# Auxiliary liver transplantation

Auxiliary liver transplantation

Auxiliary LT involves implanting a healthy liver graft placed either heterotopically or orthotopically while leaving all or part of the native liver intact. Auxiliary heterotopic LT , where the graft is implanted below the native liver, was proposed as an alternative to orthotopic LT in the early era of  transplantation when recipient hepatectomy was associated with massive blood loss and transfusion requirements. But the technique was marred with failures due to the heterotopic position of the graft resulting in poor venous drainage. More recently there has been a renewed interest in auxiliary LT for ALF and certain metabolic liver diseases. To overcome the previous technical di ffi culties, the procedure is now performed with a ient partial hepatectomy to create space for the graft ( Figure 89.6 ). The procedure is therefore termed auxiliary partial orthotopic liver transplantation (APOLT). It is a technically - /uni25CF /uni25CF /uni25CF /uni25CF - /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF 

Figure 89.6
Right lobe auxiliary partial orthotopic liver transplantation (APOLT) for acute liver failure due to yellow phosphorus poisoning.
(a)
Recipient left lateral section of the liver looking pale and fatty owing to yellow phosphorus poisoning; right lobe graft from the donor
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implanted into the orthotopic position.
(b)
Hepatobiliary iminodiacetic acid (HIDA) scans done over the
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rst year after transplant in a left lobe
APOLT. The scans show regression of the left lobe auxiliary graft and functioning native liver.
TABLE 89.2
Extended criteria donors in liver
transplantation.
Type of extended criteria donor
Primary risk to the recipient
Advanced donor age
Delayed graft function
Macrovesicular steatosis
Delayed graft function
Donation after circulatory death
Biliary complication
organs
Organ dysfunction at
Delayed graft function,
procurement:
primary non-function
ICU stay >7 days
Hypernatraemia >165
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mmol/L
Bilirubin >51
/uni00A0
µmol/L
Elevated liver enzymes (AST,
ALT)
Vasopressor use
Cause of death: anoxia,
Delayed graft function, biliary
cerebrovascular accident
complication
Disease transmission:
Infectious risk
Hepatitis B core antibody-
positive donor
Hepatitis B surface antigen-
positive donor
Hepatitis C virus-positive
donor
HIV-positive donor
High-risk history (active drug
abuser, etc.)
Extrahepatic malignancy
Delayed graft function,
Cold ischaemia time >12 hours
primary non-function
(long storage of organ after
procurement)
ALT, alanine aminotransferase; AST, aspartate aminotransferase; HIV,
human immunode
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ciency virus; ICU, intensive care unit.

native liver regeneration in ALF . The most important benefit of  APOLT is the potential for immunosuppression withdrawal when the native liver fully regenerates, although outcomes have been suboptimal in less experienced hands. In metabolic liver diseases in children, APOLT is performed with the intention of  keeping part of  the native liver for future gene therapy .