Special Issues in Split and Pediatric Liver Transplantation
Several additional problems contribute to an increased biliary morbidity after split LT. These include cut-surface leaks due to unclosed or aberrant bile ducts and necrosis of liver tissue, mainly of segment 4 in the case of asymmetric splitting. Biliary complications are reported in 29% of adult and 40% of pediatric recipients of partial liver grafts. Nevertheless, excellent long-term results are reported in the case of extended right/left lateral splitting, with 10% surgical revisions in adult and 28% in pediatric recipients. No significant differences between in situ and ex vivo splitting were observed. The risk of bile leaks from the cut-surface is higher than after LDLT; e.g. in the Hanover experience 15% cut surface leaks were observed. Most cut surface leaks have a favourable managed either by percutaneous drainage or surgical revision. Although available evidence is sparse, some authors recommend routine use of fibrin glue or fibrin–collagen sponges for prophylaxis of cut-surface leaks. Due to devascularization of the hilar plate in split grafts, bile duct necrosis is observed in up to 5% of cases, which requires surgical revision or even retransplantation.
However, the overall survival after split LT, e.g. of extended right lobes is not significantly different from whole LT; therefore the slightly increased biliary complication rate has to be disregarded, especially since split LT is unavoidable in pediatric LT due to the lack of an adequate number of full size organs. The biliary morbidity in pediatric recipients of partial liver grafts is also significantly higher than in recipients of whole liver grafts. The cumulative 2-year biliary complication rate was 17% in pediatric whole LT compared to 29% in pediatric split LT and 40% in pediatric LDLT. Since about 75% of pediatric LT are performed with a bilioenteric anastomosis, most biliary complications are managed by percutaneous intervention. Additionally an overall surgical revision rate of 30% is reported. Since the biliary morbidity in pediatric LT consists mainly of anastomotic complications, the treatment success is good and retransplantation is rarely required.