How to apply ex-vivo split liver transplantation safely and feasibly: A three-step approach

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 theχ²-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.

Outcomes of ABO-incompatible liver transplantation in end-stage liver disease patients co-infected with hepatitis B and human immunodeficiency virus

BACKGROUND Human immunodeficiency virus(HIV)-positive patients coinfected with hepatitis B virus(HBV)are eligible for liver transplantation(LT)in Africa and Southeast Asia,particularly China.However,the outcome of HIV-HBV coinfected patients referred for ABO-incompatible LT(ABOi-LT)is unknown.AIM To clarify the outcome of ABOi-LT for HIV-HBV coinfected patients with endstage liver disease(ESLD).METHODS We report on two Chinese HIV-HBV coinfected patients with ESLD who underwent A to O brain-dead donor LT and reviewed the literature on HIV-HBV coinfected patients treated with ABO-compatible LT.The pretransplantation HIV viral load was undetectable,with no active opportunistic infections.Induction therapy consisted of two sessions of plasmapheresis and a single dose of rituximab in two split doses,followed by an intraoperative regimen of intravenous immunoglobulin,methylprednisolone,and basiliximab.Post-transplant maintenance immunosuppressive agents consisted of tacrolimus and mycophenolate mofetil,and prednisone.RESULTS At the intermediate-term follow-up,patients showed undetectable HIV viral load,CD4(+)T cell counts greater than 150 cells/μL,no HBV recurrence,and stable liver function.A liver allograft biopsy showed no evidence of acute cellular rejection.Both patients survived at 36-42 mo of follow-up.CONCLUSION This is the first report of ABOi-LT in HIV-HBV recipients with good intermediate-term outcomes,suggesting that ABOi-LT may be feasible and safe for HIV-HBV coinfected patients with ESLD.

Reconstructing the portal vein through a posterior pancreatic tunnel:New choice for portal vein thrombosis during liver transplantation

BACKGROUND Thrombectomy and anatomical anastomosis(TAA)has long been considered the optimal approach to portal vein thrombosis(PVT)in liver transplantation(LT).However,TAA and the current approach for non-physiological portal reconstructions are associated with a higher rate of complications and mortality in some cases.AIM To describe a new choice for reconstructing the portal vein through a posterior pancreatic tunnel(RPVPPT)to address cases of unresectable PVT.METHODS Between August 2019 and August 2021,245 adult LTs were performed.Forty-five(18.4%)patients were confirmed to have PVT before surgery,among which seven underwent PV reconstruction via the RPVPPT approach.We retrospectively analyzed the surgical procedure and postoperative complications of these seven recipients that underwent PV reconstruction due to PVT.RESULTS During the procedure,PVT was found in all the seven cases with significant adhesion to the vascular wall and could not be dissected.The portal vein proximal to the superior mesenteric vein was damaged in one case when attempting thrombolectomy,resulting in massive bleeding.LT was successfully performed in all patients with a mean duration of 585 min(range 491-756 min)and mean intraoperative blood loss of 800 mL(range 500-3000 mL).Postoperative complications consisted of chylous leakage(n=3),insufficient portal venous flow to the graft(n=1),intra-abdominal hemorrhage(n=1),pulmonary infection(n=1),and perioperative death(n=1).The remaining six patients survived at 12-17 mo follow-up.CONCLUSION The RPVPPT technique might be a safe and effective surgical procedure during LT for complex PVT.However,follow-up studies with large samples are still warranted due to the relatively small number of cases.

Topological approach of liver segmentation based on 3D visualization technology in surgical planning for split liver transplantation

BACKGROUND Split liver transplantation(SLT)is a complex procedure.The left-lateral and right tri-segment splits are the most common surgical approaches and are based on the Couinaud liver segmentation theory.Notably,the liver surface following right trisegment splits may exhibit different degrees of ischemic changes related to the destruction of the local portal vein blood flow topology.There is currently no consensus on preoperative evaluation and predictive strategy for hepatic segmental necrosis after SLT.AIM To investigate the application of the topological approach in liver segmentation based on 3D visualization technology in the surgical planning of SLT.METHODS Clinical data of 10 recipients and 5 donors who underwent SLT at Shenzhen Third People’s Hospital from January 2020 to January 2021 were retrospectively analyzed.Before surgery,all the donors were subjected to 3D modeling and evaluation.Based on the 3D-reconstructed models,the liver splitting procedure was simulated using the liver segmentation system described by Couinaud and a blood flow topology liver segmentation(BFTLS)method.In addition,the volume of the liver was also quantified.Statistical indexes mainly included the hepatic vasculature and expected volume of split grafts evaluated by 3D models,the actual liver volume,and the ischemia state of the hepatic segments during the actual surgery.RESULTS Among the 5 cases of split liver surgery,the liver was split into a left-lateral segment and right trisegment in 4 cases,while 1 case was split using the left and right half liver splitting.All operations were successfully implemented according to the preoperative plan.According to Couinaud liver segmentation system and BFTLS methods,the volume of the left lateral segment was 359.00±101.57 mL and 367.75±99.73 mL,respectively,while that measured during the actual surgery was 397.50±37.97 mL.The volume of segment IV(the portion of ischemic liver lobes)allocated to the right tri-segment was 136.31±86.10 mL,as determined using the topological approach to liver segmentation.However,during the actual surgical intervention,ischemia of the right tri-segment section was observed in 4 cases,including 1 case of necrosis and bile leakage,with an ischemic liver volume of 238.7 mL.CONCLUSION 3D visualization technology can guide the preoperative planning of SLT and improve accuracy during the intervention.The simulated operation based on 3D visualization of blood flow topology may be useful to predict the degree of ischemia in the liver segment and provide a reference for determining whether the ischemic liver tissue should be removed during the surgery.