title: Long-term results after adult ex situ split liver transplantation since its introduction in 1987.
abstract: BACKGROUND
  Split liver transplantation is still discussed controversially. Utilization of split liver grafts has been declining since a change of allocation rules for the second graft abolished incentives for German centres to perform ex situ splits. We therefore analysed our long-term experiences with the first ex situ split liver transplant series worldwide.
  
  
  METHODS
  A total of 131 consecutive adult ex situ split liver transplants (01.12.1987-31.12.2010) were analysed retrospectively.
  
  
  RESULTS
  Thirty-day mortality rates and 1- and 3-year patient survival rates were 13, 76.3, and 66.4 %, respectively. One- and three-year graft survival rates were 63.4 and 54.2 %, respectively. The observed 10-year survival rate was 40.6 %. Continuous improvement of survival from era 1 to 3 was observed (each era: 8 years), indicating a learning curve over 24 years of experience. Patient and graft survival were not influenced by different combinations of transplanted segments or types of biliary reconstruction (p > 0.05; Cox regression). Patients transplanted for primary sclerosing cholangitis had better survival (p = 0.021; log-rank), whereas all other indications including acute liver failure (13.6 %), acute and chronic graft failure (9.1 %) had no significant influence on survival (p > 0.05; log-rank). Biliary complications (27.4 %) had no significant influence on patient or graft survival (p > 0.05; log-rank). Hepatic artery thrombosis (13.2 %) had a significant influence on graft survival but not on patient survival (p = 0.002, >0.05, respectively; log-rank).
  
  
  CONCLUSIONS
  Split liver transplantation can be used safely and appears to be an underutilized resource that may benefit from liberal allocation of the second graft.
authors.affiliation: Department of General, Visceral and Transplantation Surgery, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Germany, schrem.harald@mh-hannover.de.
authors.forename: Harald
authors.initials: H
authors.lastname: Schrem
authors.forename: Moritz
authors.initials: M
authors.lastname: Kleine
authors.forename: Tim Oliver
authors.initials: TO
authors.lastname: Lankisch
authors.forename: Alexander
authors.initials: A
authors.lastname: Kaltenborn
authors.forename: Lampros
authors.initials: L
authors.lastname: Kousoulas
authors.forename: Lea
authors.initials: L
authors.lastname: Zachau
authors.forename: Frank
authors.initials: F
authors.lastname: Lehner
authors.forename: Jürgen
authors.initials: J
authors.lastname: Klempnauer
mesh_terms: D000328:Adult; D000368:Aged; D057868:Anastomotic Leak / Q000209:etiology; D015209:Cholangitis, Sclerosing / Q000601:surgery; D017707:Erythrocyte Transfusion; D005260:Female; D006085:Graft Survival; D006499:Hepatic Artery; D006801:Humans; D007430:Intraoperative Care; D059032:Learning Curve; D007902:Length of Stay; D017114:Liver Failure, Acute / Q000601:surgery; D016031:Liver Transplantation / Q000009:adverse effects* / Q000379:methods* / Q000401:mortality; D008297:Male; D008875:Middle Aged; D010949:Plasma; D011169:Portal Vein; D012086:Reoperation; D012189:Retrospective Studies; D015996:Survival Rate; D013927:Thrombosis / Q000209:etiology*; D013997:Time Factors