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

Abstract

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the patient's failing liver for a period of time until the native liver (NL) has recovered and immunosuppression can be withdrawn.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. (Liver Transpl 2000;6: 805-809.)A uxiliary liver transplantation (ALT) for patients with fulminant hepatic failure supports the patient's failing liver for a period of time until the native liver (NL) has recovered. 1 A multicenter European study showed that in two thirds of the patients, liver regeneration occurred and immunosuppression could be withdrawn. 2 Auxiliary partial orthotopic liver transplantation (APOLT) has been the more commonly used technique. [3][4][5][6][7] However, this procedure is technically more difficult than orthotopic liver transplantation (OLT) because recipient hemihepatectomy is required for implantation of the partial liver graft. Auxiliary heterotopic liver transplantation (AHLT) with portal vein arterialization (PVA) has several advantages over APOLT: NL resection is not required, and the hepatic hilum is left untouched; therefore, the chances of liver regeneration are optimal. 8,9 We describe the successful application of emergency AHLT with PVA in a young patient who developed toxic fulminant hepatic failure caused by tuberculostatic drugs. Case ReportA 25-year-old black man, an illegal immigrant from an African country, was admitted to our unit with acute liver failure from toxic hepatitis. The patient had been diagnosed with tuberculous pleural effusion and treated with rifampin, 600 mg/d; isoniazid, 250 mg/d; and pyrazinamide, 1,500 mg/d. Twenty days later, he presented with a high fever, headache, vomiting, arthromyalgia, and confusion. Laboratory blood tests showed the following values: aspartate aminotransferase (AST), 11,505 U/L; amylase, 493 U/L; lipase, 3.451 U/L; creatine kinase, 1,286 U/L; international normalized ratio, 2.32; blood urea nitrogen (BUN), 46 mg/dL; and creatinine, 1.6 mg/dL. Cerebrospinal fluid and cranial computed tomography results were normal. A diagnosis of fulminant hepatic failure caused by hepatotoxic antituberculous medications was made, and the patient was referred to our unit.On admission, the patient presented with grade I encephalopathy. Blood analyses showed the following values: bilirubin, 1.6 mg/dL; AST, 7,570 U/L; prothrombin time, 30%; creatinine, 1.6 mg/dL; and negative serologic test results for viral hepatitis A, B, and C. Over the following ...

Liver Regeneration in Surgical Animal Models – A Historical Perspective and Clinical Implications

“…The recognition of the importance of portal blood to liver homeostasis and regeneration was obviously crucial to the pioneers of liver transplantation as they observed how the auxiliary graft would undergo atrophy without portal blood constituent stimulus [18]. The earlier canine and porcine PVA experiments [10,11,12,13,14,63,64,65] also illustrated to the transplantation surgeon that the auxiliary graft could be perfused by PVA as an option to leave the hilus of the native liver untouched and also in cases of portal vein thrombosis [94,95,96,97]. Could PVA of the small-for-size graft be an option in the future to avoid the small-for-size syndrome?…”

Outcome of patients with pre-existing portal vein thrombosis undergoing arterialiazation of the portal vein during liver transplantation

“…Such a situation always requires complicated vascular reconstruction, and is associated with a considerably increased peri-operative risk [15]. Aimed, nevertheless, at achieving adequate perfusion of the transplant even in such a situation, complete arterialization of the portal vein (PVA) has recently been propagated as a technically relatively simple procedure [2,4,5,6, 141. Some authors have also reported that PVA can also be employed in auxiliary liver transplantations [4,6,131.…”

“…Aimed, nevertheless, at achieving adequate perfusion of the transplant even in such a situation, complete arterialization of the portal vein (PVA) has recently been propagated as a technically relatively simple procedure [2,4,5,6, 141. Some authors have also reported that PVA can also be employed in auxiliary liver transplantations [4,6,131. Experience with the few patients that have undergone transplantation by this technique has been interpreted as a demonstration of both the technical feasibility of PVA and the regular initial function of the transplant [2,3,4,5,6,7,141.…”

“…Some authors have also reported that PVA can also be employed in auxiliary liver transplantations [4,6,131. Experience with the few patients that have undergone transplantation by this technique has been interpreted as a demonstration of both the technical feasibility of PVA and the regular initial function of the transplant [2,3,4,5,6,7,141. However, the longterm effects of this unphysiological vascular reconstruction, in particular possible morphological changes in the transplant, have not yet been adequately investigated.…”

Improved technique of heterotopic auxiliary rat liver transplantation with portal vein arterialization

“…Thus, there is less postoperative bleeding and more remaining liver mass for bridging (graft) and regeneration (native liver). The clinical results demonstrated that sufficient liver function can be achieved using this technique [3,4].…”