Fulminant and fatal gas gangrene of the stomach in a healthy live liver donor

Abstract

A 57-year-old male with a history of hypercholesterolemia and anxiety but otherwise in good health volunteered to donate the right lobe of his liver to his brother. The operation was performed uneventfully, without transfusion. Postoperatively he did well, until he developed tachycardia, profound hypotension, and coffee ground emesis on postoperative day 3. Despite resuscitative measures, he arrested and expired. Autopsy demonstrated gas gangrene of the stomach as the underlying cause of the hemorrhage and numerous colonies of Gram-positive bacilli were identified. Subsequent polymerase chain reaction (PCR) analysis identified these bacteria to be Clostridium perfringens (C. perfringens) type D. This patient's death was devastating, both to his family and his medical team. The impact of his death has transcended that of an individual occurrence. In conclusion, herein we present the facts and discuss this extraordinary example of florid clostridial infection and toxin-mediated shock. It was completely unexpected and probably unpreventable, and its cause was almost inconceivable. L iving donor liver transplants have been performed with increasing frequency. Formally and informally, 9 donor deaths have been reported. 1 -3 After performing more than 175 living donor liver transplants, we report the death of a donor in our program.The patient was a 57-year-old male with a history of hypercholesterolemia and anxiety but otherwise in good health, who volunteered to donate the right lobe of his liver to his brother. He had allergies to penicillin and bee venom. He took atorvastatin daily and clonazepam as needed. Preoperative evaluation followed our protocol. 4 Preoperative liver biopsy was normal. He was admitted the morning of surgery and received preoperative vancomycin and aztreonam.The operation was performed using previously described techniques. 5 The donor remained hemodynamically stable, required no transfusion, and was extubated in the operating room. Postoperative medications included epidural fentanyl, an H 2 -blocker, prophylactic antibiotics for 48 hours, and intravenous fluids. He stayed overnight in the recovery room and was transferred to the inpatient floor the following morning. Table 1 shows postoperative laboratory results. He was given liquids on postoperative day 1. Later, he felt so well that he asked his family for a lobster dinner from a local restaurant. The next morning, he felt well and sat in a chair. Temperature was 37.2°C, pulse was 79 beats per minute, and blood pressure was 126 / 69 mmHg. That evening, he complained of nausea and hiccups and was given metoclopramide and later thorazine. At midnight, his temperature was 36.8°C, his pulse was 115 beats per minute, and his blood pressure was 145 / 103 mmHg.Early on postoperative day 3, he was without complaints and sat in a chair. That afternoon, he again felt nauseated and had a small amount of guaiac-positive emesis. His tachycardia progressively worsened; 2 hours later he vomited again. Shortly thereafter, he became hypoxic and hypotens...

Revisiting the Safety of Living Liver Donors by Reassessing 441 Donor Hepatectomies: Is a Larger Hepatectomy Complication-Prone?

“…As shown in Figures 3 and 4, metabolic and productive burdens of remnant livers proved by blood tests after RH were large compared to those after LH or LLS, even though we set the limit on remnant liver volume at 35%. There have been devastating consequences after living liver donation around the world, most of which occurred after right hepatic donation (28)(29)(30)(31)(32). Enthusiasm for the use of extensive RH grafts has been recently dampened in many transplant centers since those devastating reports were published.…”

Minimum graft size calculated from preoperative recipient status in living donor liver transplantation

“…(1)(2)(3)(4)(5)(6) Morbidities among living donors are reported to be more frequent in right lobectomy than left lobectomy or left lateral sectionectomy. (7) Many transplant programs use a left lobe graft in LDLT to minimize morbidities in living donors.…”

Donor Morbidity After Living Donation for Liver Transplantation

“…The initial reports of high recipient successes and low donor morbidity rates 10,11 led to rapid expansion of adult-to-adult LDLT, and, by 2001, this procedure accounted for more that 400 transplantations (~10% of all adult liver transplantations done in the United States that year). However, following a well-publicized donor death in 2002, 12 rates of adult-to-adult LDLT declined precipitously and have remained in the range of 250-300 per year subsequently. A major reassessment of the risks of right lobe liver donation has led to a more cautious approach to the use of this procedure.…”