Hyper-Urgent Liver Transplantation for Posttraumatic and Surgical Iatrogenic Acute Liver Failure

  • Andrea LauterioEmail author
  • Stefano Di Sandro
  • Riccardo De Carlis
  • Arianna Ciravegna
  • Paolo Aseni
  • Luciano De Carlis


  • Few literature reports have discussed the role of hyper-urgent liver transplantation (hu-LT) in the treatment of posttraumatic and surgical iatrogenic acute liver failure, indicating that few emergency liver transplants have been performed. Urgent liver transplantation for the treatment of severe traumatic or iatrogenic liver injury may represent a surgical challenge requiring time-consuming surgical procedures such as liver procurement from a deceased donor, total hepatectomy in the recipient, LT as a two-stage procedure, temporary portocaval shunt (TPCS) or venovenous extracorporeal circulation, and complex vascular reconstructions.

  • This chapter summarizes the traumatic and iatrogenic causes of hu-LT and discusses our own experience along with surgical advances in this uncommon clinical setting. For these reasons in the era of organ shortage, when an hu-LT is indicated for a worsening ALF, a careful evaluation of the patient;s clinical conditions is paramount. Signs associated with irreversible neurologic injuries with a near-certain intraoperative or perioperative mortality should be taken into account to avoid wasting of liver grafts.



Acute-on-chronic liver failure


Acute liver failure


Bile duct injury


Extracorporeal liver support




Hyper-urgent liver transplantation


Inferior vena cava


Liver transplantation


Multiple organ failure


Primary nonfunction


Portal vein


Toxic liver syndrome


Temporary portocaval shunt


  1. 1.
    De Gasperi A, Findlay JY, Klinck JR. Critical care of the patient with liver disease. In: Oxford textbook of transplant anaeshesia and critical care.
  2. 2.
    O’Grady JC, Alexander GJ, Hayllar KM, Williams R. Early indicators of prognosis in fulminant hepatic failure. Gastroenterology. 1989;97(2):439–45.CrossRefGoogle Scholar
  3. 3.
    Ringe B, Lübbe N, Kuse E, et al. Total hepatectomy and liver transplantation as two-stage procedure. Ann Surg. 1993;218:3–9.CrossRefGoogle Scholar
  4. 4.
    Nevens F, Laleman W. Artificial liver support devices as treatment option for liver failure. Best Pract Clin Gastroenterol. 2012;26(1):17–26.CrossRefGoogle Scholar
  5. 5.
    Ginsberg Z, Thurman P, Scalea T, Stein D. Extracorporeal liver support for trauma-induced hepatic disfunction. J Trauma Acute Care Surg. 2016;80(6):1039–44.CrossRefGoogle Scholar
  6. 6.
    Tzakis AG, Reyes J, Nour B, Marino IR, Todo S, Starzl TE. Temporary end-to-side portacaval shunt in orthotopic hepatic transplantation in humans. Surg Gynecol Obstet. 1993;176(2):180–2. PMID: 8421808.PubMedPubMedCentralGoogle Scholar
  7. 7.
    Ringe B, Pichlmayr R, Ziegler H, et al. Management of severe hepatic trauma by two-stage total hepatectomy and subsequent liver transplantation. Surgery. 1991;109:792–5.PubMedGoogle Scholar
  8. 8.
    Arora H, Thekkekandam J, Tesche L, et al. Long-term survival after 67 hours of anhepatic state due to primary liver allograft nonfunction. Liver Transpl. 2010;16:1428–33.CrossRefGoogle Scholar
  9. 9.
    Robles R, Parrilla P, Acosta F, Bueno FS, Ramirez P, Lujan JA, et al. Portosuprahepatic shunt as an alternative to portocaval shunt in an hepatic patients waiting for an orthotopic liver transplant. Transplant Proc. 1999;31(6):2400–1. PMID: 10500639.CrossRefGoogle Scholar
  10. 10.
    Pratschke S, Meimarakis G, Bruns CJ, Kaspar M, Prix N, Zachoval R, et al. Temporary intraoperative porto-caval shunt: useless or beneficial in piggy back liver transplantation? Transpl Int. 2013;26(1):90–8. PMID: 23237579.CrossRefPubMedGoogle Scholar
  11. 11.
    Aseni P, Lauterio A, Slim AO, Giacomoni A, Lamperti L, De Carlis L. Life-saving super-urgent liver transplantation with replacement of retrohepatic vena cava by Dacron graft. HPB Surg. 2010;2010. pii: 828326. PMID: 20811479.
  12. 12.
    Starzl TE, Halgrimson CG, Koep LG, Weil R, Taylor PD, et al. Vascular homograft from cadaveric organ donors. Surg Gynecol Obstet. 1979;149:737.PubMedPubMedCentralGoogle Scholar
  13. 13.
    Chatzizacharias NA, Aly M, Praseedom RK. The role of arterial conduits for revascularisation in adult orthotopic liver transplantation. Transplant Rev (Orlando). 2016. pii: S0955-470X(16)30067-2. [Epub ahead of print] Review. PMID: 27884502.
  14. 14.
    Ali MA, Yong CC, Eng HL, Wang CC, Lin TL, Li WF, et al. Cryopreserved arterial grafts as a conduit in outflow reconstruction in living donor liver transplantation. J Hepatobiliary Pancreat Sci. 2015;22(6):498–504. PMID: 25783415.CrossRefPubMedGoogle Scholar
  15. 15.
    Nikitin D, Jennings LW, Khan T, Vasani S, Ruiz R, Sanchez EQ, Chinnakotla S, Levy MF, Goldstein RM, Klintmalm GB. Twenty years’ follow-up of portal vein conduits in liver transplantation. Liver Transpl. 2009;15(4):400–6. PMID: 19326411.CrossRefPubMedGoogle Scholar
  16. 16.
    Palma AF, Oberkofler CE, Raptis DA, Eshmuminov D, de Rougemont O, Schnyder A, et al. Novel rescue procedure for inferior vena cava reconstruction in living-donor liver transplantation using a vascular graft recovered 25 h after donors’ circulatory death and systematic review. Transpl Int. 2014;27(2):204–10. Review.CrossRefPubMedGoogle Scholar
  17. 17.
    Pulitanó C, Crawford M, Ho P, Gallagher J, Joseph D, Stephen M, et al. The use of biological grafts for reconstruction of the inferior vena cava is a safe and valid alternative: results in 32 patients in a single institution. HPB (Oxford). 2013;15(8):628–32. PMID: 23458108.CrossRefGoogle Scholar
  18. 18.
    Esquivel CO, Bernardos A, Makowka L, Iwatsuki S, Gordon RD, Starzl TE. Liver replacement after massive hepatic trauma. J Trauma. 1987;27:800–2.CrossRefGoogle Scholar
  19. 19.
    Krawczyk M, Grat M, Adam R, Polak WG, klempnauer J, Pinna A, et al. Liver transplantation for hepatic trauma: a study from the European Liver Transplant Registry. Transplantation. 2016;100(11):2372–81.CrossRefGoogle Scholar
  20. 20.
    Tinkoof G, Esposito TJ, Reed J, et al. American Association for the Surgery of Trauma Organ Injury Scale I: spleen, liver, and kidney, validation based on the National Trauma Data Bank. J Am Coll Surg. 2008;207:646–55.CrossRefGoogle Scholar
  21. 21.
    Hurtuk M, Reed RL, Esposito TJ, Davis KA, Luchette FA. Trauma surgeons practice what they preach: the NTDB story on solid organ injury management. J Trauma. 2006;61(2):243–54.CrossRefGoogle Scholar
  22. 22.
    Green CS, Bulger EM, Kwan SW. Outcomes and complication of angioembolization for hepatic trauma: a systematic review of the literature. J Trauma Acute Care Surg. 2016;80(3):529–35.CrossRefGoogle Scholar
  23. 23.
    Dabbs DN, Stein DM, Scalea TM. Major hepatic necrosis: a common compliction after angioembolization for treatment of high-grade liver injuries. J Trauma. 2009;66:621–9.CrossRefGoogle Scholar
  24. 24.
    Peitzman AB, Marsh JW. Advanced operative techniques in management of complex liver injury. J Trauma Acute Care Surg. 2012;73(3):765–70.CrossRefGoogle Scholar
  25. 25.
    Coccolini F, Catena F, Moore EE, Ivatury R, Biffl W, Peitzman A, et al. WSES Classification and guidelines for liver trauma. World J Emerg Surg. 2016;11:50.CrossRefGoogle Scholar
  26. 26.
    Roslyn JJ, Binns GS, Hughes EF, Saunders-Kirkwood K, Zinner MJ, Cates JA. Open cholecystectomy. A contemporary analysis of 42,474 patients. Ann Surg. 1993;218(2):129–37. PMID: 8342992.CrossRefGoogle Scholar
  27. 27.
    Richardson MC, Bell G, Fullarton GM. Incidence and nature of bile duct injuries following laparoscopic cholecystectomy: an audit of 5913 cases. West of Scotland Laparoscopic Cholecystectomy Audit Group. Br J Surg. 1996;83(10):1356–60. PMID: 8944450.CrossRefGoogle Scholar
  28. 28.
    Ardiles V, McCormack L, Quinonez E, Goldaracena N, Mattera J, Ciardullo M, et al. Experience using liver transplantation for the treatment of severe bile duct injuries over 20 years in Argentina: results from a National Survey. HPB (Oxford). 2011;13(8):544–50. PMID: 21762297.CrossRefGoogle Scholar
  29. 29.
    Parrilla P, Robles R, Varo E, Jiménez C, Sánchez-Cabús S, Pareja E, Spanish Liver Transplantation Study Group. Liver transplantation for bile duct injury after open and laparoscopic cholecystectomy. Br J Surg. 2014;101(2):63–8. PMID: 24318962.CrossRefPubMedGoogle Scholar
  30. 30.
    Strasberg SM, Gouma DJ. Extreme vasculobiliary injuries: association with fundus-down cholecystectomy in severely inflamed gallbladders. HPB (Oxford). 2012;14(1):1–8. PMID: 22151444.CrossRefGoogle Scholar
  31. 31.
    Leale I, Moraglia E, Bottino G, Rachef M, Dova L, Cariati A, et al. Role of liver transplantation in bilio-vascular liver injury after cholecystectomy. Transplant Proc. 2016;48(2):370–6. PMID: 27109958.CrossRefPubMedGoogle Scholar
  32. 32.
    Huerta S, Li Z, Livingston EH. Outcome of portal injuries following bariatric operations. Obes Surg. 2006;16(1):105–9. PMID: 16417768.CrossRefGoogle Scholar
  33. 33.
    Zaydfudim V, Wright JK, Pinson CW. Liver transplantation for iatrogenic porta hepatis transection. Am Surg. 2009;75(4):313–6. PMID: 19385291.PubMedGoogle Scholar
  34. 34.
    Di Benedetto F, Mimmo A, D’Amico G, De Ruvo N, Cautero N, Montalti R, et al. Liver transplantation due to iatrogenic injuries: two case reports. Transplant Proc. 2010;42(4):1375–7. PMID: 20534306.CrossRefPubMedGoogle Scholar
  35. 35.
    Lauterio A, De Carlis R, Di Sandro S, Ferla F, Buscemi V, De Carlis L. Liver transplantation in the treatment of severe iatrogenic liver injuries. World J Hepatol. 2017;9(24):1022–9. Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  • Andrea Lauterio
    • 1
    Email author
  • Stefano Di Sandro
    • 1
  • Riccardo De Carlis
    • 1
    • 2
  • Arianna Ciravegna
    • 1
  • Paolo Aseni
    • 3
  • Luciano De Carlis
    • 1
    • 4
  1. 1.Department of General Surgery and TransplantationASST Grande Ospedale Metropolitano NiguardaMilanItaly
  2. 2.Department of Surgical SciencesUniversity of PaviaPaviaItaly
  3. 3.Department of EmergencyASST Grande Ospedale Metropolitano NiguardaMilanItaly
  4. 4.University of Milano-Bicocca, School of MedicineMilanItaly

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