title: Auxiliary partial orthotopic versus standard orthotopic whole liver transplantation for acute liver failure: a reappraisal from a single center by a case-control study.
abstract: OBJECTIVE
  To reappraise the results of auxiliary partial orthotopic liver transplantation (APOLT) compared with those of standard whole-liver transplantation (OLT) in terms of postoperative death and complications, including neurologic sequelae.
  
  
  BACKGROUND
  Compared with OLT, APOLT preserves the possibility for the native liver to recover, and to stop immunosuppression.
  
  
  METHODS
  In a consecutive series of 49 patients transplanted for fulminant or subfulminant hepatitis, 37 received OLT and 12 received APOLT. APOLT was done when logistics allowed simultaneous performance of graft preparation and the native liver partial hepatectomy to revascularize the graft as soon as possible. Each patient undergoing APOLT (12 patients) was matched to two patients undergoing OLT (24 patients) according to age, grade of coma, etiology, and fulminant or subfulminant type of hepatitis. All grafts in the study population were retrieved from optimal donors.
  
  
  RESULTS
  Before surgery, both groups were comparable in all aspects. In-hospital death occurred in 4 of 12 patients undergoing APOLT compared with 6 of 24 patients undergoing OLT. Patients receiving APOLT had 1 +/- 1.3 technical complications compared with 0.3 +/- 0.5 for OLT patients. Bacteriemia was significantly more frequent after APOLT than after OLT. The need for retransplantation was significantly higher in the APOLT patients (3/12 vs. 0/24). Brain death from brain edema or neurologic sequelae was significantly more frequent after APOLT (4/12 vs. 2/24). One-year patient survival was comparable in both groups (66% vs. 66%), and there was a trend toward lower 1-year retransplantation-free survival rates in the APOLT group (39% vs. 66%). Only 2 of 12 (17%) patients had full success with APOLT (i.e., patient survival, liver regeneration, withdrawal of immunosuppression, and graft removal). One of these two patients had neurologic sequelae.
  
  
  CONCLUSIONS
  Using optimal grafts, APOLT and OLT have similar patient survival rates. However, the complication rate is higher with APOLT. On an intent-to-treat basis, the efficacy of the APOLT procedure is low. This analysis suggests that the indications for an APOLT procedure should be reconsidered in the light of the risks of technical complications and neurologic sequelae.
authors.affiliation: Hepatobiliary Surgery and Liver Transplant Unit, UPRES 1596, IFR 89.9, Hôpital Paul Brousse, Université Paris Sud, 94804 Villejuif, France. daniel.azoulay@pbr.ap-hop-paris.fr
authors.forename: D
authors.initials: D
authors.lastname: Azoulay
authors.forename: D
authors.initials: D
authors.lastname: Samuel
authors.forename: P
authors.initials: P
authors.lastname: Ichai
authors.forename: D
authors.initials: D
authors.lastname: Castaing
authors.forename: F
authors.initials: F
authors.lastname: Saliba
authors.forename: R
authors.initials: R
authors.lastname: Adam
authors.forename: E
authors.initials: E
authors.lastname: Savier
authors.forename: M
authors.initials: M
authors.lastname: Danaoui
authors.forename: A
authors.initials: A
authors.lastname: Smail
authors.forename: V
authors.initials: V
authors.lastname: Delvart
authors.forename: V
authors.initials: V
authors.lastname: Karam
authors.forename: H
authors.initials: H
authors.lastname: Bismuth
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D016022:Case-Control Studies; D005260:Female; D006498:Hepatectomy / Q000379:methods; D006801:Humans; D017114:Liver Failure, Acute / Q000601:surgery*; D016031:Liver Transplantation / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D008297:Male; D011183:Postoperative Complications