Chapter 76: Emergency Total Hepatectomy as a Bridge to Liver Transplantation

INDICATIONS AND ETIOLOGY OF LIVER FAILURE

• Highly unstable individuals with liver failure who:

  • Are candidates for liver transplantation

  • Have no immediately available liver grafts for transplantation

  • Have severe physiologic derangements

    • Unresponsive to therapy

    • Entirely attributable to their liver failure

• Causes of liver failure:

  • Fulminant hepatic failure associated with massive necrosis

  • Acute graft failure associated with massive necrosis

  • Primary graft nonfunction

  • Massive trauma with exsanguination

  • Spontaneous hepatic rupture

  • Massive uncontrolled hemorrhage

  • Other

• “Toxic liver syndrome”

  • Total liver necrosis

  • Cardiovascular shock

  • Renal failure

  • Likely respiratory failure

• Need for:

  • Vasopressor support

  • Renal replacement therapy

  • Mechanical ventilation

• The decision to proceed with emergency total hepatectomy as the first of a 2-stage transplant procedure should take into consideration:

  • High mortality associated with:

    • Current condition

    • Anhepatic state

  • Whether total hepatectomy will bring enough stability to justify transplantation

  • Extent and reversibility of multiorgan failure

  • Presence of sepsis

  • Neurologic status

• Intensive medical management is required to maintain some stability during the anhepatic phase.

• In instances where a liver graft becomes available, it should be determined that the recipient is stable enough to tolerate the implantation.

SURGICAL APPROACH

• Total hepatectomy is performed according to the technique chosen for liver transplantation.

• We prefer to preserve the retrohepatic IVC.

• Once the liver is removed, the suprahepatic veins are oversewn (Figs. 76-1 and 76-2).

• A temporary portocaval shunt is then constructed (Figs. 76-3 and 76-4).

• In instances where the retrohepatic IVC is removed, an external venovenous bypass can be instituted.

• Hemostasis should be carefully monitored, since during the anhepatic phase no hepatic coagulation factors are produced and all support is via infused products.

• When a liver graft is available and the recipient considered suitable for transplantation, implantation is undertaken according to the surgeon’s technique of choice.

FURTHER READING