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Background: When splitting a liver for adult and pediatric graft recipients, the retained left medial section (S4) will undergo isch emic necrosis and the right trisection graft becomes an extended right liver (ERL) graft. We investigated the fates of the retained S4 and its prognostic impact in adult split liver transplantation (SLT) using an ERL graft. Methods: This was a retrospective analysis of 25 adult SLT recipients who received split ERL grafts. Results: The mean model for end-stage liver disease (MELD) score was 27.3±10.9 and graft-recipient weight ratio (GRWR) was 1.98±0.44. The mean donor age was 26.5±7.7 years. The split ERL graft weight was 1,181.5±252.8 g, which resulted in a mean GRWR of 1.98±0.44. Computed tomography of the retained S4 parenchyma revealed small ischemic necrosis in 16 patients (64%) and large ischemic necrosis in the remaining nine patients (36%). No S4-associated biliary complications were developed. The peak liver enzyme levels were higher in the large S4 ischemic necrosis group (P≤0.002). The mean GRWR was 1.87±0.43 in the nine patients with large ischemic necrosis and 2.10±0.44 in the 15 cases with small ischemic necrosis (P=0.28). The retained S4 parenchyma showed gradual atrophy on follow-up imaging studies. The amount of S4 ischemic necrosis was not associated with graft (P=0.59) or patient (P=0.24) survival. A MELD score >30 and pretransplant ventilator support were associated with in ferior outcomes. Conclusions: The amount of ischemic necrosis of the retained S4 parenchyma is not a negative prognostic indicator in adult SLT recipients, likely due to sufficiently large GRWR. However, a high MELD score (>30) and pretransplant ventilator support are closely associated with inferior outcomes in these cases. Therefore, careful selection of donors and recipients is essential to im prove the outcomes of adult SLT.

Background: A cryopreserved iliac artery homograft (IAH) has not been considered suitable for middle hepatic vein (MHV) re construction during living donor liver transplantation (LDLT), primarily due to the low patency from its small diameter. We revised our surgical techniques for MHV reconstruction using an IAH to improve its patency. Methods: This study analyzed the causes of early conduit occlusion and developed revised techniques to address this that had clinical application. Results: The potential risk factors for early conduit occlusion were the small IAH size, small graft V5/V8 opening, and small recipient MHV-left hepatic vein stump. These factors were reflected to our revised surgical methods which included endarter ectomy of the atherosclerotic plaque, unification of the internal and external iliac artery branches for large V5, and branch-patch arterioplasty for large V8. IAH endarterectomy was applied to eight patients and resulted in a 1-month occlusion rate of 37.5%. Branch unification technique was applied to five patients and a 1-month occlusion rate of 20.0% was obtained. Branch-patch arterioplasty was applied to five patients leading to a 1-month occlusion rate of 40.0%. The overall patency rates of the IAH-MHV conduits in our 18 patients were 66.7% at 1 month, 38.9% at 3 months, and 33.3% at 1 year. Conclusions: Our refined MHV reconstruction using an IAH improved short-term MHV conduit patency, but did not effectively prevent early conduit occlusion, particularly with a small- or medium-sized IAH. Individualized reconstruction designs during LDLT operation are needed when an IAH is used for a modified right liver graft.