Temporary abdominal closure and delayed biliary reconstruction due to massive bleeding in patients undergoing liver transplantation: an old trick in a new indication

Abstract

BackgroundMassive bleeding during liver transplantation (LT) is difficult to manage surgical event. Perihepatic packing (PP) and temporary abdominal closure (TAC) with delayed biliary reconstruction (DBR) can be applied in these circumstances.MethodA prospective database of LT in a major transplant center was analyzed to identify patients with massive uncontrollable bleeding during LT that was resolved by PP, TAC, and DBR.ResultsFrom 2009 to 2013, 20 (3.6%) of 547 patients who underwent LT underwent DBR. Mean intraoperative blood loss was 20,500 ml at the first operation. The DBR was performed with a mean of 55.2 h (16–110) after LT. Biliary reconstruction included duct‐to‐duct (n = 9) and hepatico‐jejunostomy (n = 11). Complications occurred in eight patients and included portal vein thrombosis, cholangitis, severe bacteremia, pneumonia. There was one in‐hospital death. In the follow‐up of 18 to 33 months we have seen one patient died 9 months after transplantation. The remaining 18 patients are alive and well.ConclusionsIn case of massive uncontrollable bleeding and bowel edema during LT, the combined procedures of PP, TAC, and DBR offer an alternatively surgical option to solve the tough situation.

Two-staged biliary reconstruction with temporary complete external biliary drainage as a bailout procedure in a pediatric patient after difficult living donor liver retransplantation

“…Eighty-four of the 150 underwent delayed biliary reconstruction. In both reports, as well in others, the interval between LT and biliary reconstruction was approximately two days, during which hemostasis was achieved with stable vital signs and the general condition of the recipient was deemed fit for relaparotomy (6,7,9). However, our patient was considered too sick to bring back to the operating room at only a few days after reLDLT, as demonstrated by her one-month stay in the intensivecare unit.…”

“…Several centers have previously reported the usefulness of delayed biliary reconstruction after LT (6-8). Komorowski et al (7) reported that perihepatic packing and temporary abdominal closure with delayed biliary reconstruction were viable options for massive uncontrollable bleeding and bowel edema during LT. DiNorcia et al (9) reported on 150 adult patients including retransplantation (29.3%) with postreperfusion hemodynamic instability and coagulopathy during LT which required damage control. Eighty-four of the 150 underwent delayed biliary reconstruction.…”

“…In addition, Roux-en-Y (RY) hepaticojejunostomy in retransplantation cases may require extensive adhesiolysis, putting the patient at an increased risk of bile leakage (5). Delayed biliary reconstruction after a few days from liver transplantation (LT) were reported to avoid initial biliary anastomosis in the literature (6)(7)(8)(9). However, the patient's condition doesn't always recover fully to allow us to perform biliary reconstruction for a few days.…”

Staged Biliary Reconstruction After Orthotopic Liver Transplantation: A Practical Surgical Strategy for High-Acuity Adult Recipients

“…Perihepatic packing and temporary abdominal closure with delayed biliary reconstruction have been employed with reasonable success during massive intraoperative bleeding. 6,23 Busuttil et al 6 from the University of California, LA, recently reported their experience with damage control in the setting of OLT. Interestingly, despite hemodynamic instability and ongoing hemorrhage, outcomes were comparable comparing the damage control recipients and those undergoing primary biliary reconstruction.…”

Excellent Outcome in Living Donor Liver Transplantation: Treating Patients With Acute‐on‐Chronic Liver Failure

“…Moreover, the reason for major reoperation in LT recipients with ACLF in the current study was planned reexploration for staged biliary reconstruction, which was commonly used in our hospital for damage control. (43) In the condition of a higher need for massive transfusion, the bowel wall develops to become edematous and interferes with biliary reconstruction. To obtain a better condition for biliary reconstruction, recipients might be closed temporarily for damage control, and staged biliary reconstruction was performed within 2 to 3 days when the hemodynamics of the patients were stable and the bowel edema was resolved.…”