Living-related auxiliary partial orthotopic liver transplantation for primary sclerosing cholangitis - Subsequent removal of the native liver

In Japan, living-related auxiliary partial orthotopic liver transplantation (APOLT) is mainly indicated for small-for-size grafts. We present the case of a 24 year-old patient with primary sclerosing cholangitis (PSC) who underwent a living-related auxiliary partial orthotopic liver transplantation for a small-for-size graft, that was subsequently excised. During the transplantation procedure, the native liver was freed from the surrounding tissues, and was only connected to the body by the right hepatic artery and right hepatic vein. The auxiliary extended left lobe graft, corresponding to 22% of the estimated recipient liver volume, was orthotopically transplanted after extended left lobectomy of the recipient native liver. Post-transplant CT-volumetry showed rapid increase of the graft volume with atrophy of the native liver, and GSA scintigraphy showed dominant function of the graft. Although hyper-bilirubinemia was prolonged by the removal of the native liver on the 18th post-transplantation day, it gradually subsided after plasmapheresis was performed twice, and the patient was discharged on the 77th post-transplantation day. We conclude, based on this case, that subsequent removal of the native liver is necessary in APOLT for patients with potential hepatic malignancies. The optimal timing of the removal of the remnant native liver should be determined based on CT-volumetry, GSA scintigraphy, and the liver biopsy specimen of the graft.