ObjectiveTo assess and compare the value of split-liver transplantation (SLT) and living-related liver transplantation (LRT). Summary Background DataThe concept of SLT results from the development of reducedsize transplantation. A further development of SLT, the in situ split technique, is derived from LRT, which itself marks the optimized outcome in terms of postoperative graft function and survival. The combination of SLT and LRT has abolished deaths on the waiting list, thus raising the question whether living donor liver transplantation is still necessary. MethodsOutcomes and postoperative liver function of 43 primary LRT patients were compared with those of 49 primary SLT patients (14 ex situ, 35 in situ) with known graft weight performed between April 1996 and December 2000. Survival rates were analyzed using the Kaplan-Meier method. ResultsAfter a median follow-up of 35 months, actual patient survival rates were 82% in the SLT group and 88% in the LRT group. Actual graft survival rates were 76% and 81%, respectively. The incidence of primary nonfunction was 12% in the SLT group and 2.3% in the LRT group. Liver function parameters (prothrombin time, factor V, bilirubin clearance) and surgical complication rates did not differ significantly. In the SLT group, mean cold ischemic time was longer than in the LRT group. Serum values of alanine aminotransferase during the first postoperative week were significantly higher in the SLT group. In the LRT group, there were more grafts with signs of fatty degeneration than in the SLT group. ConclusionsThe short-and long-term outcomes after LRT and SLT did not differ significantly. To avoid the risk for the donor in LRT, SLT represents the first-line therapy in pediatric liver transplantation in countries where cadaveric organs are available. LRT provides a solution for urgent cases in which a cadaveric graft cannot be found in time or if the choice of the optimal time point for transplantation is vital.Living-related liver transplantation (LRT) and split-liver transplantation (SLT) are surgical strategies that have led to a reduction in the pretransplant death rate in children from 20% to nearly 0%.1-5 LRT provides a graft of excellent quality by minimizing the cold ischemic time. Primary nonfunction (PNF) after LRT is rare. In addition, this procedure is elective and thus allows flexibility in choosing the optimal time for transplantation with regard to the recipient's clinical status. Because of these advantages, worldwide long-term results of LRT are equal or even superior to those obtained with cadaveric full-size or reduced-size techniques. The actual 1-year graft and patient survival rate after LRT exceeds 80%.6 -10 The expansion of LRT for adult recipients reflects the great expectations of this procedure despite the higher risks for the donor associated with major hepatectomy.Split-liver transplantation (SLT) is technically comparable to LRT. However, as in other cadaveric procedures, it is theoretically susceptible to potential negative effects resulting from...

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Since living related liver transplantation was first performed in 1989, more than 150 cases have been performed worldwide, mostly in the United States and Japan. This paper reports the first series of living related liver transplantation in Europe. Twenty living related liver transplantation surgeries were performed over a 13‐mo period, with an overall patient survival of 85%. For patients who underwent elective transplantation (n=13), the survival rate was 100%. Technical complications included one arterial thrombosis necessitating retransplantation and five bile leaks requiring surgical revision. The technical improvements that permit avoidance of these complications are discussed. A detailed description of the living related liver procurement is given. All procurements yielded grafts of excellent quality. No intraoperative complications occurred, and no reoperations were necessary. No heterologous blood transfusion was needed. In two patients, incisional hernias developed after wound infection. Living related liver transplantation does not absolve the transplant community of efforts to promote cadaveric organ procurement. Nevertheless, living related liver transplantation does have the advantage of a readily available graft of excellent quality, permitting transplantation with optimal timing under elective conditions. Several centers are now preparing living related segmental liver transplants, following the model of our protocol, for three reasons: (a) to obtain superior results compared with cadaveric liver transplantation; (b) to overcome cadaveric organ shortage and further reduce pretransplantation mortality and (c) to provide viable organs in countries where cadaveric organ procurement is not established. When performed by a team experienced in pediatric liver transplantation and in adult liver resection, living related liver transplantation is an excellent modality for the treatment of end‐stage liver disease in children. (Hepatology 1994;20:49S‐55S.)

Hereditary hemorrhagic telangiectasia (HHT) is a vascu-

Split-liver transplantation for 2 adult recipients is a challenging procedure because of the need to split through the midplane of the donor liver. In applied techniques, usually the middle hepatic vein is retained with the left split and the vena cava retained with the right split graft, particularly to avoid serious venous congestion of the right graft after reperfusion. The indispensable division of the caudate lobe veins lead to uncertain viability of liver segment I, and resection might be necessary. To provide optimal venous drainage of both hemiliver grafts, we developed the split-cava technique. This article describes our new technique of liver splitting, which has been successfully used in 2 in situ harvesting procedures. (Liver Transpl 2000;6:703-706.) S plit-liver transplantation for 1 adult and 1 pediatric recipient has become a standard procedure, with results equivalent to those of conventional techniques. It has allowed the virtual elimination of mortality on the pediatric waiting list. However, transferring this technology to split-liver transplantation for 2 adult recipients remains problematic. Even when splitting the liver through the midplane (line of Cantilie), the 2 grafts usually will be small for the recipient's size and weight. Therefore, efforts to avoid additional damage to the graft should be made.Ischemic damage to the graft can be minimized by using the in situ splitting technique. 1 However, further ischemic damage can occur when vascular inflow or outflow of parts of the graft is compromised. This is particularly the case for venous outflow. The decision to maintain the middle hepatic vein and inferior vena cava (IVC) with 1 graft results in various degrees (depending on the anatomic situation) of compromise of the venous outflow of the contralateral graft. We describe a technique that allows preservation of optimal venous drainage of both grafts after in situ full-right and fullleft split-liver transplantation. Methods Donor and Recipient Surgical TechniquesThe donor operation is performed like any other multipleorgan harvesting procedure, with extra care to reduce central venous pressure during the hepatectomy phase.After exploration of the abdomen, the donor's infrarenal aorta and vena cava are isolated. A cholecystectomy is performed. Cholangiography through the cystic duct allows identification of the ideal line for transection of the right hepatic duct(s), marked with a clip.The right hepatic artery and right branch of the portal vein are isolated. Subsequently, the right liver lobe is mobilized. The short hepatic veins to the retrohepatic vena cava are isolated and saved. In some cases, a parenchymal bridge around the IVC has to be divided. The right hepatic vein is isolated and taped with a vessel loop. Subsequently, the lateral end of the vessel loop is braided behind those retrohepatic vein branches serving the right liver lobe. Finally, this end is passed ventral to the right hepatic artery and right portal vein in a similar way as described for classic split-liver tran...