Auxiliary liver transplantation using otherwise-discarded liver allograft combined with associating liver partition and portal vein ligation for staged hepatectomy for unresectable colorectal liver metastases

Patients with unresectable colorectal liver metastases (u-CRLM) exhibit a poor prognosis, with the 5-year overall survival (OS) rate remaining below 10% when treated with first-line chemotherapy alone. Liver transplantation (LT) has emerged as a promising therapeutic option for carefully selected patients, achieving 5-year OS rates of up to 60%, despite a relatively high recurrence rate (1-3). However, the critical challenge of organ shortage continues to limit its broader application. To address this limitation, several innovative strategies have been implemented, including the use of marginal donor livers, split LT, deceased donor-resection and partial liver segment 2/3 transplantation with delayed total hepatectomy (DD-RAPID) (4), and living donor-RAPID (LD-RAPID) (5). The discarded liver-RAPID (DL-RAPID) approach represents a novel solution, utilizing donor livers that would otherwise be discarded due to benign hepatic lesions. Herein, we present the first successful implementation of DL-RAPID in a patient with u-CRLM, using a discarded left liver lobe resected from a donor with a benign hepatic lesion.

In February 2023, a 37-year-old female (weight: 43 kg, height: 155 cm, BMI: 17.9 kg/m², blood type: A) was diagnosed with sigmoid colon cancer and multiple liver metastases [sigmoid colon adenocarcinoma, RAS/BRAF wild-type, microsatellite stable (MSS)]. The details of the patient’s subsequent treatment plan, including the associated time points for each intervention, can be found in Figure 1. Despite stable hepatic lesions throughout the treatment course and positron emission tomography-computed tomography (PET-CT) confirming the absence of extrahepatic metastases in May 2024, surgical resection was deemed unfeasible due to the multiplicity of tumors and limited healthy liver parenchyma.

Figure 1.

A concise schematic diagram depicting the patient’s treatment process. DL-RAPID, discarded liver-resection and partial liver segment 2/3 transplantation with delayed total hepatectomy; 3D, three-dimensional.

Concurrently, a 35-year-old female (blood type: A) was identified with a large hepatic tumor located in the caudate lobe, suspected to represent focal nodular hyperplasia (FNH) (Figure 2A). She was scheduled to undergo an extended left lateral hepatectomy to achieve an optimal surgical field. Subsequently, the caudate lobe was resected to achieve complete tumor excision. She also volunteered to donate her resected left lobe, which would otherwise have been discarded. Computed tomography (CT) volumetry estimated the volume of the resected extended left lateral lobe to be 281 mL, yielding a predicted graft-to-recipient weight ratio (GRWR) of 0.65%.

Figure 2.

Imaging findings of the donor and recipient, along with intraoperative observations. (A) Preoperative MRI of the donor liver (FNH in the caudate lobe with a diameter of 7.5 cm) (red directional indicator). (B) The otherwise-discarded liver graft (expanded left lateral lobe, weight 245 g). (C) Preoperative MRI of the recipient liver (multiple bilateral metastatic lesions, red directional indicators). (D) Intraoperative findings during stage 1 (multiple liver metastases, blue directional indicators). (E) The tumor-bearing left hemi-liver of the recipient was resected and replaced with the otherwise-discarded liver graft (white circular indicator). White triangle symbol indicates the right lobe of the recipient’s liver. (F) A CT scan performed 7 days post-stage 1 showed marked hyperplasia of the transplanted left lobe, increasing to 416 mL (a 70% increase) (red circular indicators). Red triangle symbol indicates the right lobe of the recipient’s liver. (G) Intraoperative view during stage 2 confirmed significant hypertrophy of the transplanted graft (white circular indicator). White triangle symbol indicates the right lobe of the recipient’s liver. (H) The tumor-bearing right lobe of the recipient was resected, leaving only the hyperplastic donor left lobe in place (white circular indicator). (I) The resected right lobe of the recipient contained 23 tumors (green directional indicators). (J) The resected left lobe of the recipient contained 10 tumors (green directional indicators). CT, computed tomography; FNH, focal nodular hyperplasia; MRI, magnetic resonance imaging.

Our multidisciplinary team (MDT) proposed the feasibility of utilizing this otherwise-discarded left lobe graft for LT as part of a personalized treatment strategy. After approval from the Zhongshan Hospital, Fudan University Medical Ethics Committee for the “DL-RAPID” procedure (No. B2022-138), the option was presented to the patient and her family. During multiple consultations, the associated risks and potential benefits were thoroughly discussed, with explicit emphasis on the palliative nature of the proposed plan, which aimed to extend survival. After careful deliberation, informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

In May 2024, the donor initially underwent a laparoscopic extended left lateral hepatectomy to expose the benign tumor located in the caudate lobe, followed by resection of the caudate lobe containing the tumor. No anatomical variations were identified in the donor’s bile ducts or arteries. During the procedure, the distal portions of the left hepatic duct and left hepatic artery were transected. Intraoperative rapid pathology confirmed the diagnosis of FNH. The retrieved left liver lobe graft was perfused with Belzer UW^® Cold Storage Solution via the left portal vein and hepatic artery stump and subsequently stored at 4 °C in the perfusion solution until implantation. The weight of the resected graft was 245 g (Figure 2B).

1. Exploratory laparotomy performed in May 2024 excluded the presence of extrahepatic diseases (Figure 2C,2D).

2. The left and right hepatic arteries, portal vein branches, and left hepatic vein were carefully dissected.

3. Left hemihepatectomy was performed, preserving the middle hepatic vein.

4. The graft was implanted using the auxiliary partial orthotopic LT technique (Figure 2E):

   1. The donor left hepatic vein was anastomosed to the common opening of the recipient’s inferior vena cava and left hepatic vein using the piggyback technique.

   2. The left portal vein branches of the donor and recipient were anastomosed, followed by anterograde graft reperfusion.

   3. Arterial anastomosis was performed using microsurgical techniques.

   4. End-to-end bile duct anastomosis was achieved using microsurgical techniques, with placement of a 10-Fr T-tube for drainage.

   5. The recipient’s right portal vein branches were ligated intraoperatively to redirect blood flow toward the graft. Subsequently, the pressure in the left branch of the portal vein was measured at 13 mmHg, with a flow rate of 0.45 m/s. Additionally, the hepatic artery exhibited a blood flow velocity of 1.02 m/s. The initial plan involved the portal inflow modulation via pharmacological intervention (terlipressin and octreotide) and splenic artery ligation (6).

Graft volume and function were closely monitored postoperatively (e.g., weekly CT scans until GRWR >0.8%). By postoperative day (POD) 7, CT demonstrated graft hypertrophy from 245 to 416 mL (70% volume increase; GRWR from 0.57% to 0.97%) (Figure 2F,2G). On POD 7, the second stage of the procedure, namely completion of right hepatectomy, was performed in accordance with the associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) protocol (Figure 2H).

The postoperative course was uneventful, and the donor was discharged on POD 7. At 12 months postoperatively (POM 12), no medical or psychological complications had arisen.

Mild ascites and transient liver dysfunction occurred following the first operation but resolved with conservative management. Recovery after the second operation was uneventful, with discharge occurring on POD 28. No surgical or immunological complications were observed during follow-up. The current immunosuppressive regimen includes a mammalian target of rapamycin (mTOR) inhibitor (at a dose of 2 mg per day, with the trough levels maintained within the range of 9–12 ng/mL), and the patient’s quality of life remains satisfactory.

All procedures were conducted in strict accordance with the ethical standards set forth by the institutional and national research committees, as well as Declaration of Helsinki and its subsequent amendments, and have been officially documented in the China Liver Transplant Registry (CLTR) System.

Final histopathological analysis of the resected liver confirmed metastatic intestinal adenocarcinoma, with 10 nodules identified in the left lobe and 23 nodules in the right lobe (Figure 2I,2J). Carcinoembryonic antigen (CEA) levels were initially >1,000 µg/L. Following chemotherapy and resection of the primary tumor, CEA levels decreased to 124 µg/L and remained stable until LT. Post-transplantation, CEA levels normalized within one month.

However, in April 2025 (11 months postoperatively), CEA levels exhibited a slight increase to 5.4 µg/L. PET-CT revealed three metastatic nodules in the right lung (<10 mm diameter). Following the MDT discussion, thoracoscopic resection of the nodules was performed in April 2025. Histopathological analysis confirmed adenocarcinoma, with four nodules identified, ranging in size from 3 to 7 mm. Subsequently, the patient received FOLFOX plus cetuximab therapy. As of the latest follow-up, the patient’s overall condition remains satisfactory. No tumor recurrence has been observed at the liver transplant site, and the patient continues to be disease-free.

Within the emerging discipline of “transplant oncology” (7,8), LT has emerged as a viable treatment option for carefully selected patients with u-CRLM. The implementation of stringent selection criteria has enabled the achievement of 5-year OS rates that are comparable to, or even exceed, those observed in other LT indications (9).

A major limitation remains the risk of early, predominantly extrahepatic (often pulmonary) recurrence (10,11). Consequently, the use of deceased-donor organs raises significant ethical concerns, particularly in regions with organ scarcity, as it may divert limited resources from patients with non-malignant diseases. The DD-RAPID scheme (4), which utilizes left lateral split grafts, offers an alternative approach but may disadvantage pediatric recipients due to potential graft size limitations. LD-RAPID represents another viable option; however, the ethical justification for exposing living donors to risks in standard living donor LT (12,13) requires careful evaluation, especially given the experimental nature of this approach, which is characterized by favorable OS rates but a high recurrence rate (14). To date, the largest reported series is a retrospective cohort study conducted between 2015 and 2022 across six European centers, where only 23 non-cirrhotic patients successfully underwent RAPID surgery (20 LD-RAPID, 3 DD-RAPID) (15).

To further minimize donor risks and expand the donor pool, the DL-RAPID approach represents a viable alternative that ensures both safety and efficacy. This innovative strategy effectively expands the donor pool while minimizing potential negative impacts on the deceased-donor waiting list. However, its application is restricted to specific patient populations and should only be conducted in highly specialized hepatobiliary surgery centers with expertise in ALPPS, as well as LT centers experienced in living donor and pediatric LT. In January 2015, our team successfully performed pediatric LT using a graft from an adult donor with FNH in the caudate lobe, utilizing an otherwise-discarded left lobe. Subsequently, in March 2022, we completed a hybrid dual-graft LT, combining an otherwise-discarded lobe with a living donor graft (16). These two recipients have demonstrated excellent recovery to date. Since 2013, our team has performed over 200 cases of ALPPS procedures (17). This extensive experience laid a solid foundation for the successful implementation of the first DL-RAPID surgery.

The principle underlying liver hyperplasia in DL-RAPID is analogous to that of ALPPS. This successful first case of auxiliary LT using an otherwise-discarded graft in combination with ALPPS for u-CRLM highlights the potential for utilizing discarded livers from patients undergoing resection for benign hepatic tumors. Such livers represent a promising novel donor source in the context of the current organ shortage.

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Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures were conducted in strict accordance with the ethical standards set forth by the institutional and national research committees, as well as Declaration of Helsinki and its subsequent amendments, and have been officially documented in the China Liver Transplant Registry (CLTR) System. After approval from the Zhongshan Hospital, Fudan University Medical Ethics Committee for the “DL-RAPID” procedure (No. B2022-138), the option was presented to the patient and her family. Informed consent was obtained from the patient for the publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.