Auxiliary partial orthotopic liver transplantation for adult onset type II citrullinemia

Auxiliary Partial Orthotopic Liver Transplantation for Selected Noncirrhotic Metabolic Liver Disease

Auxiliary partial orthotopic liver transplantation (APOLT) in selected noncirrhotic metabolic liver diseases (NCMLDs) is a viable alternative to orthotopic liver transplantation (OLT) as it supplements the function of the native liver with the missing functional protein. APOLT for NCMLD is not universally accepted due to concerns of increased technical complications and longterm graft atrophy. Review of a prospectively collected database of all pediatric patients (age ≤16 years) who underwent liver transplantation for NCMLD from August 2009 up to June 2017 was performed. Patients were divided into 2 groups: group 1 underwent APOLT and group 2 underwent OLT. In total, 18 OLTs and 12 APOLTs were performed for NCMLDs during the study period. There was no significant difference in the age and weight of the recipients in both groups. All APOLT patients needed intraoperative portal flow modulation. Intraoperative peak and end of surgery lactate were significantly higher in the OLT group, and cold ischemia time was longer in the APOLT group. There were no differences in postoperative liver function tests apart from higher peak international normalized ratio in the OLT group. The incidence of postoperative complications, duration of hospital stay, and 1- and 5-year survivals were similar in both groups. In conclusion, we present the largest series of APOLT for NCMLD. APOLT is a safe and effective alternative to OLT and may even be better than OLT due to lesser physiological stress and the smoother postoperative period for selected patients with NCMLD.

Revisiting APOLT for Metabolic Liver Disease: A New Look at an Old Idea

Even though auxiliary partial orthotopic liver transplantation (APOLT) as a technique was popularized in the late 80s, its role in metabolic liver disease remains controversial. The slow progress in gene therapy research, high incidence of technical complications, and the problem of long term graft atrophy have been roadblocks to its wider application. Better understanding of reciprocal dynamics of portal flow and regeneration between the graft and native liver along with multiple refinements in surgical technique have improved the outcomes of this operation, making it a safe alternative to orthotopic liver transplantation for patients with a wide range of noncirrhotic metabolic liver diseases (NCMLD). The ability to perform APOLT safely has also opened up a range of exciting indications in the setting of NCMLD. This article reviews the current status of APOLT for NCMLD, technical refinements which have improved outcomes and novel indications, which have rekindled fresh interest in this procedure.

Reconstruction of the Outflow Tract in Cross-Auxiliary Double-Domino Donor Liver Transplantation

BACKGROUND

Auxiliary liver transplantation is accepted as an effective manner to expand the liver donor pool. A difficult surgical technical challenge of the procedure is hepatic vein reconstruction of the graft.

METHODS

To resolve this problem, complex techniques are used to perform an innovative outflow tract reconstruction in the world's first cross-auxiliary double-domino donor liver transplantation with two whole liver grafts. The inferior vena cava-sparing hepatectomy technique was applied at harvest in the two domino liver donors. For each donor, the three major hepatic veins (right, middle, and left) were joined together to create one single orifice, but there was no sufficient tissue to perform a direct anastomosis.

RESULTS

The hepatic vein was reconstructed with the use of a longitudinally opened iliac vein graft from a cadaveric donor to prolong the outflow tract for the piggyback suturing.

CONCLUSIONS

This new technique might provide an innovative surgical approach for reconstructing the complex outflow tract of domino transplantation.