RESUMEN

In-situ splitting of the liver before extended resection has gained broad attention. This two-step procedure requires several measures to make an effective and safe procedure. Although the procedure is performed in many institutions, there is no consensus on a uniform technique. The two steps can be divided into different parts and a standardized technique may render the procedure safer and the results will be easier to evaluate. In this paper, we describe a detailed approach to in-situ splitting that allows making both procedures safe, avoids liver necrosis, and is easily reproducible. In the first procedure the portal branches to segments I and IV to VIII are divided, the arterial branches and bile ducts to these segments are preserved and encircled and the parenchyma between segments II/III and IVa/b is divided. This avoids necrosis and bile leaks of segments I and IV and avoids urgent completion operations. In particular, the handling of vital structures close to the dissection line seems important to us. Complete splitting and securing the right and middle hepatic vein will make the second step of this procedure a minimal-risk procedure at a stage where the patient is still recovering from the more demanding first step.

Asunto(s)

RESUMEN

BACKGROUND: Split liver transplantation addresses donor shortages by facilitating the transplant of two recipients using one donor liver. Some still consider these grafts inferior due to prolonged cold ischaemia time and at times difficult vascular reconstruction. Techniques such as in-situ splitting, machine perfusion and interposition grafts may address these challenges and thereby address these concerns. The aim of this review is to assess these technical advances in split liver transplantation, their utility and outcomes. METHODS: A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Keywords included 'split liver transplantation', 'arterial reconstruction', and 'machine perfusion'. Data found was synthesised into sections including: methods of splitting, full-left full-right splitting, donor cholangiography, machine perfusion and arterial reconstruction. RESULTS: A total of 78 articles met inclusion criteria after screening of 151 eligible articles. These were subdivided into the following categories: in-situ (25), ex-vivo (25), full-left full-right splitting (15), donor cholangiography (2), machine perfusion (6), and arterial reconstruction (5). The in-situ splitting technique reduces the cold ischaemia time compared to the ex-vivo technique which may improve graft quality and liver splitting during normothermic machine perfusion is a novel technique with the potential to incorporate the best aspects of both techniques. Interposition grafts are often required during split liver transplantation but have an increased risk of hepatic artery thrombosis. CONCLUSION: Advancements in technique have allowed many of the unique challenges of split liver transplantation to be overcome. Overall, this supports the use of split liver transplantation in broader and riskier settings and we advocate for liver transplant surgeons to not hesitate in using these grafts liberally and expanding their recipient selection criteria.

Asunto(s)

RESUMEN

Advances in surgical technique and better perioperative management have significantly improved patient outcomes after liver surgery. Even major hepatectomy can be performed safely with low morbidity and mortality. Post-resection liver failure is among the most feared complications after extended hepatectomy. In order to increase the future liver remnant (FLR) and to expand the pool of candidates for surgical resection, Schnitzbauer et al recently presented a new 2-stage surgical approach which combines right portal vein ligation (rPVL) with in situ splitting (ISS) of the liver parenchyma. In comparison to other current strategies, such as interventional portal vein embolization, hypertrophy of the FLR was more pronounced (median volume increase = 74%; range: 21%-192%) and more rapid (after a median of 9 d; range: 5-28 d) after rPVL and ISS. In this commentary, we discuss the technical aspects and clinical impact of rPVL combined with ISS. Based on the reported data, this new 2-stage therapeutic approach represents a promising new strategy for patients with locally advanced liver disease, previously regarded as marginally resectable or even unresectable, potentially enabling curative resection. However, morbidity is significant and mortality not negligible.