PARENCHYMAL LIVER INJURIES IN ORTHOTOPIC LIVER TRANSPLANTATION (OLT)

Field: Medicine (Health Sciences)

380 Purpose: A 35-year period of clinical development resulted in OLT becoming a standardized surgical procedure. Despite this progress, the rate of technical complications is still high and methods of surgical treatment are poorly reported. So the aim of the study was to present the first published report on the incidence, treatment and clinical course of parenchymal liver injuries in orthotopic liver transplantation. Methods: 572 consecutive OLTs performed between 1988 and 1998 were analyzed in a retrospective study. Parenchymal liver injury was diagnosed by means of examination of the surgical reports. The lesions were classified according to the Organ Injury Scale after Moore. Results: Parenchymal liver injury was diagnosed in 23 (4%) patients. The recipients were 18 men (78%) and 5 women (22%) with a mean age of 52 +/− 7 years. The lesions were classified as grade Ia 13.1%, grade Ib 13.1%, grade IIb 52.1%, grade IIIa 17.4% and grade IIIb in 4.3%. In 19 patients (82.6%) the lesion was detected during OLT and in 4 patients (17.4%) during relaparotomy. The latter group showed significantly higher graded injuries (p=0.01). The causes of the injuries were surgical failures during organ harvesting in 8 cases (34.9%), in 6 cases (26.1%) the lesion came about while the graft was being implanted, in 1 case (4.3%) the lesion was set during intraoperative mechanical cardiopulmonary resuscitation and in one more case (4.3%) the injury originated preoperatively in a donor with polytrauma. In 7 cases (30.4%) the lesion is basically of undetermined origin but came about during the early reperfusion period along with massive reperfusion edema of the transplant. These grafts had no significant longer CIT. Furthermore we observed that the lesion became more severe due to reperfusion edema during intraoperative observation in 3 patients (13,1%) with parenchymal injury that was not primarily associated with reperfusion. There was no significant correlation between the grade and cause of injury, shipped allografts, cold ischemia time, donor age, donor gender or cause of donor death. Treatment was suture or fibringlue alone 17.4%, fibringlue and haemostyptics 26.1%, mesh wrapping 30.4%, and mesh packing 26.1%. Seven patients (30.4%) underwent relaparotomy for several reasons. Further active bleeding or local infection due to implanted foreign material was not found in any of them. Statistical analysis found a correlation between injury grade and relaparotomy rate (p=0.04). Grade of injury or treatment had no significant influence on primary organ function. No patients died or had to be retransplanted due to parenchymal liver injury. Conclusions: Comparing our strategies with common proceedings in traumatology, such a concept is much more aggressive with respect to the low graded injuries. The reason for this different approach is the central role of reperfusion edema, worsening the injury by increased parenchymal tension. So in conclusion, parenchymal liver injuries can be treated well with no adverse effect on patient or graft survival, but an early diagnosis and decision concerning the surgical procedure is required to avoid further complications relating to reperfusion edema.