The reduced liver (segments 2, 3, half of 4 with a weight of 550 grams) from a heart-beating brain-dead multi-organ 80 kg donor was first transplanted auxiliary to the native liver of a 25-year-old 42 kg woman with ALF due to 30 days of tuberculostatic therapy with isoniazide and rifampin for proven axillary lymph node tuberculosis, as described (9). She fulfilled the King's College Hospital criteria for transplantation, was in coma with elevated intracranial pressure and hepatorenal syndrome, ventilated, on inotropic medication, and treated with continuous veno-venous haemofiltration (CVVH) with molecular absorbent recirculating system (MARS) and hypothermia. Cold ischemia time (CIT) was 682 min and warm ischemia time (WIT) was 40 min. Arterial reconstruction was performed with a donor iliac graft to the aorta; portal reconstruction end-to-side to recipient portal vein; venous reconstruction by end-to-side caval anastomosis after left-sided resection of segment 1; biliary reconstruction by choledocho-gastrostomy. Immunosuppression was with tacrolimus, prednisolone and basiliximab. Within 1 day relaparotomy was necessary to remove a partial portal vein thrombosis of the graft, probably caused by low flow due to competition for portal blood between native liver and graft. Allthough there was no portal vein kinking, revision of the anastomosis was performed after thrombectomy and heparin infusion was started. Histology of the resected native liver segment 1 showed multilobular necrosis. Ethambutol and levofloxacin were given as nonhepatotoxic tuberculostatics. The auxiliary graft functioned well with normalization of liver function including INR and bilirubin. Hepatorenal syndrome and coma resolved immediately after APOLT. Mebrofenin scintigraphy (HIDA) on day 3 showed a functioning graft and virtually no uptake and excretion in the native liver. On day 18 posttransplant the liver histology from the graft was normal with some granulocytic infiltration. On day 27 after transplantation the native liver had regenerated sufficiently, as shown by histology, CT volumetry (1100 mL) and HIDA to allow resection of the hypertrophied auxiliary graft. The graft had a weight of 1150 g at resection. Immunosuppression was discontinued. At that time work-up for a fever only disclosed a primary CMV-infection with positive plasma CMV-DNA. PCR for TBC was negative on native liver and auxiliary graft. The axillary lymph node was not detectable anymore on CT-scan and palpation. CMV-DNA and fever disappeared with 2 weeks of i.v. gancyclovir. Ethambutol and pyrazinamide were given for another 9 months after removal of the graft, then stopped. After ethical committee approval and informed consent from both this PALT recipient and potential second recipient the partial liver graft was removed from the first recipient and then orthotopically transplanted into a second recipient. This first recipient is in good health 2 years later without recurrence of tuberculosis.
A 37-year-old multiparous female with ALF due to acute fatty liver of pregnancy (AFLP) at 37 weeks gestation worsened with increasingly disturbed clotting, hyperbilirubinemia and coma with brain oedema in the 3 days after delivery of the intrauterinely deceased child. She fulfilled the King's College criteria for liver transplantation. After stabilization with CVVH, MARS and hypothermia PALT was performed with segments 2, 3 and half of 4 (weight 456 g) of a brain-dead post-mortal donor liver. We did this using the technique as described above, but with the portal vein anastomosed to the left renal vein that was disconnected from the caval vein and the hepatic artery conduit anastomosed end-to-side to the aorta just below the diaphragm. The surgical technique of PALT with REPALT (Figure 1) was as follows:
Figure 1. Surgical technique of auxiliary liver transplantation with renoportal anastomosis (REPALT). I: Partial resection of segment 1 of the native liver for venous access to the caval vein in orthotopic position (with the graft in heterotopic position). II, III, IV: Auxiliary graft. (1) Tool-kit-donor common and external iliac artery, (2) Left hepatic artery, (3) Left portal branch (portal vein), (4) Tool-kit-donor common and external iliac vein, (5) Left renal vein, (6) Coeliac trunk, (7) Left hepatic bile duct on stomach, (8) Left hepatic vein, (9) Inferior caval vein, (10) Aorta. Drawn by Jan-Hein van Dierendonck.
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Partial resection of segment 1 of the native liver for venous access to the caval vein in orthotopic position (with the graft in heterotopic position).
End-to-side anastomosis of the left hepatic vein of the graft to the recipient caval vein just below the level of recipients left hepatic vein.
Portal venous inflow from the recipient's left renal vein. The portal vein from the graft was first lengthened utilizing donor iliac vein, positioned dorsal of the pancreas and anastomosed end-to-end to the left renal vein.
Arterial anastomosis with the iliac conduit of the donor, previously anastomosed end-to-side to the recipient's aorta above the celiac trunk.
Biliary drainage by end-to-side anastomosis between the donor common bile duct and the anterior stomach wall of the recipient.
We recently described this technique of REPALT in detail (1). CIT was 623 min, WIT 50 min. Immunosuppression was with tacrolimus, basiliximab and prednisolone. The resected native liver segment 1 histology confirmed AFLP. There was immediate graft function, and within a day patient was ectubated. After 1 more week on CVVH there was restoration of renal function and patient left the intensive care unit. Liver biopsies from the native liver showed rapid normalization of histology within 1 month, the size of the native liver on CT did not change as expected in AFLP. The graft hypertrophied to 1066 mL on day 4 and then remained stable at 1042 mL day 15 on CT volumetry (Vitrea, Vital Images Inc., Minnetonka, MN) and HIDA. Graft volume at day 26 after REPALT, 4 days before transplantectomy had not changed when ultrasound-guided liver biopsies were obtained: Histology of the native liver still showed some steatosis, graft histology was normal. The initial critical illness neuropathy fully resolved.
After informed consent of this REPALT recipient and the potential second recipient the graft, which then had a weight of 1050 g, was removed 1 month after REPALT and reused for OLT in the second recipient. All previous anastomosis were dismanteled, primary closure of caval vein, aorta and stomach was performed. The resected graft was perfused with UW and cold-stored. The left renal vein in this first recipient was reanastomosed to the caval vein and scintigraphy revealed normal function of the left kidney.
We successfully performed a third REPALT in ALF due to fulminant hepatitis B similarly, but this patient had slower regeneration of the native liver as shown before in hepatitis B, while graft regeneration was as rapid as in the second patient described above. After full regeneration of the native liver, a year after REPALT, laparotomy was performed with the aim of removing and possibly reusing the graft. In this case, removal of the graft was considered too risky due to adherence of the graft to surrounding tissues, and the graft was left in situ to atrophy with decreasing immunosuppression. This patient is also doing well off immunosuppression now, with normal liver and kidney function and normal renal scintigraphy.