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Invited Critique
Sep 2011

There's More Than 1 Way to Split a Liver and Skin a Cat: Comment on “Outcomes With Split Liver Transplantation in 106 Recipients”

Author Affiliations

Author Affiliations: Department of Surgery, Dumont-University of California, Los Angeles Transplant and Liver Cancer Centers, Pfleger Liver Institute, David Geffen School of Medicine, University of California, Los Angeles, California.

Arch Surg. 2011;146(9):1059-1060. doi:10.1001/archsurg.2011.217

The scarcity of organs for transplantation makes any innovation to increase the organ supply extremely important. Splitting the liver of a deceased donor to yield functional grafts for 2 recipients has improved the availability of donor organs and lowered mortality rates for patients on the liver transplant waiting list. There are 2 methods of splitting the liver. In situ splitting, or dividing the hepatic parenchyma in the heart beating brain-dead donor, has the potential advantage of shorter cold ischemia times, minimal graft rewarming, and less blood loss after reperfusion. This technique, however, adds 1 to 1.5 hours to the duration of a multi-organ procurement procedure and requires an experienced donor surgeon.1 In the ex vivo method (described in the article by Vagefi et al2 in this issue of the Archives), the whole liver is retrieved, preserved, and transported to the transplantation center of the recipients and then divided into 2 functional grafts on the back table. Although ex vivo splitting does not require advanced technical skills in the donor institution during organ procurement, preparation of the graft requires additional procedures, including cholangiography and angiography, resulting in graft rewarming. The debate on the superiority of one technique over the other among surgeons is ongoing. However, to declare the “superior” method of splitting of the liver, we must define the outcome measures based on the number of functional grafts obtained, recipient survival outcomes, and complications.

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