Busuttil R W, Goss J A
Department of Surgery, The Dumont-UCLA Transplant Center, University of California, Los Angeles School of Medicine, 90095-7054, USA.
Ann Surg. 1999 Mar;229(3):313-21. doi: 10.1097/00000658-199903000-00003.
This study reviews the indications, technical aspects, and experience with ex vivo and in situ split liver transplantation.
The shortage of cadaveric donor livers is the most significant factor inhibiting further application of liver transplantation for patients with end-stage liver disease. Pediatric recipients, although they represent only 15% to 20% of the liver transplant registrants, suffer the greatest from the scarcity of size-matched cadaveric organs. Split liver transplantation provides an ideal means to expand the donor pool for both children and adults.
This review describes the evolution of split liver transplantation from reduced liver transplantation and living-related liver transplantation. The two types of split liver transplantation, ex vivo and in situ, are compared and contrasted, including the technique, selection of patients for each procedure, and the most current results.
Ex vivo splitting of the liver is performed on the bench after removal from the cadaver. It is usually divided into two grafts: segments 2 and 3 for children, and segments 4 to 8 for adults. Since 1990, 349 ex vivo grafts have been reported. Until recently, graft and patient survival rates have been lower and postoperative complication rates higher in ex vivo split grafts than in whole organ cadaveric transplantation. Further, the use of ex vivo split grafts has been relegated to the elective adult patient because of the high incidence of graft dysfunction (right graft) when placed in an emergent patient. Reasons for the poor function of ex vivo splits except in elective patients have focused on graft damage due to prolonged cold ischemia times and rewarming during the long benching procedure. In situ liver splitting is accomplished in a manner identical to the living donor procurement. This technique for liver splitting results in the same graft types as in the ex vivo technique. However, graft and patient survival rates reported for in situ split livers have exceeded 85% and 90%, respectively, with a lower incidence of postoperative complications, including biliary and reoperation for bleeding. These improved results have also been observed in the urgent patient.
Splitting of the cadaveric liver expands the donor pool of organs and may eliminate the need for living-related donation for children. Recent experience with the ex vivo technique, if applied to elective patients, results in patient and graft survival rates comparable to whole-organ transplantation, although postoperative complication rates are higher. In situ splitting provides two grafts of optimal quality that can be applied to the entire spectrum of transplant recipients: it is the method of choice for expanding the cadaver liver donor pool.
本研究回顾了离体和原位劈离式肝移植的适应证、技术要点及经验。
尸体供肝短缺是阻碍终末期肝病患者肝移植进一步应用的最主要因素。儿科受者虽仅占肝移植登记患者的15%至20%，却因缺乏大小匹配的尸体器官而受影响最大。劈离式肝移植为扩大儿童和成人的供肝来源提供了理想途径。
本综述描述了劈离式肝移植从减体积肝移植和活体亲属供肝移植发展而来的过程。对离体和原位两种劈离式肝移植进行了比较和对照，包括技术、每种手术患者的选择以及最新结果。
离体肝劈离是在尸体肝脏取出后在操作台上进行。通常将其分为两个移植物：儿童用第2和第3肝段，成人用第4至8肝段。自1990年以来，已报道349例离体移植物。直到最近，离体劈离移植物的移植物和患者生存率一直低于全器官尸体移植，术后并发症发生率更高。此外，由于紧急患者植入时移植物功能障碍（右移植物）发生率高，离体劈离移植物已仅限于择期成年患者使用。除择期患者外，离体劈离效果不佳的原因主要集中在长时间冷缺血时间及长时间操作台上复温导致的移植物损伤。原位肝劈离的操作方式与活体供肝获取相同。这种肝劈离技术产生的移植物类型与离体技术相同。然而，原位劈离肝报道的移植物和患者生存率分别超过85%和90%，术后并发症发生率较低，包括胆系并发症和因出血再次手术。在急诊患者中也观察到了这些改善的结果。
尸体肝劈离扩大了器官供肝来源，可能消除儿童活体亲属供肝的需求。如果将离体技术应用于择期患者，近期经验显示患者和移植物生存率与全器官移植相当，尽管术后并发症发生率更高。原位劈离可提供两个质量最优的移植物，适用于各类移植受者：是扩大尸体肝供肝来源的首选方法。
