Chapter 69: Auxiliary Liver Transplantation

GENERAL PRINCIPLES

Auxiliary liver transplantation (ALT) is an alternative to total transplantation. The primary goal is to assist a problematic hepatic function until the patient’s inherited liver dysfunction passes. A partial left or right donor lobe is used, acting as a temporary support while all or part of the native liver remains in situ. Then the graft can either be surgically removed or chronically disposed of in order to relieve the patient of chronic immunosuppressive therapy. Even if the inherited liver is not regenerated, the adjuvant graft may function as a normal liver. The primary goal is to restore the liver function as soon as possible in order to avoid the development of cerebral edema and irreversible brain damage.

OPTIMAL SITUATIONS

• Patient age <40 years

• Excellent temporary liver graft

• Hemodynamic stability

CRITERIA OF ACUTE LIVER FAILURE SEVERITY

• Model for End-Stage Liver Disease (MELD) score (more useful)

• King’s College

• Clichy Criteria

• APACHE II

Indications

ALT in Acute Liver Failure

• Overdose of paracetamol

• Viral hepatitis (mainly hepatitis A or B; rarely hepatitis C)

• Toxic reaction to drugs (e.g., tetracycline, troglitazone)

• Severe alcoholic hepatitis

• Acute liver steatosis in pregnancy

• Reye syndrome

• Idiopathic ALF with no known cause

• Wilson disease

ALF in Chronic Liver Disease

• When hepatectomy becomes technically impossible

• Coagulation disorders, cachexia, and severe respiratory dysfunction in patients with end-stage chronic liver disease

• To address the lack of transplants

ALF in Metabolic Liver Diseases

• Homozygous familial hypercholesterolemia

• Urea cycle disorders

• Fatty acid metabolism

• Hemophilia

• Crigler-Najjar syndrome type I

Surgical Techniques

The partial graft can be placed:

• Below the native liver (heterotopic)

• Replacing the resected right or left native lobe (orthotopic)

In heterotopic auxiliary liver transplantation (HALT):

• The hepatic vein of the graft is anastomosed in the inferior vena cava (IVC)

• The portal vein (PV) is anastomosed in the anterior mesenteric vein (AMV) or in the PV of the recipient

• The hepatic artery (HA) of the graft occurs in the abdominal aorta or the right joint iliac artery

• A Roux-en-Y cholopeptic anastomosis is performed

In auxiliary partial orthotropic liver transplantation (APOLT):

• A right or left hepatectomy is performed in order to create a space capable to receive the adjuvant graft

• The HV of the graft is anastomosed in the IVC

• An end-to-side anastomosis of the 2 PVs is performed

• An end-to-end arterial anastomosis with the splenic artery or with the abdominal aorta of the recipient is performed

• A Roux-en-Y cholopeptic anastomosis is performed

Ringers et al. described a variant of APOLT where instead of the PV, the renal vein of the patient is used ...