title: Directing portal flow is essential for graft survival in auxiliary partial heterotopic liver transplantation in the dog.
abstract: OBJECTIVE
  Auxiliary liver transplantation is an attractive alternative for orthotopic liver transplantation in patients with certain inborn errors of metabolism of the liver in which complete resection of the liver is unnecessary or even contraindicated. Because in these diseases portal hypertension is mostly absent, finding a balance in portal blood distribution between native liver and graft is complicated. The objective of this study was to investigate requirements for long-term (180 days) graft survival in auxiliary partial heterotopic liver transplantation (APHLT) in a dog model.
  
  
  METHODS
  A metabolic defect was corrected in 26 dalmation dogs with a 60% beagle heterotopic auxiliary liver graft. Four groups of different portal inflow were studied. In the ligation group the portal vein to the host liver was ligated. In the split-flow group graft and host liver received separate portal inflow. In the banding group the distribution of the portal flow was regulated with an adjustable strapband and in the free-flow group the portal blood was allowed to flow randomly to host or graft liver.
  
  
  RESULTS
  Metabolic correction increased in all groups after transplantation from 0.19 +/- 0.02 to 0.70 +/- 0.05 (P< .0001) but remained significantly better in the ligation and split-flow groups (graft survival, 135 +/- 27 and 144 +/- 31 days). In the banding group metabolic correction decreased significantly after 70 days, and although the grafts kept some function for 155 +/- 14 days, in 4 of 6 dogs portal thrombosis was found. In the free-flow group, competition for the portal blood led to reduced correction within 12 days and total loss of function in 96 +/- 14 days. Graft function also was assessed with technetium (Tc) 99m dimethyl-iminodiacetic acid uptake. A good linear association between HIDA uptake and metabolic correction was observed (r = 0.74; P < .0005). Grafts that contributed more than 15% to the total uptake of HIDA showed biochemical correction. This indicates a critical graft mass of about 15% to 20% of the hepatocyte volume to correct this metabolic defect.
  
  
  CONCLUSIONS
  Auxiliary partial heterotopic liver transplantation can be a valuable alternative treatment for inborn errors of hepatic metabolism if the native liver and the graft receive separate portal blood inflow.
authors.affiliation: Department of Surgery, Erasmus Medical Centre Rotterdam/Sophia Children's Hospital, The Netherlands.
authors.forename: J
authors.initials: J
authors.lastname: de Jonge
authors.forename: G C
authors.initials: GC
authors.lastname: Madern
authors.forename: O T
authors.initials: OT
authors.lastname: Terpstra
authors.forename: M
authors.initials: M
authors.lastname: Sinaasappel
authors.forename: J C
authors.initials: JC
authors.lastname: Molenaar
authors.forename: A P
authors.initials: AP
authors.lastname: Provoost
authors.forename: H W
authors.initials: HW
authors.lastname: Tilanus
mesh_terms: D000818:Animals; D004285:Dogs; D006085:Graft Survival / Q000502:physiology*; D016031:Liver Transplantation / Q000000981:diagnostic imaging / Q000379:methods* / Q000502:physiology; D008661:Metabolism, Inborn Errors / Q000601:surgery; D011168:Portal System / Q000502:physiology* / Q000601:surgery; D011877:Radionuclide Imaging; D019275:Radiopharmaceuticals; D019780:Technetium Tc 99m Lidofenin
chemical_list: D019275:Radiopharmaceuticals; D019780:Technetium Tc 99m Lidofenin