135: Use of a split liver graft to facilitate adult mutlivisceral transplantation in a small adult recipient

One of the major challenges in intestinal transplantation is the reduction of abdominal domain in potential recipients. This is of particular concern in patients with liver failure where limited time is available to access appropriate grafts from a size and immunological perspective. A 37-year old female patient was referred to our unit in Feb 2021 for urgent transplant assessment. She had ischaemic small bowel due to early onset atheroscelerosis on a background of 10 years of abdominal angina. In 2018 she had an iliac to SMA bypass. In 2020, she had acute occlusion of her SMA graft, interventions were unsuccessful and she had her small bowel and right colon removed. At the time of listing in April 2021 the patient was 41.6Kg, blood group B and had a cRF (calculated reaction frequency) of 89% (HLA Class I antibodies). On the waiting list she developed worsening abdominal sepsis with a pancreatic fistula and after 11 months an appropriate donor had not been identified (both from an immunological and size perspective). She remained an in patient throughout this time with pancreatic fistulation and sepsis In April 2022 a suitable donor was identified (15 year old female, 45Kg), but had been allocated to a super urgent recipient for whom a segmental graft would be required. Under normal circumstances this would have precluded the use of the bowel and right lobe as a multivisceral block (MVT) as a consequence of the prolonged cold ischaemic time (CIT). Discussions with the paediatric centre resulted in the ability to transplant both recipients. The paediatric liver transplant surgeon travelled to the donor hospital and joined the retrieval team from our centre. The hilar anatomy was confirmed during the warm phase of the retrieval but the liver was split on the back table with the left lateral segment being split from the block. The multivisceral block left the donor hospital in under two hours from cross clamp and the total cold ischaemia time was (5 hours 24 minutes). We successfully performed an MVT with a right lobe split liver. The adult recipient had no biliary complications but did develop a proximal GI anastomotic leak that resolved completely. Both recipients are alive and well.This is the first case that we are aware of utilising a cadaveric split liver graft for an adult MVT and paediatric lobe graft from a single paediatric donor. Conclusion: This case demonstrates the feasibility of this approach to increase access to small donors for small adult mutivisceral recipients without compromise to the paediatric liver transplant population.