Auxiliary Liver Transplantation With Delayed Total Hepatectomy: Evolution From 2-stage APOLT to RAPID Following the ALPPS Principles

The resection and partial liver segment 2/3 transplantation with delayed total hepatectomy (RAPID) represents an innovative fusion of 2 of the most challenging procedures of modern liver surgery: auxiliary partial orthotopic liver transplantation and associating liver partition and portal vein ligation for staged hepatectomy. By combining the principles of auxiliary partial orthotopic liver transplantation of partial graft implantation with staged parenchymal modulation of associating liver partition and portal vein ligation for staged hepatectomy, RAPID enables sequential hypertrophy of the transplanted graft followed by complete native liver removal, addressing critical limitations in donor-recipient size matching. Current evidence highlights its primary application in treating unresectable hepatic malignancies, demonstrating advantages over conventional strategies in preserving functional liver volume, minimizing the risk of small-for-size syndrome, and accelerating graft regeneration. However, the procedure faces unresolved challenges, including ethical debates over living donor utilization in oncological contexts, necessity and feasibility of portal inflow modulation, optimal timing for delayed hepatectomy, insufficient long-term oncological outcome data and so on. This review provides an overview of the past and current status of RAPID, especially with respect to its evolution, indication, and technical details, as well as the potential challenges that have been discussed. Additionally, future directions of this surgical paradigm are outlined.