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Auxiliary liver transplantation with a small deceased liver graft for cirrhotic liver complicated by hepatocellular carcinoma

Dear Sirs, Liver transplantation (LT) is the treatment of choice for small hepatocellular carcinoma (HCC) in patients with chronic liver disease and portal hypertension [1]. One of the drawbacks of this treatment is the dropout rate of patients on the waiting list because of disease progression [2], related to a low MELD score and general organ shortages [3]. In the same way, certain small liver grafts (SLG) are not accepted because of the inadequate graft/recipient weight ratio (GRWR) with the risk of small-for-size syndrome (SFSS) and postoperative liver failure (POLF). A GRWR >0.8% is recommended [4]. Although the notion of auxiliary partial orthotropic liver transplantation (APOLT) is usually described for potentially reversible fulminant hepatic failure (auxiliary temporary aid by the graft), this technique has been also described in patients with chronic liver disease, metabolic diseases and small liver grafts for the opposite reason (auxiliary temporary or permanent aid by the native liver), with cadaveric [5,6] or living donor grafts [7,8]. According to our knowledge, this technique has never been described in patients with HCC. A 43-year-old male patient was admitted for LT related to Child A5 alcoholic cirrhosis with steatohepatitis. HCC was 22 mm in diameter and located in segment VIII. LT was decided due to impaired liver function as assessed by a prothrombin time (PT) <60% and platelet count at 40 x 10/l and a Meld score at 8. HCC was treated successfully by arterial chemoembolization with complete tumour necrosis and alpha-fetoprotein levels decreased from 508 to 5.7 UI/ml. The patient’s weight and height were 100 kg and 168 cm respectively (BMI 35.4 kg/m). The donor was a brain-dead 82-year-old man and the graft weighed 770 g (GRWR = 0.77%). The decision for APOLT was made to avoid both SFSS and waiting time for HCC patients. Surgical exploration found a single nodule and uneventful right trisectionectomy (removing segments IV– VIII) was performed. Piggyback caval anastomosis was performed. End-to-side portal anastomosis was performed with partial ligation of the native portal vein and end-toend arterial anastomosis between the graft celiac trunk and the common hepatic artery. Biliary anastomosis was performed between the graft main bile duct and the recipient right bile duct with a biliary drain (Fig. 1d). The cold and warm ischemia times were of 540 and 55 min respectively. The graft was preserved with CELSIOR and surgery lasted 450 min without any transfusions. The postoperative course was uneventful and the liver function tests recovered rapidly with (PT = 91%; bilirubin = 13 lmol/l) and (PT = 87%; bilirubin = 16 lmol/l) on postoperative days (POD) 3 and 5 respectively. Immunosuppression consisted of glucocorticoid, Mycophenolate mofetil and tacrolimus. US Doppler evaluation showed a measured portal flow in the liver graft and native liver at 30–40 cm/s and 10– 15 cm/s respectively. Scintigraphic and scannographic evaluation (Fig. 1a–c) showed progressive enhancement of the liver graft function, especially after ipsilateral native portal vein embolization, which was performed on POD 15 to enhance the hypertrophy of the liver graft. The pathology of the resected liver showed a 1-cm completely necrotic nodule with two small foci of well to moderately differentiated HCC on the periphery. The adjacent liver showed alcoholic cirrhosis with steatohepatitis. Left lateral sectionectomy was performed on POD 30 and Surgery lasted 150 min and the estimated blood loss was 250 ml. No nodule was found on the specimen. The patient was discharged home on POD 42. After a mean follow-up of 20 months, there is no tumour relapse, but the patient presented anastomotic biliary stenosis, which was successfully treated by endoscopic stenting. This case report shows that APOLT in the setting of HCC is a viable option. Although it is very difficult to anticipate the postoperative course if this SLG was not transplanted as an auxiliary graft, we can conclude that the present strategy was effective based on the excellent postoperative liver function, the uncomplicated removal of the native liver and the uneventful postoperative course. The number of