Surgical aspects of choledochal cyst in children and adults: an experience of 106 cases.

PURPOSE: To describe clinical features of choledochal cyst (CC) patients in terms of demographic data, clinical presentation, investigations, treatment, and outcomes among children and adults. METHODS: The medical records of patients undergoing choledochal cyst (CC) surgery from 2002 to 2021 at a university hospital were retrospectively reviewed. The patients were divided into two groups: children (< 15 years) and adults (≥ 15 years). Descriptive statistics were used. RESULTS: There were 106 cases of CC (Female/male = 88/18, children/adult = 53/53). Abdominal pain was the predominant presenting symptom, followed by jaundice in both groups. Adults were significantly more prone to present with abdominal pain compared to children (86.8% vs. 52.8%; p < 0.001), while children were more likely to experience acholic stool than adults (22.6% vs. 3.8%; p = 0.004). Ultrasound was the preferred investigation screening modality (75.5%). Most patients were presented with type I CC (71.7%). Laparoscopic-assisted approach was performed in 8.5%. CC excision with roux-en-y hepatico-jejunostomy was the main procedure (88.7%). Adults had a higher incidence of post-op complications, including stones, anastomosis stricture, abdominal collection, and cholangitis. Adults were significantly more likely to require intervention after surgery, compared to children (26.4% vs. 5.7%; p = 0.04). CONCLUSIONS: Ultrasound was the most common screening tool for diagnosis. Postoperatively, adults with CC experience more serious post-op complications compared to children. This could be attributed to long-standing cystic inflammation. Therefore, prompt definitive surgery is recommended for CC patients.

Cirrhotic and non-cirrhotic huge hepatocellular carcinoma (≥ 10 cm): a comparative study of surgical management and follow-up treatment in a single institution.

PURPOSE: Liver resection (LR) of huge hepatocellular carcinoma (HCC) has increasingly been regarded as a viable option of enhanced efficacy for patients, but most studies have focused on comparing various tumor sizes and the outcomes of surgery. The study aim was to evaluate the clinicopathologic characteristics and surgical outcomes of huge HCC with and without cirrhosis that underwent LR, and to delineate the treatment for recurrence. METHODS: Sixty-three patients with huge HCC who underwent hepatectomy from 2010 to 2019 were enrolled and reviewed. Clinicopathological findings, surgical outcomes of the entire cohort, and differences between the cirrhotic and non-cirrhotic groups were analyzed. RESULTS: Forty patients (60.3%) had huge HCC with cirrhosis. Clinicopathological findings were not different between the two groups, except tumor size ≥ 15 cm (40% in cirrhosis vs 17.4% in non-cirrhosis, p = 0.024) and major portal vein tumor thrombus were detected only in the cirrhosis group (11 patients, p = 0.006). Extended LR was performed in 13 cirrhotic patients (32.5%) and in 1 non-cirrhotic patient (4.4%) (p = 0.010). Operative data, postoperative complications including postoperative liver failure, and pattern of recurrence were not different between the two groups. For the entire cohort, mortality rate was 1.5%. The 1-, 3-, and 5-year overall survival rates (OS) were 81%, 54%, and 39%. Multivariate analysis showed resection margin ≥ 0.1 cm was a good prognostic factor for OS (HR 0.247 (p = 0.017)). For tumor recurrence, local ablative treatment for liver recurrence and resection for lung recurrence provided good long-term outcomes. CONCLUSION: Although huge HCC with cirrhosis has been a more unfavorable tumor, LR still provided long-term survival with acceptable risk morbidity and mortality.

B-cell activating factor, a predictor of antibody mediated rejection in kidney transplantation recipients.

AIM: Donor-specific antibody (DSA) is a widely-used biomarker for antibody-mediated rejection (ABMR) but correctly indicates only 30-40% of patients with ABMR. Additional biomarkers of ABMR in kidney transplant recipients are needed. METHODS: All 68 kidney transplanted-recipients enrolled in this study were negative for graft rejection as determined by surveillance-biopsy ELISA at day 7 post-transplantation. Allograft biopsy was then performed at 6 months post-transplantation for subclinical-ABMR detection. Recipients were stratified by pre-transplant DSA and BAFF at day 7 into four groups. RESULTS: During the study period, 13.2% of the recipients demonstrated subclinical-ABMR at 6 months, without patient with clinical ABMR presentations. Overall mean BAFF at day 7 was 393 pg/mL (95% CI = 316-471 pg/mL). The optimal cut-off value for low vs. high BAFF level was 573 pg/mL, with sensitivity and specificity at 77.8% and 88.1%, respectively. Fifty percent of recipients with high BAFF at day 7 (14 patients) and only 3.7% of patients with low BAFF demonstrated ABMR (P < 0.05). Indeed, ABMR was more common in patients high BAFF level (hazard ratio = 7.30; 95% CI = 3.77-14.15). The prevalence of ABMR among negative pre-transplant DSA/low BAFF, positive DSA/low BAFF, negative DSA/high BAFF, and positive DSA/ high BAFF recipients were 4.4, 0, 37.5 and 66.7%, respectively (P < 0.05). CONCLUSIONS: Post-transplant ABMR can be predicted by perioperative serum BAFF level. Together with DSA testing, BAFF provides additional predictive value for ABMR.

Improving the Surgical Outcomes after Liver Resection with ERAS Program.

Background: Enhanced recovery after surgery (ERAS) has been accepted as the program to improve the surgical outcomes. This program has been increasingly utilized in liver resection. Objective: To evaluate the outcomes of patients underwent liver resection by applying ERAS program. Material and Method: All patients underwent liver resection between January 2007 and April 2011 at King Chulalongkorn Memorial Hospital were included into the present study. Patients' characteristics, preoperative factors, operative data, postoperative care that correlated to ERAS components, and postoperative outcomes were recorded. Outcomes including postoperative length of stay (LOS), intensive care unit (ICU) stay, complications, rate of reoperation, interventional treatment, and mortality were compared between patients in ERAS group (applied ERAS components >4) and conventional group (applied ERAS components <4). Results: Three hundred forty seven patients were enrolled in present the study. There were 165 and 182 patients in ERAS and conventional groups, respectively. When compared between these two groups, ERAS group had better postoperative LOS (7 days vs. 10 days; p = 0.0001), ICU stay (0 days vs. 1 days; p = 0.0001), reoperation rate (1.2% vs. 4.9%; p = 0.047) and reintervention rate (15% vs. 27%; p = 0.005). There were no significant differences in complication rate (31% vs. 40%; p = 0.096) and mortality rate (0.6% vs. 1.1%; p = 0.62). Conclusion: ERAS program improves the surgical outcomes in patients who underwent liver resection.

Orthotopic liver transplantation at King Chulalongkorn Memorial Hospital: a report.

Orthotopic liver transplantation (LT) is the treatment of choice for various liver diseases including early hepatocellular carcinoma (HCC). After the first successful LT in Thailand at King Chulalongkorn Memorial Hospital (KCMH) in 1987, the number of LT has gradually been increasing in parallel with the improvement in patient survival. The recent outcomes of LT are reported herein. From January 1, 2002 to June 30, 2013, 120 cases of adult LT and 24 cases of pediatric LT were performed. The most common indication for LT was HCC in the adult whereas biliary atresia was the most common indication for LT in pediatric patients. As for the severity of liver disease, the average model of end stage liver disease (MELD) and pediatric end stage liver disease (PELD) scores were 19 in adult LT and 21.5 in pediatric LT respectively. The most common perioperative complication in adult LT was acute renal failure (25%). One-, five-year patient survival in adult LT and pediatric LT were 85%, 69% and 96%, 91%, respectively. In conclusion, the outcomes of LT at KCMH have gradually been improving close to the world standard, especially the patient survival.

Comparison of Three Inferior Vena Cava Reconstruction Techniques in Adult Orthotopic Liver Transplantation: Result From King Chulalongkorn Memorial Hospital, Thailand.

BACKGROUND: In orthotopic liver transplantation (OLT), 3 caval reconstruction techniques are being performed worldwide. These are conventional, piggyback technique, and side-to-side cavocaval anastomosis (CCA). Each has its own advantages and drawbacks. Herein we report the result from our hospital comparing the 3 techniques. METHODS: We retrospectively reviewed the detail of OLT performed from January 2008 to March 2020. Data being collected included type of caval reconstruction, blood loss, operative time, ischemic time, length of stay in the intensive care unit (ICU) and total hospital stay, and several postoperative complications. RESULTS: In the given period, 11 conventional, 90 piggyback, and 113 CCA caval reconstruction were done. There were no statistically significant differences in blood loss, operative time, cold ischemic time, and length of ICU and hospital stay. The CCA group had the lowest warm ischemic time (40 minutes) followed by the piggyback technique (43 minutes) and the conventional technique (47 minutes; P < .001). Regarding postoperative complications, there were no statistically significant differences in rate of primary nonfunction, early allograft dysfunction, hepatic artery/portal vein/biliary complication, or rate of acute kidney injury. The hepatic venous outflow complication rate was indifferent between 3 groups. CONCLUSIONS: The present study showed no difference in outflow obstruction rate among the 3 techniques. The choice for reconstruction should rely on the preference of each institute and the suitability of each patient. The CCA technique may provide the lowest warm ischemic time.

Immunogenicity, Immune Dynamics, and Subsequent Response to the Booster Dose of Heterologous versus Homologous Prime-Boost Regimens with Adenoviral Vector and mRNA SARS-CoV-2 Vaccine among Liver Transplant Recipients: A Prospective Study.

Background: Heterologous prime-boost vaccination potentially augments the immune response against SARS-CoV-2 in liver transplant (LT) recipients. We investigated immunogenicity induced by different primary prime-boost vaccination protocols and the subsequent response to the booster vaccine among LT recipients. Methods: LT recipients, who received primary immunisation with ChAdOx1/ChAdOx1 or ChAdOx1/BNT162b2, were administered the third dose of mRNA-1273 three months following the primary vaccination. Blood samples were collected before and after primary vaccination and post-booster. The levels of receptor binding domain antibody (anti-RBD) and neutralising antibody (sVNT) and spike-specific T-cell responses were assessed. Results: Among the 89 LT recipients, patients receiving ChAdOx1/BNT162b2 had significantly higher anti-RBD titres, sVNT, and cellular response after primary vaccination than those receiving ChAdOx1/ChAdOx1 (p < 0.05). The antibody response decreased 12 weeks after the primary vaccination. After the booster, humoral and cellular responses significantly improved, with comparable seroconversion rates between the heterologous and homologous groups. Positive sVNT against the wild type occurred in >90% of LT patients, with only 12.3% positive against the Omicron variant. Conclusions: ChAdOx1/BNT162b2 evoked a significantly higher immunological response than ChAdOx1/ChAdOx1 in LT recipients. The booster strategy substantially induced robust immunity against wild type in most patients but was less effective against the Omicron strain.

Partial segments 4/5 liver resection facilitates the repair of complicated bile duct injuries: a technical challenge and long-term outcomes.

Adequate exposure with optimal anteroposterior view of the hilar plate is challenging and crucial in a surgical repair of complicated hilar bile duct injuries. A high-quality anastomosis depends on the ability to identify non-scarred, non-inflamed, non-ischemic bile ducts. This study provides operative details of the Partial Segments 4/5 Liver Resection with a Roux-en-Y hepaticojejunostomy (PS4/5LRHJ) and presents its long-term outcomes. 36 patients with the Strasberg type E bile duct injuries (BDIs) who underwent the PS4/5LRHJ from 2003 to 2019 were retrospectively reviewed. Outcomes of the surgical treatments were analyzed. The mean age of the patients was 46.3 years. 22 patients underwent BDI repair as index operations and 14 patients as re-repair operations. Operative times between the index operation group and the re-repair group (396.6 min vs 391.3 min, respectively, p = 0.876) and blood loss (590.6 ml vs 640 ml, respectively, p = 0.587) were not statistically different. The mean length of hospital stay was 23 days. The median follow-up duration was 73 months. Major complications developed in 10 patients (27.8%), of which intra-abdominal collection was the most common (eight patients, 22.2%). Anastomotic stricture developed in one patient (2.8%). The mortality rate was zero. The overall 10-year patency rate was 95.2%. PS4/5LRHJ offered long-term patency with acceptable morbidity in the hilar bile duct injuries and re-repair operations.

The first report of kidney transplantation in a human immunodeficiency virus-positive recipient in Thailand and literature review: Encouragement for developing countries in Southeast Asia.

Patients with human immunodeficiency virus infection are at risk of chronic kidney disease and end-stage renal disease. Human immunodeficiency virus infection impedes patients' accessibility to transplantation in Thailand and other developing countries in Southeast Asia, where the burdens of human immunodeficiency virus infection and chronic kidney disease are rapidly increasing. We report the successful kidney transplantation in a human immunodeficiency virus-positive recipient in Thailand and provide brief information about the current knowledge of human immunodeficiency virus medicine and transplantation that are needed for conducting kidney transplantations in such patients. Patient selection and evaluation, the choice of antiretroviral therapy, immunosuppressive regimens, and infectious complications are reviewed and discussed. The aim is to encourage kidney transplantation in end-stage renal disease patients with well-controlled human immunodeficiency virus infection, especially in countries where the prevalence of human immunodeficiency virus infection is high and the accessibility to transplantation is still limited.

Benefits of simultaneous laparoscopic colorectal surgery and liver resection for colorectal cancer with synchronous liver metastases: Retrospective case-matched study.

INTRODUCTION: Laparoscopic surgery for colorectal cancer and liver tumors are accepted as alternative procedure to open surgery. However, few studies reported outcomes of simultaneous laparoscopic surgery of these two procedures. The aim of this study was to compare short-term outcomes between laparoscopic and open approach. MATERIALS AND METHODS: Between June 2010 to December 2019, simultaneous laparoscopic cases were retrospectively matched (1:2) to open cases. Peri-operative and short-term outcomes were compared between both groups. RESULTS: Twelve patients in laparoscopic group were matched to 24 patients in open group according to age, gender, body mass index, american society of anesthesiologists physical status, preoperative laboratory data, number and size of liver metastases and extent of colorectal and liver resection, Most patients in each group had left-sided colon or rectal cancer and underwent wedge liver resection. The mean number of liver metastases was 1.3 vs 1.5 and size of liver metastases was 2.2 ± 1.4 vs 2.7 ± 1.1 cm in laparoscopic compared to open group. Estimated blood loss and length of hospital stay were significantly lower in laparoscopic group. However, operative time was significantly longer in laparoscopic group. Peri-operative complication was not significant difference between both groups and there was no mortality. CONCLUSION: Simultaneous laparoscopic colorectal surgery and minor liver resection is feasible and safe. Laparoscopic approach has better peri-operative outcome in term of shorter length of hospital stay compared to open approach.

Combination of Euro-Collins and University of Wisconsin Solution: An Effective and Economic Substitute for Organ Procurement.

PURPOSE: Many types of preservation fluid were used in liver procurement. Undoubtedly, the gold standard is the University of Wisconsin (UW) solution. But the solution is expensive. The aim of this study was to evaluate the results of combined acetated Ringer solution, Euro-Collins solution, and UW solution. MATERIALS AND METHODS: All patients undergoing adult liver transplantation from cadaveric donor during January 2013 to December 2017 in King Chulalongkorn Memorial Hospital were included in this study. Donor and recipient characteristics, preservation fluid, operative data, and postoperative outcomes were recorded. RESULTS: A total of 102 patients receiving liver transplants were enrolled into the study. The mean age of donors was 34.2 years. The mean total ischemic time was 420.93 minutes. In recipients, posttransplantation complications were the following: (1) primary nonfunction in 1 patient (0.98%); (2) early allograft dysfunction in 23 patients (22.5%); (3) hepatic artery thrombosis in 3 patients (2.7%); (4) hepatic venous outflow obstruction in 2 patients (1.96%); (5) biliary leakage in 1 patient (0.98%); (6) biliary anastomosis stenosis in 4 patients (3.92%); and (7) biliary nonanastomosis stenosis in 1 patient (0.98%). No inhospital mortality was occurred. Overall mortality rate is 7.8% (8/102). One-, 3-, and 5-year survival were 95.9%, 91.5%, and 88.4%, respectively. CONCLUSIONS: The combination of acetated Ringer solution, Euro-Collins solution, and UW solution is effective and economic for liver preservation. Further study should be conducted.

Partial segment-IV/V liver resection facilitates the repair of complicated bile duct injury.

The ability to perform a technically perfect anastomosis remains the key to success in bile duct repair. This report describes our technique in facilitating the performance of a good surgical anastomosis for difficult bile duct repair. In the present study are presented 3 cases of bile duct repair for a Strasberg type-E3 stricture, a Strasberg type-E4 fistula and an anastomotic stricture of a previously performed choledochojejunostomy for the correction of bile duct injury. The approach was to perform partial resection of the lower part of segments IV and V. The hepatoduodenal ligament was not dissected. The anterior surface of the bile duct was utilized to perform Roux-en-Y hepaticojejunostomy. Operative times ranged from 4 to 5 hours, and Pringle times 15 to 25 minutes. There was no vascular injury. We were able to perform wide anastomoses, facilitated by excellent exposure of the hilar plate. There was no any complication. Partial resection of the hepatic segments IV-V provides excellent exposure of the hilar plate. The risk of vascular injury was minimized by avoiding dissection of the hepatoduodenal ligament. It is believe this technique may offer a superior approach to difficult repair of complicated bile duct injury.

Role of portal vein embolization in hepatobiliary malignancy.

BACKGROUND/AIMS: Inadequate remnant liver volume is the major cause of postoperative liver failure. Preoperative portal vein embolization (PVE) is the well accepted procedure to increase future liver remnant (FLR) volume and decrease the incidence of this complication. This study described the author's experience of preoperative PVE at King Chulalongkorn Memorial Hospital since 2002. METHODOLOGY: The clinical data of 29 patients who underwent PVE were reviewed. The FLR volumes before and after the procedure were calculated by CT volumetry. PVE was performed when estimated FLR volume was < 25% in normal liver or < 40% in damaged liver and also when major liver resection combined with major intraabdominal surgery was planned. The complications after PVE and hepatectomy were recorded. RESULTS: There were no deaths or complications after PVE. The mean growth of FLR was 11%. Power of liver regeneration was suboptimal in old age patients. Sixteen patients underwent liver resection (resectability rate 55.17%). There were 2 cases of postoperative hyperbilirubinemia (12.5%). The hospital mortality rate was 1/16 (6.25%). CONCLUSIONS: PVE is a useful and safe optional procedure to increase FLR. It not only reduces the postoperative liver failure but also increases the chance of curative resection.

Acute mesenteric ischemia: still high mortality rate in the era of 24-hour availability of angiography.

BACKGROUND: Acute mesenteric ischemia (AMI) is a serious condition with high mortality rate due to difficult and late diagnosis. Early and aggressive evaluation in high risk patients by mesenteric angiography is the key to the reduction in mortality rate. However; many physicians hesitated to perform it because of its availability, the risk of complications and high negative results. This study reviewed outcome of AMI in term of mortality rate, factors associated with mortality and the rate of angiography in high risk patients. MATERIAL AND METHOD: The clinical data of the patients who were diagnosed as AMI were retrospectively reviewed. The clinical outcome was recorded and the factors associated with mortality were analysed. RESULTS: Thirty-five patients were enrolled into this study during 5 years. The mortality rate was 74.3%. There were 22 high risk patients for AMI. The rate of angiography performed in this group was 4.5% (1/22). The factors associated with mortality were age more than 60 years, patients with peritonitis, hypotension, arterial cause, time interval between admission and operation or treatment more than 24 hours, bowel gangrene >100 cms. However all these factors were not statistically significant. CONCLUSION: The mortality rate of AMI is still high even at the tertiary hospital where the angiography is available 24 hours. To decrease the mortality rate, the physicians must have the high index of suspicion in high risk patients and do not hesitate to perform early mesenteric angiography.

Risk factors associated with major intraoperative blood loss in hepatic resection for hepatobiliary tumor.

BACKGROUND AND PURPOSE: Hepatic resection is the mainstay treatment of hepatobiliary tumor Nowadays, mortality is less than 6%. However, morbidity is still high. Bleeding is one of the most common problems during hepatic resection which can sometimes lead to catastrophe. The purpose of the present study was to investigate the risk factors associated with major blood loss during hepatic resection for hepatobiliary tumor. MATERIAL AND METHOD: A total of 69 consecutive patients who underwent elective hepatic resection for hepatobiliary tumor from May 2002 to April 2004 were enrolled into this retrospective study. The Patients were divided into 2 groups(group I and II) according to the intraoperative blood loss. Patients who had a blood loss of more than 1000 ml were defined as the major blood loss group(group I). Thirteen variable factors were analyzed to determine the risk of major intraoperative blood loss. Operative outcomes between the two groups were also compared. RESULTS: Of the sixty-nine patients, 36 patients were in group I and 33 patients were in group II. 75% of the patients in group I and 36.4% of the patients in group II were transfused. Median blood transfusion in group I and II were 3 and 0 units of packed red cell. Univariate analysis showed tumor size, extent of hepatic resection, tumor pathology and operative time were factors affecting major intraoperative blood loss. However, multivariate analysis showed only operative time and tumor size to be independent risk factors. Patients in group I had higher surgical morbidity and prolonged hospital stay compared with patients in group II. CONCLUSION: Blood loss is still a major concern in performing hepatic resection. From the present study, tumor size and operative time are the independent factors affecting major intraoperative blood loss. Proper screening or a surveillance program may enhance the chance to find small tumors. Refined operative techniques such as anterior approach and liver hanging would facilitate resection for large right sided tumors.

Preoperative portal vein embolization in hepatobiliary tract malignancy: an experience at King Chulalongkorn Memorial Hospital.

BACKGROUND: Major hepatic resections are increasingly performed for both primary and secondary liver cancers nowadays. However, morbidity from these operations is still high. One of the dreadful complications, sometimes lead to fatality, is postoperative liver failure. There are many factors which are associated with this complication such as chronic liver disease, low residual liver volume after resection. Portal vein embolization (PVE) is the procedure which increases the liver volume of the non-embolized lobe. Now, PVE has gained acceptance in many centers to overcome or reduce this complication. This report described the authors' experiences of PVE since 2001 at King Chulalongkorn Memorial Hospital. MATERIAL AND METHOD: The records of 10 patients who had PVE were reviewed CT volumetry of the liver was done before and after procedure. The authors calculated future liver remnant from CT volumetry and compared this volume to standard liver volume. The postoperative complications and hospital courses of these patients were also recorded. RESULTS: Mean growth of future liver remnant (FLR) ratio after PVE was 13.7 +/- 6.2% (median 13, range 4-25). There was no major complication after PVE. Six patients underwent liver resection and there was no major complication or mortality. No one had persistent hyperbilirubinemia 2 weeks after operation. CONCLUSION: The PVE is the useful and safe optional procedure to increase future liver remnant volume. It not only reduces the postoperative liver failure but increases the chance for curative resection.

Minimally invasive surgery training in soft cadaver (MIST-SC).

OBJECTIVES: The purpose of this study was to evaluate the surgical anatomy, tissue plane, organ consistency of soft cadaver and the possibility of minimally invasive surgery training in soft cadaver. SETTING: Surgical Training Center. Department of Anatomy and Department of Surgery Faculty of Medicine, Chulalongkorn University. DESIGN: Prospective descriptive study. MATERIAL AND METHOD: 2 soft cadavers were scheduled for fully laparoscopic surgery in upper gastrointestinal, colorectal, hepatopancreatobiliary and solid organs surgery. All the procedures were performed by the experienced surgical staffs and assisted by surgical staffs and/or surgical residents. The surgical anatomy, tissue plane, organ consistency and the satisfactory in performing the procedures were recorded for evaluation. RESULTS: The surgical anatomy, the tissue consistency the anatomical plane were very well preserved with mean score of 4.72 +/- 0.45. All the surgeons were satisfied with the findings, the mean score was 4.97 +/- 0.18. All the plan procedures were completely performed with great satisfactory results. CONCLUSION: The Minimally Invasive Surgery Training in Soft Cadaver (MIST-SC) was feasible with great satisfactory. This successful integration of basic and advanced laparoscopic procedures into the soft cadaver setting would be the next step in evolution of MIS training.

Longterm outcomes for whole and segmental liver grafts in adult and pediatric liver transplant recipients: a 10-year comparative analysis of 2,988 cases.

BACKGROUND: Data on longterm outcomes after liver transplantation with partial grafts are limited. We compared 10-year outcomes for liver transplant patients who received whole grafts (WLT), split grafts from deceased donors (SLT), and partial grafts from living donors (LDLT). STUDY DESIGN: We conducted a single-center analysis of 2,988 liver transplantations performed between August 1993 and May 2006 with median followup of 5 years. Graft types included 2,717 whole-liver, 181 split-liver, and 90 living-donor partial livers. Split-liver grafts included 109 left lateral and 72 extended right partial livers. Living-donor grafts included 49 left lateral and 41 right partial livers. RESULTS: The 10-year patient survivals for WLT, SLT, and LDLT were 72%, 69%, and 83%, respectively (p=0.11), and those for graft survival were 62%, 55%, and 65%, respectively (p=0.088). There were differences in outcomes between adults and children when compared separately by graft types. In adults, 10-year patient survival was significantly lower for split extended right liver graft compared with adult whole liver and living-donor right liver graft (57% versus 72% versus 75%, respectively, p=0.03). Graft survival for adults was similar for all graft types. Retransplantation, recipient age older than 60 years, donor age older than 45 years, split extended right liver graft, and cold ischemia time>10 hours were predictors of diminished patient survival outcomes. In children, the 10-year patient and graft survivals were similar for all graft types. CONCLUSIONS: Longterm graft survival rates in both adults and children for segmental grafts from deceased and living donors are comparable with those in whole organ liver transplantation. In adults, patient survival was lower for split compared with whole grafts when used in retransplantations and in critically ill recipients. Split graft-to-recipient matching is crucial for optimal organ allocation and best use of a scarce and precious resource.