半离体肝切自体余肝移植术后肝再生的研究

目的 观察半离体肝切自体余肝移植术后肝再生的规律及其代偿能力.方法 通过CT计算5例半离体肝切自体余肝移植术后患者不同时间点的肝再生并监测术后肝脏功能变化.结果 病例1、4的谷丙转氨酶(GPT)在术后第6、4天降至正常;病例2、3、5的GPT在术后10天左右降至正常水平.病例1术后2个月、1年肝体积再生率分别为21.62%、42.85%;病例2术后2个月、1年肝体积再生率分别为12.50%、61.84%;病例3术后2个月肝体积再生率为11.32%;病例4术后2个月肝体积再生率为25.98%;病例5术后2个月肝体积再生率为9.32%.结论 该技术为难以常规肝切除的患者提供了可行性技术径路;术后残肝具有较强的再生能力,能满足机体代谢需要;尽量缩短肝脏冷缺血时间是减轻术后肝损伤,保护肝再生能力的关键.     

劈离式肝移植术后肝再生的影响因素及其对预后的影响

目的探讨劈离式肝移植术后肝再生的影响因素及其对预后的影响。方法回顾性分析2015年1月至2021年7月在青岛大学附属医院接受劈离式肝移植手术的44例受者的临床资料, 其中男性19例, 女性25例, 年龄(49±12)岁。根据肝再生率(LRR)是否大于100%, 分为两组:再生良好组(LRR≥100%, n=24)和再生不良组(LRR<100%, n=20)。比较两组受者围手术期相关资料差异及术后生存率。通过门诊复诊或电话随访。结果术后15、30、90、180 d的移植肝体积变化率分别为(117.04±7.00)%、(164.03±16.72)%、(180.98±26.30)%、(159.40±26.28)%。受者的体质量指数、无肝期时间、术中出血量、术中输血量、住院时间、肝功能恢复时间, 以及供肝脂肪变性和供肝类型是劈离式肝移植术后肝再生的影响因素。再生良好组受者术后第2、3、4、5、6、7天的天冬氨酸氨基转移酶以及术后第1、2、3、4、5、6、7天的丙氨酸氨基转移酶均低于再生不良组, 差异具有统计学意义(P<0.05)。再生良好组受者术后第5、6、7天的总胆红素水平低于再...     

部分供肝肝移植术后急性肝静脉流出道阻塞二例报道

劈离式肝移植与活体供肝肝移植部分缓解了供肝的缺乏,是治疗终末期肝病的有效方法,但肝静脉流出道重建是部分供肝肝移植的难点.肝静脉流出道阻塞,门静脉过度灌注会引起移植肝充血,功能紊乱,最终导致移植肝功能丧失.活体右半供肝肝移植术后流出道阻塞的发生率为0～4%[1],大多数发生在术后2个月或以后,发生在术后1周左右的急性流出道阻塞极少[2].我院有2例患者在部分供肝肝移植术后发生急性肝静脉流出道阻塞.现结合文献分析报道如下.     

完全右半肝-左半肝劈离式肝移植的临床应用:附四例报告

目的探讨完全右半肝-左半肝劈离式肝移植在成人-成人或成人-大体重儿童中的临床应用。方法回顾2019年1月至12月间首都医科大学附属北京友谊医院完成的4例完全右半肝-左半肝劈离式肝移植的供受者临床资料,分析劈离式肝移植的手术方式、冷缺血时间、手术时间、术中输血量,观察患者术后并发症及相关预后。结果4例完全右半肝-左半肝劈离式肝移植的受者包括3例成人和1例大体重儿童(45 kg),年龄范围14~48岁,体重范围45~61 kg,终末期肝病模型评分分别为21、12、41和30分。移植物质量与受者体质量比为0.85%~1.35%。冷缺血时间457~650 min,手术时长460~575 min。4例患者移植术后早期肝功能恢复顺利,均未出现小肝综合征。随访至术后6个月,其中1例出现胆道吻合口漏,经内镜逆行胰胆管造影术治疗后治愈;1例出现胆道狭窄,经皮肝穿刺胆道引流术治疗后反复胆道感染;1例术后6个月死于肺部感染。结论在严格病例选择的情况下,可以开展完全右半肝-左半肝劈离式肝移植。     

中国一类供者二例供肝在体劈离后行肝移植临床报道

目的 总结在体劈离式肝移植的临床经验.方法 回顾性分析2例中国一类心脏死亡器官捐赠(DCD)供者接受供肝在体劈离手术,并将劈离后的供肝移植给4例终末期肝病患者的临床资料.供肝的劈离手术中,在保证供者循环稳定的情况下使用超声吸引刀劈离肝实质,离体劈离肝脏血管和胆道,并对供肝进行修整.供者例1的全肝质量为1800 g,劈离成右三叶供肝和左外叶供肝,右三叶供肝移植给1例成人受者,左外叶供肝经减体积后移植给1例儿童受者.供者例2的全肝质量达2100 g,在体劈离成左右半肝,分别移植给2例成人受者.结果 在体劈离肝实质的手术耗时分别为1h和45 min,离体劈离肝血管和胆道的耗时分别为30 min和40 min.供肝热缺血时间均为0 min,冷缺血时间为120～360 min,移植肝质量与受者体质量比(GRWR)为1.5％～2.2％.肝移植后,1例成人受者出现门静脉血栓形成,经手术取尽门静脉血栓后,行门静脉-腔静脉搭桥,术后早期出现肝性脑病症状,经内科治疗后好转.肝移植后4例受者均恢复顺利,随访期间移植肝功能正常,均未发生排斥反应和感染并发症.结论 对于中国一类供者,实施在体劈离式肝移植是安全可行的,此项术式有望成为扩展供肝来源的重要途径,详细的术前评估技术和精细的手术操作是保证肝移植顺利进行的关键.     

2010年全国器官移植学术会议纪要(续)

4.亲属活体肝移植和扩大标准的供肝移植:由于供移植的器官来源短缺,亲属活体肝移植和扩大标准的供肝移植日益增多,随之而来的伦理学问题和技术问题更多地出现在交流讨论中.朱志军等介绍了天津市第一中心医院扩大供肝来源的经验:(1)开展新的术式,如活体肝移植、劈离式肝移植、多米诺肝移植;(2)合理使用扩大标准的供肝,如高龄供肝、脂肪肝、华支睾吸虫供肝、肝炎病毒阳性等供肝的使用.汤晓寅等报告,活体部分肝移植术后早期他克莫司(Tac)的用量与植入供肝的体积显著相关,成人活体右半肝移植术后早期的用量约相当于尸体全肝的70%,随着植入供肝的不断再生,至术后28 d可基本接近全肝移植水平.     

体外劈离式肝移植22例临床分析

目的 总结22例体外劈离式肝移植的临床经验.方法 回顾性分析2006年6月至2010年1月间22例劈离式肝移植的临床资料,第一阶段(2006年6月至2(D7年2月)移植10例,第二阶段(2009年1月至2010年1月)移植12例.共对11例供肝进行劈离,获得22个移植物,其中超右半肝8个,左外侧叶肝8个,含肝中静脉的右半肝3个,不含肝中静脉的左半肝3个.观察术后移植肝功能的恢复情况、血管和胆道并发症的发生率及受者的存活率.结果 22例受者术后中位随访时间为11.7个月(0.5～43个月),术后1年和3年累积存活率分别为82%和63.7%.动脉并发症的发生率为9.1%,胆道并发症发生率为33.3%.22例受者中有5例死亡,其中2例的死亡原因与外科技术并发症相关,但均为第一阶段移植的受者.结论 随着供肝劈离技术和部分肝移植技术的进步,体外劈离式肝移植的受者和移植肝的存活率与全肝移植相近.应在我国推广此技术,从而增加供肝数量.缩短受者等待移植的时间.     

不同比例缩小体积肝移植的大动物研究

目的研究不同比例缩小体积肝移植的结果,确定猪能耐受的最小体积的肝移植。方法远系繁殖猪70头分为原位全肝移植作为对照组和3组不同比例缩小体积原位肝移植(按照缩小体积的移植肝占受体切除肝脏重量的百分比;1组:60%;2组:30%;3组:20%);实验采用原位经典肝移植方式(静脉转流)。术后第3天和第5天取肝标本。结果对照组和3组不同比例缩小体积肝移植的移植物与受体肝脏重量百分比(GIWRW)分别为87·4%±8·3%、59·9%±5·2%、33·6%±4·9%和22·1%±3·4%;移植物与受体体重百分比(GIWBW)分别2·4%±0·4%、1·43%±0·17%、0·81%±0·09%和0·53%±0·06%。对照组、1组和2组存活率达100%;3组存活率仅为53%。4个组的动物处死后肝脏移植物重量均有显著的增加。结论安全的缩小体积肝移植,应以移植物与受体肝脏重量百分比不小于33%,同时移植肝与受体重量百分比不小于0·8%为限。     

儿童小体积供肝肝移植治疗成人急性肝衰竭1例附文献复习

目的总结儿童小体积供肝肝移植治疗成人急性肝衰竭的临床经验。方法回顾性分析1例低龄儿童小体积供肝肝移植治疗成人急性肝衰竭病例的临床资料并进行文献复习。结果供体为4.5岁儿童,脑死亡器官捐献供肝质量为544.6 g,受体体质量52 kg,移植物受体体质量比为1.05%。手术采用经典原位肝移植术。术后艰难康复,相继并发脑水肿、应激性消化道大出血、急性肾损伤、小肝综合征、肺不张、肺部感染、真菌感染、腹腔感染、胸腔积液等并发症。经对症综合治疗后,移植肝功能逐渐恢复正常,2~3周再生至移植成人标准肝体积大小,住院102 d后康复出院。术后10个月随访受体肝功能正常,生活质量良好。结论儿童小体积供肝可以成功应用于成人受体,但需要根据供肝情况选择合适的受体、手术方式及围手术期精细管理。     

超声造影在劈离式肝移植术后监测的应用价值初探

目的初步探讨超声造影在劈离式肝移植术后监测的应用价值。方法对10例劈离式肝移植术后受者行常规二维超声、彩色多普勒超声(彩超)及超声造影检查。总结10例劈离式肝移植受者的预后情况;分析受者术后常规二维超声、彩超和超声造影的检测结果。结果 10例劈离式肝移植受者中,死亡2例,1例死于肿瘤复发多器官转移及多器官功能衰竭,1例死于心脏骤停,余8例预后良好。10例受者中,彩超检查肝动脉显示率为80%,未见显示的2例进一步行超声造影,结果提示肝动脉栓塞1例,肝动脉显示良好1例。10例中,常规二维超声肝实质回声显示异常5例,其中1例S5段呈高回声;1例S7段呈低回声;1例S4段呈高回声;1例S5及S6段先呈先低回声后高回声;1例肝内多发低回声及略高回声。超声造影显示3例回声异常区微循环血流灌注与正常回声区明显不同步,呈现早到达早消退的图像特征,考虑与肝静脉回流不畅有关;1例回声异常区其微循环血流灌注与正常区域明显不同步,呈现早到达同步消退的图像特征,考虑肝静脉回流不畅和心肌梗死导致肝脏断面处淤血及水肿;1例肝内多发"快进快出"异常灌注区,考虑术后肿瘤复发。结论超声造影在劈离式肝移植术后监测中可作为常规二维超声及彩超的有效补充,有助于了解劈离式移植肝的血流及灌注情况,可及时发现肝移植术后早期并发症。     

急诊成人活体右半肝肝移植治疗重型肝炎肝功能衰竭的临床研究

目的 探讨急诊成人活体右半肝肝移植在治疗重型肝炎肝功能衰竭中的作用.方法 2007年4至12月接受活体肝移植患者中,共有10例接受了急诊活体肝移植治疗(4例为慢性重型肝炎、6例为急性肝功能衰竭;9例为乙型肝炎、1例为药物性肝功能衰竭).终末期肝病模型(MELD)评分平均为33.22±6.55.ABO血型相同者8例,相容者2例,Rh不相容者1例.对术后的相关指标进行前瞻性分析.结果 1例术后发生腔静脉血栓形成致急性肾功能衰竭死亡,另1例发生肝动脉血栓形成致移植物失功能而死亡,余受者和所有供者均恢复良好,受者随访6～14个月,中位生存已达8.5个月,均无并发症发生.平均移植物重量和受者体重比值为(1.19±0.14)%,移植物容积和受者估计标准肝容积比为(65.13±8.75)%;带肝中静脉右半肝移植物3例,不带肝中静脉右半肝合并Ⅴ段和Ⅷ段流出道重建3例,不带肝中静脉右半肝4例.术后血清肌酐、内毒素水平、凝血酶原活动度及总胆红素分别在术后第3、7、14、28天恢复到正常水平.结论 急诊成人活体右半肝肝移植治疗重型肝炎肝功能衰竭效果满意,作为重型肝炎肝功能衰竭的抢救治疗疗效确切.     

Hepatic flow optimization in full right split liver transplantation

Split liver transplantation for two adults offers a valuable opportunity to expand the donor pool for adult recipients.However,its application is mainly hampered by the physiological limits of these partial grafts.Small for size syndrome is a major concern during transplantation with partial graft and different techniques have been developed in living donor liver transplantation to prevent the graft dysfunction.Herein,we report the first application of synergic approaches to optimise the hepatic hemodynamic in a split liver graft for two adults. A Caucasian woman underwent liver transplantation for alcoholic cirrhosis(MELD 21)with a full right liver graft (S5-S8)without middle hepatic vein.Minor and accessory inferior hepatic veins were preserved by splitting the vena cava;V5 and V8 were anastomosed with a donor venous iliac patch.After implantation,a 16G catheter was advanced in the main portal trunk.Inflow modulation was achieved by splenic artery ligation.Intraportal infusion of PGE1 was started intraoperatively and discontinued after 5 d.Graft function was immediate withnormalization of liver test after 7 d.Nineteen months after transplantation,liver function is normal and graft volume is 110%of the recipient standard liver volume. Optimisation of the venous outflow,inflow modulation and intraportal infusion of PGE1 may represent a valuable synergic strategy to prevent the graft dysfunction and it may increase the safety of split liver graft for two adults.     

Liver Graft Regeneration in Right Lobe Adult Living Donor Liver Transplantation

Optimal portal flow is one of the essentials in adequate liver function, graft regeneration and outcome of the graft after right lobe adult living donor liver transplantation (ALDLT). The relations among factors that cause sufficient liver graft regeneration are still unclear. The aim of this study is to evaluate the potential predisposing factors that encourage liver graft regeneration after ALDLT. The study population consisted of right lobe ALDLT recipients from Chang Gung Memorial Hospital-Kaohsiung Medical Center, Taiwan. The records, preoperative images, postoperative Doppler ultrasound evaluation and computed tomography studies performed 6 months after transplant were reviewed. The volume of the graft 6 months after transplant divided by the standard liver volume was calculated as the regeneration ratio. The predisposing risk factors were compiled from statistical analyses and included age, recipient body weight, native liver disease, spleen size before transplant, patency of the hepatic venous graft, graft weight-to-recipient weight ratio (GRWR), posttransplant portal flow, vascular and biliary complications and rejection. One hundred forty-five recipients were enrolled in this study. The liver graft regeneration ratio was 91.2 ± 12.6% (range, 58–151). The size of the spleen (p = 0.00015), total portal flow and GRWR (p = 0.005) were linearly correlated with the regeneration rate. Patency of the hepatic venous tributary reconstructed was positively correlated to graft regeneration and was statistically significant (p = 0.017). Splenic artery ligation was advantageous to promote liver regeneration in specific cases but splenectomy did not show any positive advantage. Spleen size is a major factor contributing to portal flow and may directly trigger regeneration after transplant. Control of sufficient portal flow and adequate hepatic outflow are important factors in graft regeneration.     

成人间活体扩大右半肝移植治疗急性肝功能衰竭

目的介绍成人间活体扩大右半肝移植治疗急性肝功能衰竭的临床经验。方法对1例42岁男性急性肝功能衰竭合并肝性脑病Ⅲ期患者行活体扩大右半肝移植治疗。其45岁姐姐为供者,CT评估供者包含肝中静脉的扩大右半肝体积为728．4cm^2（801g）,供肝／受者体重比为1．3％。供肝之肝右、中静脉整形后与受者整形后之肝右静脉行端-侧吻合;供受者门静脉、肝动脉行端．端吻合。供肝胆管整形后与受者胆总管行端-端吻合。结果供、受者手术均成功。供者术后恢复顺利,受者术后8h恢复意识,14d后丙氨酸转氨酶、总胆红素等指标首次下降至正常水平。术后16d曾出现转氨酶明显升高,给予甲泼尼龙1000mg冲击治疗后恢复正常。随访至今,供受者已健康生存8个月,均未出现胆管、肝动脉及静脉回流等并发症。结论扩大右半肝移植在技术上完全可行。能为成人患者提供足够重量的移植物,尤其对于急性肝功能衰竭患者具有重要意义,术前精确的影像学评估,熟练的肝切除和肝移植技术是确保该类手术成功的关键因素。     

成人活体肝移植单中心56例临床报告

目的探讨成人间右半肝移植手术中保证供、受者安全的方法。方法2002年1月至2006年9月四川大学华西医院对56例受者施行了成人右半肝移植,其中52例不含肝中静脉,4例双供肝肝移植。受者原发病为乙型肝炎肝硬化35例（62．5％,含急性肝功能衰竭12例）,肝细胞肝癌17例（30．4％）,其他4例;MELD评分〉25分者10例。供者常规行三维CT计算全肝体积及右半肝体积,并进行了移植手术技术改进。结果58例供者共摘取55例右半供肝及3例左半供肝。右半供肝均不含肝中静脉,重量为400—860g（中位数550g）,右半供肝与受者标准肝重比为31．7％-71．7％（中位数45．4％）,供者残肝体积均大于全肝体积的35％。58例供者发生并发症7例（12．5％）,无死亡。术后住院时间7—30d（中位数11d）。术后对56例受者随访2—52个月（中位数11个月）,发生并发症15例（26．8％）,死亡4例（7．2％）。1年实际生存率92．8％。结论采用不包含肝中静脉的右半供肝,术前CT测量残肝体积〉35％,同时右半供肝与受者标准肝重比〉40％者进行右半肝移植可保证供受者安全,反之则应考虑采用双供肝肝移植。     

Liver regeneration and function in donor and recipient after right lobe adult to adult living donor liver transplantation

BACKGROUND: Regeneration of the liver to a predetermined size after resection or transplantation is a well described phenomenon, but the time course over which these events occur has not been well defined. It is not clear how initial liver mass, reperfusion, immunosuppression, or steatosis influence this process. METHODS: Liver regeneration was assessed prospectively by volumetric magnetic resonance imaging (MRI) in living right lobe liver donors and the recipients of these grafts. Imaging was performed at regular intervals through 60 days after resection/transplantation, and liver mass was determined. Liver function tests and synthetic function were monitored throughout the study period in donors and recipients of these grafts as well as recipients of cadaveric grafts. RESULTS: MRI consistently overestimated liver mass by a mean of 45 g (+/-65) (range 10-123). Donor liver mass increased by 101%, 110%, 115%, and 144% at 7, 14, 30, and 60 days after resection, respectively. Recipient liver mass increased by 87,101, 119, and 99% at 7, 14, 30, and 60 days after transplantation, respectively. Steatosis did not influence the degree of regeneration or graft function, nor was there a functional difference between grafts of >1% graft to recipient body weight ratio or <1%. CONCLUSIONS: MRI accurately determines right lobe mass. Most liver regeneration occurs in the 1st week after resection or transplantation, and the time course does not differ significantly in donors or recipients. The mass of the graft or remnant segment affects the duration of the regeneration process, with a smaller initial liver mass prolonging the course. Steatosis of <30% had no bearing on liver function or regeneration and, therefore, should not be an absolute criterion for exclusion of donors. A calculated graft to recipient body weight ratio of 0.8% is adequate for right lobe living donor liver transplantation.     

Regeneration and function of hemiliver graft: right versus left

BACKGROUND: A right liver graft used almost routinely for adult living donor liver transplantation (LDLT), is associated with a higher incidence of morbidity and mortality in the donor. We compared volume regeneration and graft function between left and right liver grafts to examine the feasibility of using left liver grafts. METHODS: The left liver was considered acceptable as a graft when it was estimated to be over 40% of the recipient standard liver volume. Otherwise, right liver harvesting was used, provided the estimated right liver volume was less than 70% of the donor's standard liver volume. Graft volume on computed tomography and the results of liver function tests 1, 3, and 12 months after LDLT were compared between recipients with left (n = 76) and right (n = 83) grafts. Possible factors influencing graft regeneration were evaluated by multivariate analysis. RESULTS: A higher regeneration rate in the left liver graft group resulted in the same ratio of graft to standard liver volume as in the right liver graft group (88% vs 87%) 1 year after LDLT. Liver function tests and 5-year survival rates were comparable between the 2 groups. An episode of acute rejection was a predictive factor for impaired graft regeneration 1 month after LDLT. The initial ratio of graft volume to standard liver volume was an independent factor for regeneration 1 year after LDLT. CONCLUSIONS: A properly evaluated left liver graft can be used as safely as a right liver graft in adult-to-adult LDLT. The findings of the present study justify LDLT with a left liver graft under specific selection criteria and may be preferred to a right liver graft.     

中叶供肝肝移植的可行性动物实验研究

目的：探索肝中叶作为独立供肝进行移植的可行性,以进一步拓宽供肝来源。
方法：普通级健康犬分成供体组（n=12,20~25 kg）和受体组（n=12,10~15 kg）,供受体随机配对。供体手术将位于中央区的方叶、右中叶在体内劈离,原位灌注后保留其专属的门静脉中支、肝中动脉和中肝管,得到独立的中央区供肝并称重。受体手术先建立临时性门腔分流,供肝背驮式植入,流出口和腔静脉壁端侧吻合,供肝门静脉中支和受体门静脉主干行端端吻合后恢复新肝血流,重建动脉和胆管。术后观察受体腹腔及胆汁引流,每日检测肝功能,死亡后行尸检,移植物取标本行病理检查。
结果：犬肝被深陷的叶间裂分隔成7叶,各叶间由较少的肝桥连接,方叶和右中叶由门静脉中支、中肝动脉营养血回流至肝中静脉,胆汁引流至中肝管。供体组体内劈离技术全部得以完成,手术时间（215.0±67.7）min,失血量（229.3±66.5）mL。比较GRWR,中央区供肝[（1.3±0.3）%]和假设的左侧区供肝的[（2.1±0.4）%]及右侧区供肝的[（0.9±0.1）%]之间差异均有统计学意义（均P<0.01）。受体组手术时间（327.6±75.3）min,无肝期（33.6±7.5）min,失血量（415.5±79.8）mL。12个供肝均成功植入,冷缺血时间为（41.9±12.1）min,（8.3±3.6）min后排泌胆汁。受体肝功能指标在术后第1天发生明显变化,随后逐渐恢复,中位存活时间92.5（18~272）h,未发现有因吻合口出血、血栓等外科技术性并发症而死亡受体。
结论：犬动物模型证实肝中央区可以劈离出来作为一个独立的供肝器官,为将来拓宽供肝来源提供了另外一种思路。     

应用供者髂动脉行腹主动脉搭桥重建移植肝动脉的临床分析

目的探讨应用供者髂动脉行腹主动脉搭桥重建移植肝动脉对肝移植受者预后的影响。 方法回顾性分析中国医科大学附属第一医院2006年1月至2018年4月应用供者髂动脉行腹主动脉搭桥重建肝动脉的肝移植受者临床资料,观察其术后肝功能恢复情况及肝动脉血栓等并发症的发生情况,分析采用搭桥方式进行移植肝动脉重建的原因。 结果共纳入8例受者,其中1例存在脾动脉盗血综合征导致肝总动脉供血不足,3例肝总动脉纤细,4例肝总动脉壁薄弱或分层。重建后肝动脉平均血流为(315±178)mL/min。术后2例受者分别因肝脏流出道和胆管吻合口狭窄导致黄疸,其余受者移植肝功能恢复良好。1例受者术后2个月出现肝动脉血栓形成,继发肝脓肿,半年后因多脏器功能衰竭死亡。其余7例受者随访至2018年11月均存活,肝动脉均通畅,无狭窄或血栓形成。 结论当供、受者常规肝动脉端端吻合无法实施时,应用供者髂动脉行腹主动脉搭桥重建移植肝动脉是一种可行的肝动脉重建方法。     

In situ split liver transplantation for two adult recipients

BACKGROUND: Modifications of the in situ split liver technique are needed for safe transplantation in two adult recipients with a single donor. METHODS: The graft from a brain-dead donor, 187 cm tall and weighing 89 kg, was split in situ with a transection performed along the main portal fissure retaining the middle hepatic vein with the left graft. The right and left grafts, which weighed 985 and 760 g, respectively, were transplanted in two adult recipients weighing 70 and 56 kg, respectively. RESULTS: Both recipients had minor intraoperative blood loss and were discharged from intensive care on day 3. Both grafts were rapidly functional, and the two patients were in excellent condition with normal liver function tests 9 months after surgery. CONCLUSION: In situ split liver transplantation can be performed with the middle hepatic vein retained in the left graft to obtain a sufficient volume of the two grafts suitable for two adult recipients. This modification of the technique could expand the donor pool for adult recipients.