Auxiliary Partial Autologous Liver Transplantation for High-selective Alveolar Echinococcosis: A Proof of Concept

Hepatic alveolar echinococcosis (AE) has been regarded as a neglected tropical disease with high pathogenicity and mortality. Radical lesion resection with negative margins associated with antiparasitic medication therapy is the only curative option.1 Even allogenic liver transplantations and ex vivo liver resection and autotransplantation (ELRA) techniques have been introduced for advanced AE cases.2 CASE PRESENTATION An 18-year-old female patient was referred to our center with chief complaint of liver mass detected by ultrasonography. She was diagnosed as hepatic AE, with the help of computed tomography, magnetic resonance imaging, and positive serological tests. Positron-emission-tomography using [18F] fluorodeoxyglucose showed metabolic activity of the lesion. Three-dimensional visualization revealed that the lesion was mainly located in segments (S.) VIII and S.IV, and extended into S.V, S.VII and partially S.I; main stems of right and middle hepatic veins (RHV, MHV) plus right orifice of left hepatic vein (LHV) were also infiltrated; retro-hepatic inferior vena cava (RHIVC) was stenosed; estimated volume of left lateral lobe (LLL) and right posterior lobe were, respectively, 318.5 cm3 and 431.2 cm3, composing 27.8% and 37.7% of estimated standard liver volume (Figure S1, SDC, https://links.lww.com/TP/B857). Conventional hepatectomies seemed risky because there would be prolonged vascular blockade, severe ischemic-reperfusion injuries or major bleedings. LLL alone could not tolerate and there might be postoperative small-for-size syndrome.3 Techniques like portal vein embolization and associated liver partition and portal vein ligation for staged hepatectomy would have wasted 1 of the liver parts and probably increased complications. Therefore, after multidisciplinary team discussion, risk stratification, and based on our past experiences in ELRA,2 we planned auxiliary partial autologous liver transplantation with 3 major steps (Figure S2, SDC, https://links.lww.com/TP/B857). SURGERY First, whole liver was mobilized and right trisectionectomy was performed, leaving a small piece of lesion at the LHV wall to keep the vein safe and minimize blood loss. Then the liver was immediately placed into back-table sterile ice-bath under histidine-tryptophan-ketoglutarate solution at 0–4°C infusion via portal vein and hepatic artery. During extracorporeal hepatectomy, that little lesion piece was radially removed and the LHV was sutured using 6-0 proline. Notably, RHIVC was sutured for minor lesion invasion, and its normal morphology was restored. Second, ex vivo liver resection was performed to lesion eradication using previous methods. An auto-graft with segment VI plus partial segments VII and V was prepared. Third, the graft was autotransplanted back to the liver fossa: RHV was anastomosed to RHIVC with end-to-side pattern; right portal vein, hepatic artery and hepatic duct were anastomosed to the relevant vasculatures using end-to-end style. At last, the graft liver formed the partial autologous graft, while, LLL remained as native/residual liver, for which ischemic-reperfusion injury was avoided (Figure 1).FIGURE 1.: Three-step surgical procedure. A, Surgical exposure of upper abdominal cavity, liver, right diaphragm as well as lesion surface. B and C, Liver parenchymal partition (B) for extended right hepatectomy (C). D and E, Ex vivo liver resection (D) and the prepared right posterior lobe graft (E). F, Autotransplantation of the right posterior lobe graft.Whole procedure and postoperative recovery were uneventful without any obvious complications. Bilirubin and aminotransferase recovered to normal ranges at 6 and 13 days after surgery, respectively. Histopathological evaluation confirmed hepatic AE diagnosis. The patient was discharged at postoperative 13th day and followed-up routinely for 24 months, during which she took 10 mg/kg/day albendazole (Figures S3 and S4, SDC, https://links.lww.com/TP/B857). She is now having a happy and normal life. DISCUSSION In this proof of concept, ELRA was modified into APALT in this high-selective case, enriching treatment options for advanced AE cases as well as the practice and knowledge of transplant society to alleviate organ shortage. This pioneering procedure integrated techniques from split liver transplantation, partial liver transplantation, living-donor liver transplantation, reduced-size liver transplantation, auxiliary liver transplantation, and showed great advantages. To conclude, we reported world first case that received APALT for advanced AE, with no apparent procedure-specific complications and full recovery. This promising technique may fulfill liver transplantation criteria and treatment modalities in high-selective patients and increase tumor resectability. Possible most amount of parenchymal preservation, no need for immunosuppressive drugs, unnecessity for organ donor were the 3 main elements that best characterize this technique. See Supplemental Digital Contents for more information.