Subtotal hepatectomy and whole graft auxiliary transplantation for acetaminophen-associated acute liver failure

Here is my highlight from the February edition of the journal HPB the official journal of the IHPBA

The legend of Prometheus that first documented the extraordinary capacity of the liver to regenerate is familiar to liver surgeons. Major liver resection relies on this regenerative capacity of the liver to restore volume and function after surgery. Acetominophen toxicity (paracetomol) causes widespread hepatocyte necrosis but we know from animal models and human survivors that complete hepatic regeneration is possible. The time to allow liver regeneration is unfortunately too slow for many patients who will either die or require urgent liver transplantation to avoid the consequences of severe acute liver failure. In this edition of HPB, the Leeds group present a series of patients who have been managed in an extraordinary way. These patients who all had acute liver failure and who met criteria for urgent transplantation (which equates to a near 90% mortality without transplantation),underwent a right trisegmentectomy, preserving segments 1,2 & 3 and then underwent a reduced or split graft right lobe auxiliary liver transplant. After recovering from the procedure a HIDA scan was performed to test regeneration and function in the native remnant liver and then immunosuppression was gradually withdrawn over a 6–12 month period resulting in atrophy of the transplanted liver and compensatory hypertrophy of the native liver. This innovative approach to liver transplantation has allowed a resurrection of what by many would be considered an irretrievably damaged liver. The avoidance of the need for long term immunosuppression in what is usually a young population may contribute in part to the better 5 year survival in patients. This is however, a technical tour de force and it will be interesting to see if other centres are persuaded to give it a go.

Prometheus

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