Liver Transplantation for Hepatic Trauma

Krawczyk, Marek; Grąt, Michał; Adam, René; Polak, Wojciech; Klempnauer, Jürgen; Pinna, Antonio; Benedetto, Fabrizio Di; Filipponi, Franco; Senninger, N.; Foss, Aksel; Rufián-Peña, Sebastián; Bennet, William; Pratschke, Johann; Paul, Andreas; Settmacher, Utz; Rossi, G.; Salizzoni, Mauro; Fernandez-Selles, Carlos; Rituerto, S. Tomé Martínez de; Gómez‐Bravo, Miguel Ángel; Pirenne, Jacques; Detry, Olivier; Majno, Pietro; Němec, Petr; Bechstein, Wolf O.; Bartels, Michael; Nadalin, Silvio; Pruvot, F.R.; Mirza, Darius F.; Lupo, L.; Colledan, M.; Tisone, Giuseppe; Ringers, J.; Daniel, J.; Charco, Ramón; González, Enrique Moreno; Bañares, Rafael; Cuervas-Mons, Valentín; Rodríguez, Fernando San Juan; Yilmaz, Sezai; Remiszewski, Piotr

doi:10.1097/tp.0000000000001398

Cited by 29 publications

(14 citation statements)

References 59 publications

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“…Apart from HCC and high MELD scores, several other conditions are reported to be associated with particularly poor posttransplant outcomes resembling that of the highest-risk HCC patients, such as retransplantation for hepatitis C virus recurrence, trauma, and unresectable neuroendocrine tumors metastases. 25 , 30 , 31 Considering survival benefit, it is the high-risk HCC patients and non-HCC patients that are reported to benefit most from undergoing LT. 18 , 32 , 33 However, pretransplant alpha-fetoprotein was previously found to be inversely correlated with transplant benefit. 34 Therefore, potential expansion of the selection criteria into patients with high alpha-fetoprotein should be considered with great caution considering both transplant utility and benefit.…”

Section: Discussionmentioning

confidence: 99%

Challenging the principle of utility as a barrier for wider use of liver transplantation for hepatocellular cancer

et al. 2017

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Background. Although transplant benefit appears superior for patients with advanced hepatocellular cancer (HCC), liver transplantation remains limited to selected low-risk HCC patients to keep their outcomes similar to heterogeneous group of non-HCC patients. The purpose of this study was to assess the rationale for current policy of restricting access to liver transplantation to minority of HCC patients based on utility principle. Methods. This retrospective cohort study comprised 1246 liver transplant recipients, including 206 HCC and 1040 non-HCC patients. Patient survival was the primary outcome measure. Patients with HCC and benign diseases were divided into low-, moderate-, and high-risk subgroups basing on independent risk factors for disease-free survival and model for end-stage liver disease (MELD) score (\30, 30-40, [40), respectively. Results. MELD (p \ 0.001) and presence of HCC (p = 0.008) were independent risk factors for early and late mortality, respectively. Total tumor volume (p = 0.008) and alpha-fetoprotein (p = 0.013) were independent predictors of recurrence and mortality used for division of HCC patients into low-, moderate-, and highrisk subgroups, with disease-free survival rates of 74.9% (5 years), 51.7% (5 years), and 8.0% (3 years), respectively (p \ 0.001). There were no differences in 5-year overall survival between low-risk HCC (74.9%) and non-HCC (81.9%) patients (p = 0.210), moderate-risk HCC (63.3%) and non-HCC (68.0%) patients (p = 0.372), and high-risk HCC (55.0%) and non-HCC (56.0%) patients (p = 0.559). Conclusions. The principle of utility is unequally applied for restriction of access to liver transplantation for HCC patients. The results provide rationale for discussion on reinitiation of liver transplantation for advanced HCCs.

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Section: Discussionmentioning

confidence: 99%

Challenging the principle of utility as a barrier for wider use of liver transplantation for hepatocellular cancer

et al. 2017

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“…38,39 We found that 9.7% of patients transplanted for trauma were listed as status 1A (acute liver failure), with no significant differences in long-term graft and patient survival compared with those listed under a different status. A study analyzing the European Liver Transplantation registry by Krawczyk et al 9 reported that patients receiving OLT for hepatic trauma had 5-year patient and graft survival rates of 50.7% and 44.9%, respectively, with a notably high 90-day mortality rate of 42.5%. In contrast, we found a 90-day mortality rate of 8.3%, which was not significantly higher than that of the matched control group transplanted for other indications.…”

Section: Discussionmentioning

confidence: 99%

“…Orthotopic liver transplantation is reserved as an alternative treatment for selected patients with complex hepatic injuries. In extreme cases, two-stage total hepatectomy followed by OLT with a portosystemic shunt for up to 36 hours has been described as a salvage procedure for life-threatening injuries 8–33 …”

Section: Discussionmentioning

confidence: 99%

“…It was first described by Esquivel et al 8 in 1987 as a salvage therapeutic option in two patients with nonreconstructable injuries to the porta hepatis with massive destruction of the right hepatic lobe after motor vehicle accidents. Orthotopic liver transplantation can be the only therapeutic option in selected patients with uncontrollable hemorrhage, ischemic cholangiopathy, recurrent cholangitis, or irreversible liver failure after trauma, 8–33 and available data evaluating the role of transplantation after severe hepatic trauma are limited. This study aimed to analyze the surgical outcomes of patients undergoing liver transplantation for hepatic trauma using the United Network for Organ Sharing (UNOS) data set.…”

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confidence: 99%

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Liver transplantation for severe hepatic trauma: A multicenter analysis from the UNOS data set

Orozco,

Gupta,

Ancheta

et al. 2023

J Trauma Acute Care Surg

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Background Orthotopic liver transplantation (OLT) is rarely indicated after hepatic trauma but it can be the only therapeutic option in some patients. There are scarce data analyzing the surgical outcomes of OLT after trauma. Methods We used the UNOS dataset to identify patients who underwent OLT for trauma from 1987 to 2022, and compared them to a cohort of patients transplanted for other indications. Cox proportional hazard and multivariable logistic regression analyses were performed to assess predictors of graft and patient survival. Results 72 patients underwent OLT for trauma during the study period. Patients with trauma were more frequently on mechanical ventilation at the time of transplantation (26.4% vs. 7.6%, p < 0.001) and had a greater incidence of pre-transplant portal vein thrombosis (PVT) (12.5% vs. 4%, p = 0.002). Our 4:1 matched analysis showed that trauma patients had significantly shorter wait times, higher incidence of pre-transplant PVT and prolonged length of stay (LOS). Trauma was associated with decreased overall graft survival (HR = 1.42, 95% CI = 1.01-1.98), and increased LOS (p = 0.048). There were no significant differences in long term patient survival. Conclusion Unique physiological and vascular challenges after severe hepatic trauma might be associated with decreased graft survival in patients requiring liver transplantation. Level of evidence Retrospective cohort study, III.

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“…Grade V–VI injuries are associated with hepatic avulsion or porta hepatis injury (grade III, Niamieno et al ). [3] It suppose such a challenge for any surgeon that, in extreme cases, liver transplantation may be the best therapeutic option [4].…”

Section: Introductionmentioning

confidence: 99%

Liver transplantation following hepatic artery avulsion in a trauma patient

Cepedal

Mateo

Prieto

et al. 2019

Journal of Surgical Case Reports

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Background Hepatic artery avulsion following politrauma is an extremely rare condition with a very high mortality rate. Management is based on damage control surgery given the precarious situation of these patients. Ligating the artery is one option under such circumstances, despite potential consequences including ischemic cholangiopathy (IC). Ischemic cholangiopathy, which can be caused by an insufficient blood supply to the bile duct, generally results in stricture and recurrent cholangitis, and the need for a liver transplant in extreme cases. Case presentation We present the case of a 37-year-old male with multiple traumas after falling from the third floor of a building. He was hemodynamically unstable upon arrival at the emergencies department, with no improvement on administration of aggressive fluid therapy. A Echo-FAST exam evidenced fluid in all quadrants, so the patient was transferred to the operating room where a 4-litre hemoperitoneum secondary to total avulsion of the proper hepatic artery was observed. The patient required massive transfusion and vasoactive drugs, with instability throughout the intervention; therefore, we decided to ligate the proper hepatic artery. Hepatic dysfunction and diffuse IC with multiple episodes of recurrent cholangitis were observed during the postoperative period. Given the irreversible clinical picture, we opted for a liver transplant 70 days after the patient’s initial admission. The patient died on Day 34 post-transplant due to irreversible ischemic brain damage and a right occipital hemorrhage. Conclusions Hepatic artery avulsion due to trauma is very rare and its management very complex, and in certain situations the artery must be ligated. The main consequence of ligating the hepatic artery is IC, which is more frequently observed secondary to iatrogenic lesions or systemic diseases, while very few cases have been published in which IC is secondary to hepatic artery avulsion caused by hepatic trauma. Treatment depends on the extent of ischemia, and when the damage is diffuse, as in our case, it may involve a liver transplant.

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Liver Transplantation for Hepatic Trauma

Abstract: Liver transplantation seems to be justified in selected patients with otherwise fatal severe liver injuries, particularly in whom cross-clamping without extracorporeal bypass can be omitted. The ISS cutoff less than 33 may be useful in the selection process.

Cited by 29 publications

References 59 publications

Challenging the principle of utility as a barrier for wider use of liver transplantation for hepatocellular cancer

Challenging the principle of utility as a barrier for wider use of liver transplantation for hepatocellular cancer

Liver transplantation for severe hepatic trauma: A multicenter analysis from the UNOS data set

Liver transplantation following hepatic artery avulsion in a trauma patient

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