meta-analysis of In situ split right lobe grafts
Outcome Odds Ratio Confidence Interval p value
Patient Survival (One year) 0.85 0.62-1.16 0.31
Graft Survival (One year) 0.91 0.76-1.08 0.27
Biliary Complications 1.66 1.29-2.15 lt0.001
Bile leaks 4.3 2.97-6.23 lt0.001
Vascular complications 1.81 1.29-2.53 lt0.001
HAT 1.71 1.17-2.5 lt0.005
Outflow Obstruction 4.17 1.75-9.94 0.001

• Patient and graft survival similar
• Complications not identified in study found to be
  statistically significant
• Biliary complications and outflow obstruction
  more common in split liver graft
• Ex vivo split worse outcome then in situ split
• Should match appropriate recipient with risk of
  graft

Wan et al, Liver Transpl, 2015
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CCHMC Graft use 2004-2015

• Increased use of Split segments starting in 2004
• Number of transplant 248
• Whole 123, Technical variants - 125
• Reduced Size 90 Split 25 Living related 10
• Split 25
• Extended Right - 2, Right Lobe - 2
• Left Lobe - 10 , LLS - 11
• Donor age range - 7 - 45
• In situ vs ex vivo 18 in situ, 7 ex vivo
• Local - 2, Region - 23

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CCHMC Outcomes

• Graft Survival

• Patient Survival

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Conclusions

• In situ split livers is an alternative to
  increase donor pool but should be used in a
  select population
• In our region, allocation to pediatric patient is
  logical trigger for in situ split liver
  consideration
• Requires significant cooperation between OPO,
  transplant teams

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The Risk of any Journey must be appreciated by
all parties..(Prior to beginning the Journey !)
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