Auxiliary Partial Liver Transplantation Research Articles

INTRAOPERATIVE HEMODYNAMICS IN LIVER TRANSPLANTATION COMPARING ORTHOTOPIC WITH HETEROTOPIC TRANSPLANTATION IN THE PIG

The intraoperative hemodynamic changes and several graft function parameters were studied comparing orthotopic liver transplantation with auxiliary partial liver transplantation (APLT) in the pig. Thirty-one Yorkshire pigs (ca. 25 kg b.w.) were randomly allocated to OLT (n = 16) or APLT (n = 15). During the construction of portal anastomosis the median cardiac output dropped to 67% of the initial value in OLT and to 49% in APLT (P less than 0.02). Median duration of the portal flow interruption was shorter in APLT: 15 min versus 48 min in OLT (P less than 0.002). After unclamping of the aorta, the median systolic blood pressure dropped to 75 mmHg in OLT and to 90 mmHg in APLT (P less than 0.02). APLT is less time-consuming: median duration of transplantation was 128 min versus 165 min in OLT (P less than 0.002). SGOT levels were lower in APLT than in OLT (median SGOT on the first postoperative day 67 was IU/L versus 177 IU/L, P less than 0.002). It is concluded that APLT is a shorter procedure than OLT with a shorter portal flow interruption, being less offensive to the recipient.

Auxiliary partial liver transplantation: imaging evaluation in 10 patients.

Auxiliary partial liver transplantation involves placement of a heterotopic graft in the subhepatic space, with the liver of the recipient left unaltered. We studied the values of three imaging procedures (Doppler sonography, diisopropyl iminodiacetic acid [DISIDA] scintigraphy, and cholangiography) to evaluate the transplant and the native liver after surgery in 10 patients. Special attention was paid to the Doppler waveform of the hepatic artery of the graft and to the resistive index. An increase of the index above 0.80 was not specific for, but was always associated with graft dysfunction (rejection, primary nonfunction, multiple organ failure, or portal vein thrombosis). DISIDA scintigraphy also lacked specificity and was of limited value in the detection of postoperative complications. It proved useful in routine imaging to monitor atrophy of the native liver and hypertrophy of the transplant. Cholangiography was useful for visualization of the biliary tree. Our experience suggests that these three noninvasive imaging procedures are sufficient for the proper postoperative evaluation of patients after auxiliary partial liver transplantation.

Role of fibrinolysis during auxiliary partial liver transplantation

Role of fibrinolysis during auxiliary partial liver transplantation

Auxiliary Partial Liver Transplantation for End-Stage Chronic Liver Disease

Auxiliary heterotopic liver transplantation is theoretically attractive because it leaves the recipient's liver in place. The surgical trauma of hepatectomy is avoided, and failure of the graft does not necessarily lead to the death of the patient or a second, emergency transplantation. Another advantage is that matching the body sizes of the donor and the recipient is not mandatory, which increases the number of possible donors. However, previous clinical results of auxiliary liver transplantation have been poor. We performed auxiliary partial liver transplantation in six consecutive patients with end-stage chronic liver disease who were not accepted for orthotopic liver transplantation because they had massive ascites, deficient clotting function, cachexia, or poor pulmonary reserve. The donor liver was transplanted to the right subhepatic region after removal of segments II and III, and it was provided with portal and arterial blood. There were no major changes in hemodynamic measurements during surgery. The mean hospital stay after transplantation was 22.7 days (range, 14 to 29). After a mean follow-up period of 14 months (range, 5 to 23), all patients were alive, with good graft function as demonstrated by scintigraphy, Doppler ultrasonography, and synthesis of clotting factors. From these observations we conclude that auxiliary partial liver transplantation is an attractive alternative to orthotopic liver transplantation in high-risk patients. Its role in other patients who need liver transplants remains to be defined.

Coagulation and fibrinolysis in the first human auxiliary partial liver transplantation in rotterdam

Coagulation and fibrinolysis parameters were extensively monitored during and after a case of auxiliary partial liver transplantation (APLT). Preoperative coagulation tests demonstrated a severe liver dysfunction. Routine coagulation tests were prolonged and low levels of fibrinogen, antithrombin III (AT-III), and ( α 2-antiplasmin ( α 2-AP) were measured. Pro-urokinase (pro-UK), total Uk-antigen and plasminogen activator inhibitor (PAI) activity were increased (6.2; 5.4 ng/ml and 12.5 IU/ml, respectively). During transplantation no major changes in haemostasis were detected by either standard coagulation tests or thrombelastography and only a minimal increase of fibrinogen degradation products (0.6–1.0 μg/ml) was seen just before graft recirculation up till the end of the operation. PAI levels remained high during the operation and neither tissue-type plasminogen activator (t-PA) nor active urokinase (u-PA) were detectable. After APLT, graft function was reflected by normalisation of coagulation parameters and increase of AT-III and α 2-AP to normal levels. Pro-Uk and PAI activity levels decreased after transplantation to normal values; a transient increase of t-PA activity (max. 1360 mIU/ml) was seen from the tenth to nineteenth day. It was demonstrated that a heterotopically placed partial liver allograft can provide synthesis of haemostasis factors and inhibitors and restore clearance which is adequate to reverse coagulopathy.

Auxiliary partial liver transplantation: Intraoperative changes in fibrinolysis

Auxiliary partial liver transplantation: Intraoperative changes in fibrinolysis

Liver hypertrophy and atrophy after auxiliary partial liver transplantation for chronic end-stage liver disease

Liver hypertrophy and atrophy after auxiliary partial liver transplantation for chronic end-stage liver disease

A prospective randomized trial comparing orthotopic versus auxiliary partial liver transplantation in the pig

A prospective randomized trial comparing orthotopic versus auxiliary partial liver transplantation in the pig

An experimental study of auxiliary partial liver allotransplantation in dogs.

Different experimental models of auxiliary partial liver transplantation (APLT) in dogs are described in the present paper. The results of paraorthotopic APLT with the graft placed in the right parahepatic fossa were relatively favourable because of good reestablishment of blood supply and drainage of bile duct. In this group, however, the survival time of the dogs submitted to reestablishment of arterial and portal circulation was longer than of those submitted to arterial revascularization only. Histologically, donor hepatocellular regeneration was observed in the former, but there was no such regeneration in the latter. It has further been proved that splanchnic blood supply is of importance to the viability of the graft and the survival of the animal. The experimental results, at the same time, show that auxiliary transplantation of 37 % of the liver is not only of suitable bulk for transplantation, but also provides adequate liver function and promotes regeneration of the host liver.

Hemodynamics and coagulation in experimental auxiliary liver transplantation during fulminant hepatic failure.

In pigs, ischemic liver cell necrosis was induced by 6 hours' occlusion of the hepatic artery and the portal vein 3 days after construction of a side-to-side portacaval shunt and division of the hepatic ligaments. Two thirds of the liver of an MLC-compatible donor was heterotopically transplanted 13 hours (group I), and 3 hours (group II) after induction of liver failure. In group I (N = 11), three animals died of liver failure before or shortly after induction of anesthesia. Of the remaining pigs, two animals survived more than 2 weeks. In group II (N = 10), intraoperative hypotension was prevented by reduction of the interval between liver failure and transplantation and by thermodilution catheter monitored fluid replacement. A significant decrease in cardiac output and an increase of pulmonary and systemic vascular resistance were observed during auxiliary partial liver transplantation (APLT). In the immediate postoperative period, six pigs died of deficiencies in hemostasis that were caused by consumptive coagulopathy related to severe host liver damage rather than fibrinolysis. Two pigs in group II survived in good condition 12 and 42 days after APLT. In the longer surviving pigs of both groups, either the graft or the host liver recovered. Processes that might be responsible for the observed hemodynamic changes and coagulation disorders are discussed. These results indicate that APLT is technically feasible in severely ill pigs with acute hepatic failure.

Rejection and survival of auxiliary partial liver grafts in non-tissue-typed pigs.

A technique for auxiliary heterotopic transplantation of 60% of the liver has been developed in the pig to study acute and chronic rejection. Transplantations were performed in 13 non-tissue-typed donor-recipient combinations without immunosuppressive medication. Three pigs died in the 1st postoperative week from technical problems. In the remaining 10 animals acute rejection of the graft was not found, but signs of chronic rejection developed in 6 animals. It is concluded that auxiliary partial liver transplantation is technically feasible in the pig. Although the auxiliary liver graft is subject to immune attack, long-term graft survival without immunosuppressive medication can be achieved.

Treatment of acute liver failure in pigs by auxiliary partial liver transplantation

Treatment of acute liver failure in pigs by auxiliary partial liver transplantation

Auxiliary partial liver transplantation in Macaca mulatta.

Malt, Ronald A. M.D.; Seigne, T. David M.B.; Corry, Robert J. M.D.; ChÁvez-PeÓN, Federico M.D.; Schauble, James F. M.D.; Miyakuni, Toshio M.D. Author Information

Auxiliary partial liver transplantation in the dog.

Auxiliary liver allotransplantation1has advantages not yet realized in practice. In patients with portal hypertension and extensive venous collaterals, heterotopic transplantation would doubtless carry a lower morbidity and mortality than hepatectomy and orthotopic transplantation. The diversion of portal blood necessary to prevent atrophy of either a normal or a transplanted liver2-8should not be harmful in patients undergoing auxiliary transplantation, because they would already have severely impaired liver function. Further-more, the surgeon would have the alternative of removing the auxiliary liver and replacing it with another allograft if rejection occurs. We present here a method of auxiliary partial liver transplantation that provides for complete diversion of portal blood flow (portalization) through the graft. Like the method suggested by Price5and Mito6and their colleagues, it provides also for transplantation of only part of the liver in order both to allow the auxiliary transplant to fit easily