AUXILIARY PARTIAL ORTHOTOPIC LIVER-TRANSPLANTATION (APOLT) FOR FULMINANT HEPATIC-FAILURE - 1ST SUCCESSFUL CASE-REPORT

Fulminant hepatic failure is a life-threatening event with a high mortality rate up to 80%. Orthotopic liver transplantation has markedly decreased this mortality rate and is therefore a well established procedure for hepatic failure. However, this treatment neglects the fact that patients surviving hepatic failure without liver transplantation experienced a complete morphologic and functional recovery of their own liver. Temporary support of liver function in such cases could therefore be desirable and adequate therapy. Auxiliary liver transplantation could fulfill this demand. However, the standard technique of auxiliary grafting, transplanting a graft in a heterotopic position, is burdened by problems such as elevated venous back-pressure, insufficient respectively competing portal blood supply for both livers with an unpredictable long-term outcome. In order to cope with these problems, we performed an auxiliary transplantation in an orthotopic position. To accomplish this procedure we had to reduce the size of both the recipient and the donor livers. We, thus, performed an auxilliary partial orthotopic liver transplant (APOLT). The first patient was a 33 year old female who was transplanted on November 25, 1989. She developed a HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome and fell into a deep coma. At the time of transplantation histologic examination of her own liver revealed 80% confluent necrosis. We resected segments 2 and 3 of the recipient liver and transplanted the whole left lobe of the donor liver into this position. The graft showed immediate function. Five months after transplantation both histology and function as detected by cholescintigraphy were normal, and the patient had fully recovered. Sixteen months after transplantation, the immunosuppression was tapered off and the graft shrunk. The patient has since shown permanent recovery. This procedure combines the advantages of auxiliary grafting with the advantages of an orthotopic normal position of the graft. It avoids graft failure due to the heterotopic position. It is a reversible step thus facilitating timely decision making for indication. The APOLT procedure indicates a new way in the treatment of fulminant hepatic failure.