Organ shortages present a problem for liver transplant. Use of traumatized livers could be a way of expanding the donor pool.

We report the case of a liver transplant we did in which we used a deeply lacerated liver obtained from a donor, previously treated with a super-selective embolization of segment VI-VII arterial branches to control bleeding. At the back table, the lacerations were repaired using fibrin sealant and stitches. Organ reperfusion was homogeneous, without signs of bleeding. The recipient’s postoperative course was uneventful.

Injured livers, if well selected, may not be considered an absolute contraindication for liver transplant. However, in these cases, arterial embolization must not routinely be used for a graft for a liver transplant.

Key words : Blunt injury, Liver transplant, Interventional radiology,Expanded donor pool, Fibrin sealant

Introduction

Organ shortages represent a challenging problem for a liver transplant (LT). Today, extended-criteria donations are largely adopted to expand the donor pool1; traumatized livers from deceased-donors after blunt injury are considered in this group.²

Trauma is a common cause of multiorgan donor death.³ However, limited reports exist on the use of injured livers for LT^.2,4-8 Many centers consider traumatized grafts a contraindication for LT, mainly because of high-grade lacerations; consequently, several of these donors are commonly declined.⁹ We report the case of a successful LT performed using a high-grade lacerated liver previously treated with a super-selective arterial embolization for bleeding control.

A 15-year-old boy was hospitalized in an emergency department after he had been in a motor vehicle accident. On admission, the boy was comatose, with a systolic blood pressure of 60 mm Hg and no response to pain stimuli. After he was stabilized, a computed tomography scan was performed, which showed a massive intracerebral hemorrhage and a grade 4 liver laceration involving segments VI and VII (Figure 1A). After unsuccessful liver packing, a hepatic arteriography followed by a super-selective embolization of the VI-VII arterial branches were performed, blocking the bleeding (Figure 1B).

After confirming the status of the brain death, the patient was considered suitable for organ donation. Procurement was performed 48 hours after the first laparotomy: during depacking, no signs of bleeding were observed. At the back table, deep parenchymal lacerations of segments VI-VII were repaired using a fibrin sealant and then stitched. Other minor parenchymal lesions were stitched exclusively. At the level of the porta hepatis, no lesions involving vessels and major bile ducts were ruled out. We used Prolene 2.0 and 3.0 for the stitches, placing simple and figure 8 stitches according to the characteristics and dimensions of the liver lacerations to be repaired.

The liver recipient was a 57-year-old woman who had hepatitis C-related cirrhosis. She was selected according to the philosophy of “the sickest first”: in fact, this patient had a higher Model for End-Stage Liver Disease score (17 points) compared with the other candidates of the same blood group on the waiting list.

Organ reperfusion was homogeneous and without bleeding from the lacerated areas (Figure 2); an immediate liver function restoration was observed. A computed tomography scan performed 48 hours after an LT showed a normal parenchyma without signs of altered perfusion or segmental ischemia. The patient was discharged 14 days after the LT, and was followed until the time of this writing in our out-patient clinic for 36 months (Figure 3).

Transplant surgeons consider traumatized livers as high-risk grafts: parenchymal lacerations, postre­per­­fusion bleeding, and posttraumatic hypoperfusion areas may represent risk factors for developing initial poor graft function.² Moreover, an injured liver also could lead to hepatic abscesses or bilomas.⁵

Only careful donor selection could reduce these risks.⁴ In our case, a super-selective arterial embolization was performed to stabilize the donor before procurement. A radiologic approach is commonly used to manage massive liver trauma, and arterial branch embolization is often adopted as first-line approach with excellent results.¹⁰

Obviously, despite the excellent results obtained in the aforementioned case, this case represents an exception more so than a rule. In our opinion, systematic application of embolization in severely lacerated livers for an LT must be avoided, and only well-selected organs not affected by major vascular or biliary lesions should be considered for this approach.

References:

1. Mittler J, Pascher A, Neuhaus P, Pratschke J. The utility of extended criteria donor organs in severely ill liver transplant recipients. Transplantation. 2008;86(7):895-896.
   CrossRef - PubMed
2. Mehrabi A, Fonouni H, Ahmadi R, et al. Transplantation of a severely lacerated liver--a case report with review of the literature. Clin Transplant. 2009;23(3):321-328.
   CrossRef - PubMed
3. Singhal AK, Sheng X, Drakos SG, Stehlik J. Impact of donor cause of death on transplant outcomes: UNOS registry analysis. Transplant Proc. 2009;41(9):3539-3544.
   CrossRef - PubMed
4. Avolio AW, Agnes S, Chirico AS, Cillo U, Frongillo F, Castagneto M. Successful transplantation of an injured liver. Transplant Proc. 2000;32(1):131-133.
   CrossRef - PubMed
5. Cowie SE, Yoshida EM, Ryan AG, et al. Hepatic abscesses after liver transplantation secondary to traumatic intrahepatic bile duct injuries in a cadaveric allograft donor. Transpl Int. 2004;17(7):379-383.
   CrossRef - PubMed
6. Broering DC, Gundlach M, Bockhorn M, Malagó M, Rogiers X. Transplantation of traumatized livers: is it safe? Transplant Proc. 1999;31(1-2):540.
   CrossRef - PubMed
7. Di Benedetto F, Quintini C, De Ruvo N, et al. Successful liver transplantation using a severely injured graft. J Trauma. 2007;63(1):217-220.
   CrossRef - PubMed
8. Tucker ON, Girlanda R, Rela M, Heaton ND, Muiesan P. Successful outcome following transplantation of an injured liver from a nonheart beating donor. Transpl Int. 2005;18(6):724-726.
   CrossRef - PubMed
9. Geenen IL, Sosef MN, Shun A, et al. Usage and outcomes of deceased donor liver allografts with preprocurement injury from blunt trauma. Liver Transpl. 2009;15(3):321-325.
   CrossRef - PubMed
10. Wahl WL, Ahrns KS, Brandt MM, Franklin GA, Taheri PA. The need for early angiographic embolization in blunt liver injuries. J Trauma. 2002;52(6):1097-1101.
    CrossRef - PubMed