Right Ex Situ Split Grafts for Adult Liver Transplantation

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OBJECTIVE: To analyze outcomes after adult right ex situ split graft liver transplantations and compare with available outcome benchmarks from whole liver transplantation (WLT). BACKGROUND: Ex-situ split liver transplantation (SLT) may be a valuable strategy to tackle the increasing graft shortage. Recently established outcome benchmarks in WLT offer a novel reference to perform a comprehensive analysis of results after ex situ right split liver transplantation. METHODS: This retrospective multicenter cohort study analyzes all consecutive adult SLT performed using right ex situ split grafts from January 1, 2014, to June 1, 2022. Study endpoints included 1-year graft and recipient survival, overall morbidity expressed by the comprehensive complication index (CCI), and specific post-LT complications. Results were compared with the published benchmark outcomes in low-risk adult WLT scenarii. RESULTS: In 224 adult right ex-situ SLT, the 1-year recipient and graft survival rates were 96% and 91.5%, within the WLT benchmarks. The 1-year overall morbidity was also within the WLT benchmark (41.8 CCI points vs <42.1). Detailed analysis revealed cut surface bile leaks (17%, 65.8% grade IIIa) as a specific complication without a negative impact on graft survival. There was a higher rate of early hepatic artery thrombosis after SLT, above the WLT benchmark (4.9% vs ≤4.1%), with a significant impact on early graft but not patient survival. CONCLUSIONS: In this multicentric study of right ex situ split graft LT, we report 1-year overall morbidity and mortality rates within the published benchmarks for low-risk WLT. Cut surface bile leaks and early hepatic artery thrombosis are specific complications of SLT and should be acknowledged when expanding the use of ex situ SLT.

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