Auxiliary Orthotopic Liver Transplantation Research Articles

Comment on "Refining Auxiliary Orthotopic Liver Transplantation (AOLT) Improves Outcomes in Adult Patients With Acute Liver Failure".

Comment on "Refining Auxiliary Orthotopic Liver Transplantation (AOLT) Improves Outcomes in Adult Patients With Acute Liver Failure".

Refining Auxiliary Orthotopic Liver Transplantation (AOLT) Improves Outcomes in Adult Patients With Acute Liver Failure.

To investigate whether and how experience accumulation and technical refinements simultaneously implemented in auxiliary orthotopic liver transplantation (AOLT) may impact on outcomes. AOLT for acute liver failure (ALF) provides the unique chance of complete immunosuppression withdrawal after adequate native liver remnant regeneration but is a technically demanding procedure. Our department is a reference center for ALF and an early adopter of AOLT. This is a single-center retrospective before/after study of a prospectively maintained cohort of 48 patients with ALF who underwent AOLT between 1993 and 2019. In 2012, technical refinements were implemented to improve outcomes: (i) favoring the volume of the graft rather than that of the native liver, (ii) direct anastomosis of graft hepatic artery with recipient right hepatic artery instead of the use of large size vessels, (iii) end-to-side hepaticocholedocostomy instead of bilioenteric anastomosis. Early experience (1993-2011) group (n=26) and recent experience (2012-2019) group (n=22) were compared. Primary endpoint was 90-day severe morbidity rate (Clavien-Dindo≥IIIa) and secondary endpoints were overall patient survival and complete immunosuppression withdrawal rates. Compared with the earlier experience group, the recent experience group was associated with a lower severe complication rate (27% vs 65%, P <0.001), as well as less biliary (18% vs 54%, P =0.017) and arterial (0% vs 15%, P =0.115) complications. The 1-, 3-, and 5-year patient survival was significantly improved (91%, 91%, 91% vs 76%, 61%, 60%, P =0.045). The rate of complete immunosuppression withdrawal increased to 94% vs 70%, ( P =0.091) with no need of long-term graft explant. These technical refinements favoring the liver graft and reducing morbidity may promote AOLT implementation among LT centers.

Simplified technique for auxiliary orthotopic liver transplantation using a whole graft.

BackgroundAcute liver failure is associated with a high mortality rate and the main purposes of treatment are to prevent cerebral edema and infections, which often are responsible for patient death. The orthotopic liver transplantation is the gold standard treatment and improves the 1-year survival.AimTo describe an alternative technique to auxiliary liver transplant on acute liver failure.MethodWas performed whole auxiliary liver transplantation as an alternative technique for a partial auxiliary liver transplantation using a whole liver graft from a child removing the native right liver performed a right hepatectomy. The patient met the O´Grady´s criteria and the rational to indicate an auxiliary orthotopic liver transplantation was the acute classification without hemodynamic instability or renal failure in a patient with deterioration in consciousness.ResultsThe procedure improved liver function and decreased intracranial hypertension in the postoperative period.ConclusionThis technique can overcome some postoperative complications that are associated with partial grafts. As far as is known, this is the first case of auxiliary orthotopic liver transplantation in Brazil.

Emergency Subtotal Hepatectomy: A New Concept for Acetaminophen-Induced Acute Liver Failure

Acetaminophen (paracetamol) overdose (AOD) has recently emerged as the leading cause of acute liver failure (ALF) in the United States, with an incidence approaching that seen in the United Kingdom. We describe a new way to treat AOD ALF patients fulfilling King's College criteria for "super-urgent" liver transplantation. Beginning in June 1998, we have been piloting a clinical program of subtotal hepatectomy and auxiliary orthotopic liver transplantation (ALT) for AOD ALF. Our technique is based on the following principles: (1) subtotal hepatectomy; (2) auxiliary transplantation of a whole liver graft; (3) gradual withdrawal of immunosuppression after recovery. Results were compared with patients who had undergone an orthotopic liver transplantation (OLT) for AOD ALF in the same period. Quality of life comparisons were made using the SF36 questionnaire. Thirteen patients underwent this procedure between June 1998 and March 2005. Median survival is 68 months (range, 0-102 m). Actual survival data show that 9 of 13 patients are alive (69%) compared with 7 of 13 OLT patients (54%). One ALT patient required a retransplantation with an OLT due to hepatic vein thrombosis, and immunosuppression is therefore maintained. The other 8 surviving ALT patients are off immunosuppression. These 8 ALT patients have normal liver function and have a better quality of life compared with the 7 surviving OLT patients. Our results with this new technique are encouraging: 69% actual survival, no long-term immunosuppression requirement, and improved quality of life in the 62% successful cases.

EMERGENCY SUBTOTAL HEPATECTOMY - A NEW CONCEPT FOR FULMINANT HEPATIC FAILURE DUE TO TOXIC LIVER INJURY. TEMPORARY HEPATIC SUPPORT BY AUXILIARY ORTHOTOPIC LIVER TRANSPLANTATION ENABLES LONG-TERM SUCCESS.

O23* Aims: Toxic injury due to paracetamol (acetaminophen) overdose (POD) is the leading cause of fulminant hepatic failure (FHF) in the United Kingdom and despite maximal medical therapy, 5% who develop FHF require liver transplantation. We describe a new way to treat these patients. Methods: Beginning in June 1998 we have been piloting a clinical programme of subtotal hepatectomy and auxiliary orthotopic liver transplantation for toxic injury: twelve patients up to March 2004. Our technique is based on the following principles: [1] Subtotal hepatectomy to remove 70-75% of the injured liver; [2] Auxiliary transplantation of a maximal liver volume - a whole liver graft was used in all cases; [3] Gradual withdrawal of immunosuppression after recovery. Results: Eight of twelve patients are alive with seven off immunosuppression at 14-68 months. One patient has been retransplanted for vascular thrombosis and will be maintained on full immunosuppression. One patient died from lung injury within 24 hours of surgery and one died with from a brain haemorrhage after 7 days both having normalised intracranial pressure. Two patients who received grafts from “marginal” organ donors died with primary graft non-function (recurrent after retransplantation). Following immunosuppression withdrawal, native hepatic regeneration with transplant atrophy has been confirmed by isotope and CT scanning in the long-term survivors. All surviving patients have normal liver function and have returned to a normal life within a few months. Quality of life comparisons (Short form 36 version 2) showed improved results at 1 year compared to a contemporaneous group of surviving PODFHF patients (7 survivors from 13; 54% 1 year survival) who underwent standard liver transplantation. Conclusions: Our results with this new technique are encouraging: 67% actual survival, no long-term immunosuppression requirement and improved quality of life in the 58% successful cases.

Auxiliary orthotopic liver transplantation: new technique and results in toxic liver injury

Auxiliary orthotopic liver transplantation: new technique and results in toxic liver injury

Auxiliary heterotopic liver transplantation with portal vein arterialization for fulminant hepatic failure

Auxiliary liver transplantation for patients with fulminant hepatic failure supports the patient's failing liver for a period of time until the native liver (NL) has recovered and immunosuppression can be withdrawn. Auxiliary heterotopic liver transplantation (AHLT) with portal vein arterialization (PVA) has several advantages over auxiliary orthotopic liver transplantation: NL resection is not required, and the hepatic hilum is left untouched; thus, the chances of liver regeneration are optimal. The successful application of emergency AHLT with PVA in a young patient who developed toxic fulminant hepatic failure caused by tuberculostatic drugs is described. Two and one-half months after the procedure, the NL had completely regenerated; the graft was removed, and immunosuppression was suspended.

Combined liver and kidney transplantation against a positive cross match in a patient with multispecific HLA-antibodies

Combined kidney and auxiliary orthotopic liver transplantation from the same donor is used to treat highly sensitized renal transplant recipients. Auxiliary liver can protect the transplanted kidney against hyperacute rejection.In the current case, combined kidney and splenic fossa auxiliary heterotopic liver transplantation was performed from the same donor for a highly sensitized recipient without preoperative preconditioning. No postoperative hyperacute rejection occurred.Seven days after surgery, preexisting antibody levels rose and decreased after treatment; meanwhile, the function of transplanted kidney returned to normal. During 24 months of follow-up, the grafts showed good blood perfusion and functioned well. The levels of preexisting antibodies, donor-specific antibodies (DSA) and C1q-fixing human leukocyte antigen (C1q-HLA) antibodies, all decreased.Combined kidney and splenic fossa auxiliary heterotopic liver transplantation can be used in renal transplantation for highly sensitized recipients.

Long-term follow-up of auxiliary orthotopic liver transplantation for the treatment of fulminant hepatic failure

Background . Auxiliary orthotopic liver transplantation (AOLT) was investigated as a bridge to native liver recovery in patients with fulminant hepatic failure (FHF). Methods . In the last 5 years seven patients with FHF were treated with AOLT at our institution. Five patients underwent resection of the native left lobe and orthotopic replacement with a donor left lobe (n = 3) or left lateral segment (n = 2). Two patients underwent left trisegmentectomy and whole liver auxiliary grafting. Conventional immunosuppression was used in all patients. Results . One patient had poor initial graft function and required retransplantation. Native liver function returned to normal in the six other patients. Immunosuppression was gradually tapered and completely discontinued in three patients, allowing for atrophy of the allograft. The allograft was removed in the other four patients. Despite evidence of native liver regeneration, two patients with aplastic anemia died after allograft removal. Four patients are alive at a mean follow-up of 3.5 years. Conclusions . AOLT is technically feasible, rapidly restores liver function, and should be considered an important alternative to standard orthotopic liver transplantation (OLT) in the treatment of FHF. AOLT has the advantage that patients transplanted for FHF are not committed to lifelong immunosuppression with its attendant risks.

Auxiary Liver Transplantation For Fulminant And Subfulminant Hepatic Failure

We report the first series of 9 auxiliary liver transplantations performed as a bridge to recovery in 8 patients with fulminant and subfulminant hepatic failure. Hepatic failure was due to hepatitis A virus (n = 3), hepatitis B virus (n = 1), hepatotoxic drugs (n = 2), autoimmune disease (n = 1), or it was of unknown origin (n = 1). The donor liver was reduced to a left lobe (n = 2), a left liver (n = 4), or a right liver (n = 3), and was implanted in an orthotopic position beside the native liver after it was resected by a left or a right hepatectomy. Conventional immunosuppression was used to prevent rejection. Six patients regained normal consciousness within 2 weeks, without any sequelae. Two patients had persisting encephalopathy due to graft initial dysfunction, one of whom showed portal vein thrombosis, which was successfully cleared. The other one showed hepatic vein stenosis and was retransplanted at day 15. Five of eight patients had to be reoperated because of a surgical complication. Five patients showed rapid regeneration of their native liver, but one died at day 45 from severe herpes virus broncholitis. The auxiliary grafts were removed (n = 3) or left to atrophy by tapering immunosuppression (n = 1). One patient developed cirrhosis of the native liver and died of infectious complications at day 42. The native livers of the two remaining patients are still atrophic, one at 4 months and one at 1 month posttransplant. Finally, 6 of 8 patients are alive with a follow-up of 1 to 17 months. Four of them have permanently stopped their immunosuppressive therapy. Our experience demonstrates that auxiliary orthotopic liver transplantation (1) is feasible in children and adults, using either a left or a right liver graft, (2) is efficient in providing adequate liver function, and (3) gives a real chance to the native liver to regenerate, offering these patients a future free of immunosuppression.