Left Lobe Living Donor Liver Transplantation Using Rapid Procedure in a Cirrhotic Patient With Portal Vein Thrombosis

Abstract

R apid Procedure; Resection and partial liver transplantation with delayed total hepatectomy, evolved using combination of techniques from Auxiliary Partial Orthotopic Liver Transplantation (APOLT) and Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) Procedures in order to offer timely liver transplantation (LT) for the treatment of unresectable colorectal liver metastases, has shown promising results in selected patients. 1,2 Both Rapid and Apolt procedures were developed and mostly performed for the noncirrhotic settings. Here, we present the first case with high model for end stage liver disease (MELD) score, cirrhotic patient with portal vein thrombosis (PVT), showing that Rapid Procedure could be performed in complex clinical scenarios of Liver cirrhosis and PHT.

Auxiliary Liver Transplantation for Cirrhosis: From APOLT to RAPID

“…0.8%) and laboratory tests may be used to guide the decision about the timing of the second stage. 7,8 In this review, they delay ranged from 10 days to 3 months. Scatton et al noted 9 that hepatobiliary scintigraphy assessment was not performed, which might partially explain why the delay reached 3 months.…”

“…3) The concept of portal blood flow modulation to control the resulting portal hyperperfusion and to prevent small-for-size syndrome has been progressively understood and implemented during the technical evolution of these procedures. 7,8,33 Deportalization of the native liver is necessary for patients who have a nonfibrotic liver. However, this aspect remains controversial in the cirrhotic setting.…”

“…66 Balci et al advocated that portal blood flow modulation techniques should target a portal pressure < 15 mm Hg and portal blood flow between 100 and 300 ml/ 100 gr/min of the liver graft, which ensures adequate hepatic artery flow (> 50 ml/min) and prevents arterial vasoconstriction due to the hepatic artery buffer response. 8 More importantly, the abovementioned recommended values are based on the ''small-for-size living donor LT'' literature. Measurement of portal/arterial flow and pressures should be recorded and considered standard procedure when performing these operations so that more robust data can be generated and to guide future studies and recommendations.…”

“…33 In 1 case, due to portal vein thrombosis, the graft portal vein was anastomosed to a major gastric shunt, which was used for portal blood flow modulation. 8 During the second stage, 1 patient had closure of the portosystemic shunt placed during the first stage followed by splenic artery ligation. 7 Biliary reconstruction was performed either by ductto-duct or bilio-enteric anastomosis in 2 and 7 patients, respectively.…”

“…6 RAPID is based on the stepwise evolution of APOLT and follows the principle of the associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) concept. Following these concepts and technical improvements, RAPID was expanded from nonfibrotic liver disease 6 to the context of cirrhosis, 7,8 and with this expansion several conceptual modifications and controversies have arisen, especially regarding portal hypertension management and portal blood flow modulation. This scoping review provides a brief history of the refinements to the ALT techniques from APOLT to RAPID in the setting of ESLD.…”