Format

Send to

Choose Destination
JAMA Surg. 2015 Nov;150(11):1066-72. doi: 10.1001/jamasurg.2015.1853.

Damage Control as a Strategy to Manage Postreperfusion Hemodynamic Instability and Coagulopathy in Liver Transplant.

Author information

1
Division of Hepatopancreatobiliary Surgery and Abdominal Organ Transplantation, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles.
2
Dumont-UCLA Liver Cancer and Transplant Centers, Pfleger Liver Institute, Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles.
3
Department of Anesthesiology, David Geffen School of Medicine at University of California, Los Angeles.

Abstract

IMPORTANCE:

Damage control (DC) with intra-abdominal packing and delayed reconstruction is an accepted strategy in trauma and acute care surgery but has not been evaluated in liver transplant.

OBJECTIVE:

To evaluate the incidence, effect on survival, and predictors of the need for DC using intra-abdominal packing and delayed biliary reconstruction in patients with coagulopathy or hemodynamic instability after liver allograft reperfusion.

DESIGN, SETTING, AND PARTICIPANTS:

We performed a retrospective analysis of adults undergoing liver transplant at a large transplant center from February 1, 2002, through July 31, 2012.

MAIN OUTCOMES AND MEASURES:

Predictors of DC, effects on graft, and patient survival.

RESULTS:

Of 1813 patients, 150 (8.3%) underwent DC during liver transplant, with 84 (56.0%) requiring a single additional operation for biliary reconstruction and abdominal closure and 57 (38.0%) requiring multiple additional operations. Compared with recipients without DC, patients requiring DC had greater Model for End-stage Liver Disease scores (33 vs 27; P < .001); more frequent pretransplant hospitalization (72.0% vs 47.9%; P < .001), intubation (33.3% vs 19.9%; P < .001), vasopressors (23.2% vs 10.9%; P < .001), renal replacement therapy (49.6% vs 30.3%; P < .001), and prior major abdominal operations (48.3% vs 21.9%; P < .001), including prior liver transplant (29.3% vs 8.9%; P < .001); greater operative transfusion requirements (37 vs 13 units of packed red blood cells; P < .001); worse intraoperative base deficit (10.3 vs 8.4; P = .03); more frequent postreperfusion syndrome (56.2% vs 27.3%; P < .001); and longer cold (430 vs 404 minutes; P = .04) and warm (46 vs 41 minutes; P < .001) ischemia times. Patients who underwent DC followed by a single additional operation for biliary reconstruction and abdominal closure had similar 1-, 3-, and 5-year graft survival (71%, 62%, and 62% vs 81%, 71%, and 67%; P = .26) and patient survival (72%, 64%, and 64% vs 84%, 75%, and 70%; P = .15) compared with recipients not requiring DC. Multivariate predictors of DC included prior liver transplant or major abdominal operation, longer pretransplant recipient and donor length of stay, greater Model for End-stage Liver Disease score, and longer warm and cold ischemia times (C statistic, 0.75).

CONCLUSIONS AND RELEVANCE:

To our knowledge, this study represents the first large report of DC as a viable strategy for liver transplant recipients with coagulopathy or hemodynamic instability after allograft reperfusion. In DC recipients not requiring additional operations, outcomes are excellent and comparable to 1-stage liver transplant.

PMID:
26308380
DOI:
10.1001/jamasurg.2015.1853
[Indexed for MEDLINE]

Supplemental Content

Full text links

Icon for Silverchair Information Systems
Loading ...
Support Center