Ann Surg Treat Res.  2021 Jul;101(1):37-48. 10.4174/astr.2021.101.1.37.

Fates of retained hepatic segment IV and its prognostic impact in adult split liver transplantation using an extended right liver graft

  • 1Department of Surgery, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
  • 2Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea


When splitting a liver for adult and pediatric graft recipients, the retained left medial section (S4) will undergo ischemic necrosis and the right trisection graft becomes an extended right liver (ERL) graft. We investigated the fates of the retained S4 and its prognostic impact in adult split liver transplantation (SLT) using an ERL graft.
This was a retrospective analysis of 25 adult SLT recipients who received split ERL grafts.
The mean model for end-stage liver disease (MELD) score was 27.3 ± 10.9 and graft-recipient weight ratio (GRWR) was 1.98 ± 0.44. The mean donor age was 26.5 ± 7.7 years. The split ERL graft weight was 1,181.5 ± 252.8 g, which resulted in a mean GRWR of 1.98 ± 0.44. Computed tomography of the retained S4 parenchyma revealed small ischemic necrosis in 16 patients (64.0%) and large ischemic necrosis in the remaining 9 patients (36.0%). No S4-associated biliary complications were developed. The mean GRWR was 1.87 ± 0.43 in the 9 patients with large ischemic necrosis and 2.10 ± 0.44 in the 15 cases with small ischemic necrosis (P = 0.283). The retained S4 parenchyma showed gradual atrophy on follow-up imaging studies. The amount of S4 ischemic necrosis was not associated with graft (P = 0.592) or patient (P = 0.243) survival. A MELD score of >30 and pretransplant ventilator support were associated with inferior outcomes.
The amount of S4 ischemic necrosis is not a prognostic factor in adult SLT recipients, probably due to a sufficiently large GRWR.


Deceased donor; Donor shortage; Extended right liver graft; Left medial segment; Whole liver graft
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