Resection remains the treatment of choice in liver cancer. In order to avoid liver transplantation in conventionally unresectable tumors ex-situ ("bench" procedure), in-situ and ante-situm resection technique should be preferred whenever feasible. Despite the deficiency of donor organs, a single center experience with 198 patients reveals that liver transplantation continues its role as a therapeutic option for selected patients. At present "favorable" indications for transplantation are International Union against Cancer (UICC) - stage II hepatocellular carcinoma as well as the subtype fibrolamellar carcinoma, uncommon tumors such as epitheloid hemangioendothelioma, hepatoblastoma, and liver metastases from neuroendocrine tumors. Due to unsatisfying results, intrahepatic bile duct-, stage III and IV hepatocellular carcinoma, hemangiosarcoma, and liver metastases from nonendocrine primaries should be excluded from liver transplantation alone. For these advanced tumors, especially in cases of extrahepatic involvement, a combination of liver transplantation and multivisceral resection has been proven feasible. However, a significant improvement in patient survival may only be expected only by currently investigated multimodality treatment protocols which will require further randomized studies.

Some primary and secondary liver tumours are not absolutely irresectable, but cannot be resected using a conventional approach because of the limited warm ischaemia tolerance of the liver or poor accessibility of the tumour region. In such situations, the techniques of ex vivo liver surgery, pioneered by Rudolf Pichlmayr some 10 years ago, offer new chances for R0 resection. All the three different approaches, namely "in situ"-, "ante situm"-, and "ex situ" resection, require the use of measures originally developed for transplantation, such as hypothermic liver perfusion and veno-venous bypass. They differ mainly in the extent to which major vessels are divided in order to achieve optimal mobility of the organ. The results show that radical resection can be achieved accomplished in many cases. If necessary, complex vascular reconstructions can be performed. Although perioperative morbidity and mortality are high, there are a number of long-term survivors. Tumour recurrence, however, remains the main problem over the long term. In conclusion, ex vivo liver surgery is an important extension of surgical treatment possibilities. However, the procedure is suitable only for a small number of carefully selected patients and should be reserved for use in specialised centres. Furthermore, in view of the fact that the results are not yet optimal, additive and adjuvant treatment modalities are needed.

The cardioplegic HTK-solution (Bretschneider) has not been used in human liver transplantation as yet. Herein the first results obtained from 14 patients with HTK-preserved liver grafts are presented. The suitability of HTK-solution could be shown. All grafts functioned primarily except one, where initial non-function was obviously due to donor reasons. The early postoperative peak values of transaminases as a sign of ischemic damage were average and similar to the values of other flushout solutions. Using HTK primary function could be achieved even in livers prospectively assessed as only of fair quality, and livers with poor donor function tests (MegX) functioned from the beginning. HTK-solution therefore seems to allow widening of the acceptance criteria for donor livers. It was not the aim of this trial to extend cold ischemic time, but 3 livers with 11 h and 12 h 25 showed immediate function. How far cold ischemic time can be extended is a still open question. All livers were rapidly cooled and homogeneously flushed out due to the low viscosity of HTK-solution. All livers had a soft consistency after perfusion indicating a low degree of cell edema. HTK therefore is an effective solution for liver preservation.

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