Revisiting Auxiliary (APOLT) Transplantation in Children

Auxiliary partial orthotopic liver transplantation (APOLT) has evolved from a technical challenge into a sophisticated therapeutic strategy for selected pediatric patients with acute liver failure (ALF) and non-cirrhotic metabolic liver diseases (NCMLD). In ALF, APOLT acts as a temporary bridge to native liver regeneration, offering the unique possibility of complete immunosuppression withdrawal. For patients with NCMLD, the procedure corrects critical metabolic defects while preserving the native liver, positioning it as a biological platform for emerging curative treatments like in vivo gene editing. Historically, the widespread adoption of APOLT was limited by technical challenges, notably portal steal leading to graft atrophy. This review summarizes the evolution of APOLT, detailing its indications, technical refinements, and outcomes; thereby presenting its advanced surgical techniques, such as portal flow modulation and refined anastomotic strategies, that have successfully overcome these risks, achieving outcomes comparable to standard orthotopic liver transplantation in experienced centers. We also highlight innovations like domino-auxiliary procedures and the first successful robotic APOLT, which underscore the procedure's technical progress. The conclusion asserts that APOLT's future is tied to advances in regenerative medicine, especially CRISPR-based gene therapies that may offer a definitive cure. Realizing this potential, however, necessitates a structured global effort to disseminate surgical expertise through mentorship programs and international registries. APOLT now serves as a critical bridge between conventional transplantation and a new era of molecular and regenerative cures for pediatric liver disease.