Emergency subtotal hepatectomy: a new concept for acetaminophen-induced acute liver failure: temporary hepatic support by auxiliary orthotopic liver transplantation enables long-term success.
BACKGROUND
Acetaminophen (paracetamol) overdose (AOD) has recently emerged as the leading cause of acute liver failure (ALF) in the United States, with an incidence approaching that seen in the United Kingdom. We describe a new way to treat AOD ALF patients fulfilling King's College criteria for "super-urgent" liver transplantation.


METHODS
Beginning in June 1998, we have been piloting a clinical program of subtotal hepatectomy and auxiliary orthotopic liver transplantation (ALT) for AOD ALF. Our technique is based on the following principles: (1) subtotal hepatectomy; (2) auxiliary transplantation of a whole liver graft; (3) gradual withdrawal of immunosuppression after recovery. Results were compared with patients who had undergone an orthotopic liver transplantation (OLT) for AOD ALF in the same period. Quality of life comparisons were made using the SF36 questionnaire.


RESULTS
Thirteen patients underwent this procedure between June 1998 and March 2005. Median survival is 68 months (range, 0-102 m). Actual survival data show that 9 of 13 patients are alive (69%) compared with 7 of 13 OLT patients (54%). One ALT patient required a retransplantation with an OLT due to hepatic vein thrombosis, and immunosuppression is therefore maintained. The other 8 surviving ALT patients are off immunosuppression. These 8 ALT patients have normal liver function and have a better quality of life compared with the 7 surviving OLT patients.


CONCLUSIONS
Our results with this new technique are encouraging: 69% actual survival, no long-term immunosuppression requirement, and improved quality of life in the 62% successful cases.
Lodge
J Peter A
JP
HPB and Transplant Unit, St James's University Hospital, Leeds, United Kingdom. peterlodge@aol.com
Dasgupta
Dowmitra
D
Prasad
K Rajendra
KR
Attia
Magdy
M
Toogood
Giles J
GJ
Davies
Mervyn
M
Millson
Charles
C
Breslin
Niall
N
Wyatt
Judith
J
Robinson
Philip J
PJ
Bellamy
Mark C
MC
Snook
Nicola
N
Pollard
Stephen G
SG
D000082:Acetaminophen / Q000506:poisoning*; D000293:Adolescent; D000328:Adult; D018712:Analgesics, Non-Narcotic / Q000506:poisoning*; D005260:Female; D005500:Follow-Up Studies; D006498:Hepatectomy / Q000379:methods*; D006801:Humans; D017114:Liver Failure, Acute / Q000139:chemically induced / Q000401:mortality / Q000601:surgery*; D016031:Liver Transplantation / Q000379:methods*; D008297:Male; D008875:Middle Aged; D010865:Pilot Projects; D011788:Quality of Life; D012189:Retrospective Studies; D015996:Survival Rate; D013997:Time Factors; D016896:Treatment Outcome
D018712:Analgesics, Non-Narcotic; D000082:Acetaminophen