Printed below is the discussion of The European Surgical Association paper “Auxiliary Partial Orthotopic Versus Standard Orthotopic Whole Liver Transplantation for Acute Liver Failure: A Reappraisal From a Single Center by a Case Control Study” by Daniel Azoulay, MD, PhD, and colleagues. We sincerely regret the inadvertent omission of this discussion from the December 2001 issue of Annals of Surgery in which it should have been printed immediately following the paper.
The Publishers and Editors
Prof. J. Izbicki: I congratulate Dr. Azoulay and his associates on an important paper. This study clearly shows that the theoretical advantages of APOLT (namely, regeneration of the native liver and therefore the possibility of graft removal as a consequence omission of life long immunosuppression) are really achieved in your study in less than 20% of patients. With the price of higher morbidity and retransplation rate, I have two questions.
First, you conclude that APOLT rarely achieved its goal of regeneration. Could it be that this is due to the sharing of portal blood flow? Have you monitored the distribution of portal blood flow for the native liver and for the graft?
Second, although you did not say it here in the talk, I had the opportunity to review the manuscript: Although you feel the place of APOLT in the treatment of acute liver failure should be limited, you ask for further studies regarding neurological complications. Which criteria would you want in order to select those patients who should undergo APOLT?
Again, this is an important paper and I thank you for the opportunity to review it.
Prof. D. Jaeck: I appreciate your paper very much. As you know, we in Strasbourg have experienced 15 patients with fulminant hepatic failure treated by APOLT. Ten patients survived (66.7%) and six of them were able to stop immunosuppressive treatment permanently. Between 1987 and 1999 we treated 41 patients with conventional orthotopic liver transplantation for fulminant hepatic failure, with a 63% survival rate. Our strategy is to perform APOLT in younger patients (less than 40 years old) with a fulminant rather than sub-fulminant liver failure, and only if a good quality liver graft is available. I would like to know what your opinion is concerning this strategy.
Prof. P. Neuhaus: My first question is on pressure monitoring. Interestingly, you reported on two cases with severe complications. The debate about intracerebral pressure monitoring and possible complications has been a topic of discussion for a long time. What is your present advice on the use of pressure monitoring?
My second question refers to the chance of adult right lobe living donation. Would you consider living donation for the fulminant cases and use it as a total replacement, or in an auxiliary fashion? I think this is a very important paper, because the enthusiastic reports on auxiliary partial orthotopic liver transplantation deserve a scientific discussion beyond the technical aspects.
Prof. J. B. Belghiti: I can confirm that during the early phase of our experience with auxiliary liver transplantation (ALT) for acute liver failure our results were comparable to those reported by Dr. Azoulay. From 1993 to 1995, three of the four patients who underwent ALT died within the first 3 postoperative months. During the second period, however, the 1 year survival of the 15 patients who underwent ALT, including one from a living donor, was 71% as compared with 81% in the 33 patients who underwent total transplantation for the same indication. It was possible to stop immunosuppression in 50% of the patients up to 27 months after ALT.
We believe this improvement results from a change in our policy, restricting ALT to 1/3 of our patients with liver failure, excluding those with severe renal failure and/or immediate risk of cerebral herniation, and using only ABO-compatible good right liver graft. According to the good results published by the Paul Brousse group with split liver transplantation in adults, I wonder if an insufficient selection could explain these disappointing results.
Prof. J. Baulieux: My congratulations to Dr. Azoulay on an excellent paper. I have just a short question. You consider the removal of the grafts a full success after APOLT. In case of regeneration of the native liver, are you always obliged to do the removal of the graft?
Prof. D. Azoulay (closing): Thank you for all these comments. You may know that Cilelusse died last night when he was playing Verdi in Berlin. I hope I will survive all these questions and comments.
First of all, we did not monitor the portal blood flow. Second, I say in our paper that more work is needed; this is a euphemism. Really, I think that the indications of this operation are very, very limited. More work is needed and I have been asked about which group, probably about the group described by Professor Jaeck, less than 20 years with fulminant hepatitis transplanted with a good liver graft. It is clear, these are the only patients and only conditions in which more work could be done.
About the cranial pressure monitoring: we have stopped using this pressure monitoring for fulminant hepatitis because we had complications, and we have not proved that it was absolutely necessary to manage these patients.
For the living related liver transplantation: we use the living related liver transplantation for fulminant hepatitis. We would probably take the right liver for an adult recipient and probably perform a usual transplantation, the standard one.
In 1984, we did probably the first case of auxiliary liver transplantation for fulminant hepatitis with a living donor. It was reported in Annals of Surgery in 1996. We had to do an auxiliary graft, because we decided at that time to take a leg graft and we were afraid that this small graft was not enough for the recipient. In fact, it failed.
For the removal of the graft: probably, there is no absolute rule to remove the graft. The only risk is if a cimhalis develops in this graft, there is a long-term risk of hepatocellular carcinoma. However, to remove the graft is a very risky operation and several cases of death have been described after removal of the graft. So the question remains open.
For the learning curve: I am still on the learning curve and cannot answer this kind of question. I will answer it when I am on top of the curve.
Thank you again.