EXPERIMENTAL AND CLINICAL TRANSPLANTATION

Following a motor-vehicle accident, a 57-year-old man was diagnosed with a grade 4 liver injury (American Association for the Surgery of Trauma organ injury scale) with multiple contrast extravasations. He initially underwent nonoperative management, which included transcatheter arterial embolization. However, he experienced a hemorrhage after the first embo-lization procedure, and so the procedure was repeated. Thereafter, he was diagnosed with liver failure based on findings from computed tomography and liver function tests. On day 28 of hospitalization, the patient underwent deceased donor liver transplant. He experienced several complications, including acute renal failure, pneumonia, and bile leak. These were managed successfully, and the patient was discharged 4 months after the transplant. Although liver transplant procedure for hepatic trauma is technically challenging and risky, it should be considered a viable treatment option in some patients (such as patients with severe liver injury). This is the first reported case, to our knowledge, of a liver transplant performed successfully in a patient with severe hepatic trauma in Korea.

Key words : Acute liver failure, Blunt injury, Hemorrhage, Hepatic abscess

Liver trauma management has markedly evolved with time. Previously, exploratory laparotomy was the primary treatment option for liver trauma.1 However, with advancements in diagnostic and therapeutic radiology procedures (including transcatheter arterial embolization), nonoperative management has become the standard treatment for patients with stable hemodynamics.^2,3 Despite the standardization of early liver trauma management, delayed management of various complications (such as bilomas, liver abscesses, and liver necrosis) has not been standardized.⁴ Liver transplant is a highly demanding procedure; thus, it is rarely performed for the treatment of liver trauma, except for in a few serious cases (such as after acute bleeding liver trauma or after liver failure secondary to severe liver trauma).⁵ We present a case of liver transplant for successful delayed management of liver failure secondary to a blunt hepatic injury. Our case highlights the importance of transplant as a viable treatment option for severe liver injury. To our knowledge, this is the first report on liver transplant for liver trauma in Korea.

This report received ethics approval from the institutional review board of the Gachon University Gil Hospital, College of Medicine, Incheon, Korea (GDIRB2023-144). The patient provided informed consent for the study’s content and the disclosure of clinical images.

A 57-year-old man was brought to our trauma center after a motor-vehicle accident. He was alert and oriented, and his blood pressure and heart rate on arrival were 97/56 mm Hg and 82 beats/min, respectively. His medical history was unremarkable. An initial focused abdominal sonography for trauma did not reveal any fluid collection in the abdominal cavity. Thus, the patient was scheduled for a computed tomography (CT) scan, which revealed a liver injury (American Association for the Surgery of Trauma organ injury scale grade 4) with multiple contrast extravasations (Figure 1, A-C). Furthermore, he had sustained multiple rib fractures and a right acetabular fracture.

Transcatheter arterial embolization was initiated 95 minutes after arrival at the trauma center. Multiple bleeding foci were identified on a hepatic arteriogram (Figure 1D). The bleeding hepatic A3 and A7 branches and the dorsal/ventral A8 branches were embolized using Gelfoam (Pfizer) or Histoacryl (Braun). On postoperative day 2, his hemodynamic status stabilized; however, due to persistent anemia and a continuously prolonged prothrombin time, the patient required transfusion of 2 units of packed red blood cells and 3 units of fresh-frozen plasma. Therefore, to identify possible remnant bleeding, we performed follow-up CT, which revealed multiple pseudoaneurysms of hepatic segments 4 and 5. The patient underwent transcatheter arterial emboli-zation again for the pseudoaneurysms from the A4 branch, A6 branch, and cystic artery branch using Gelfoam or Histoacryl.

The patient developed acute kidney injury on postoperative day 6, and continuous renal repla-cement therapy was initiated on postoperative day 8. On the same day, the patient had a fever of 38.3 °C. His inflammatory markers were also elevated (C-reactive protein level of 21.19 mg/dL and procalcitonin level of 6.18 ng/mL). On postoperative day 12, liver CT revealed a large hepatic infarction, perihepatic fluid collection, and acute cholecystitis, which required percutaneous catheter drainage and percutaneous transhepatic gallbladder drainage. The viable liver parenchyma was estimated to be approximately 60% of the total liver volume. On postoperative day 17, the liver function parameters and total bilirubin level increased suddenly: aspartate aminotransferase, 2104 IU/L; alanine transaminase, 1716 IU/L; total bilirubin, 13.26 mg/dL; prothrombin time, 16.1 seconds; and activated partial thromboplastin time, 32.5 seconds. Thus, acute liver failure was suspected. Global hepatic infarction was observed during the third follow-up CT examination (Figure 2).

After a consultation with the Department of Transplantation, liver transplant was planned for acute liver failure. The patient was registered as a candidate for liver transplant, and 3 days later (ie, on day 28 of hospitalization) he underwent deceased donor liver transplant. The preoperative Child-Pugh score was 13. The abdominal cavity contained ascites with bile and old blood. The surgery was technically challenging because of global tissue edema/friability, adhesions, and intraoperative hemorrhage. However, the native liver was removed successfully after a 3-hour surgery. Multiple necrotic foci were identified throughout the liver and were particularly pro-minent in the hepatic dome (Figure 3A). A liver abscess (10 × 8 cm) was observed in the left lobe (Figure 3B).

The total estimated intraoperative blood loss volume was 15 000 mL; 25 units of packed red blood cells and 20 units of fresh-frozen plasma were transfused in the operating room. The total surgery duration was approximately 10 hours. Although liver transplant was successful, recovery took a long time because of the long surgery duration, massive blood transfusion, and malnutrition. From the immediate postoperative period to throughout his hospital stay, the patient was continuously administered tacrolimus (an immunosuppressant).

On postoperative day 40, CT revealed a normal appearance of the transplanted liver. The laboratory test results had normalized. The patient received treatment for complications (such as ventilator-associated pneumonia, acute kidney injury, and encephalopathy) in the intensive care unit for 3 months. Although the infection and encephalopathy improved, acute kidney injury progressed to chronic kidney disease. During hospitalization after the liver transplant, no signs of acute or chronic liver allograft rejection were noted. The patient was transferred to a general ward and discharged 4 months after the surgery.

After the patient’s discharge, a follow-up was conducted 3 months later, which included a CT scan and blood tests. The comprehensive examination yielded no abnormal findings, which indicated a favorable outcome.

Liver injury is commonly treated with nonoperative management with high success rates. However, surgical treatment should be considered if the injury is severe and the patient is hemodynamically unstable; the standard treatment in such cases is damage control surgery.⁶ The decision to perform liver transplant in cases of severe liver trauma is controversial; liver transplant should be considered the last resort when all other treatment options have been exhausted. Although the indications for liver transplant in patients with liver injury are unclear, uncontrolled bleeding from liver trauma is the most common cause for emergency liver transplant.⁷ Another important indication for liver transplant is acute liver failure secondary to liver trauma. Liver trauma can cause acute liver failure if the liver is severely damaged and unable to recover its function. Even if the patient’s condition does not deteriorate rapidly, liver transplant is a potentially lifesaving procedure for those with acute liver failure or acute liver failure secondary to liver trauma.⁸

Transcatheter arterial embolization is a reliable therapy with success rates of >90% for bleeding liver injuries.^3,9 The rate of hepatic ischemia-related complications following transcatheter arterial embo-lization is not well known. However, the incidence of hepatic necrosis and abscess formation after trans-catheter arterial embolization for liver trauma is approximately 15% and 7.5%, respectively.¹⁰ Moreover, in another study, the incidence of major hepatic necrosis after transcatheter arterial embolization increased to up to 42.2% in patients with liver injury grade ≥3; this rate was significantly higher in cases of more severe damage (grade 4 and 5 injuries: 93.4%) than in cases of relatively less severe damage (injury grade ≤3: 6.7%).¹¹ In our case, we speculate that liver failure occurred due to a combination of complex causes, including the blunt liver trauma itself, hepatic infarction followed by repetitive transcatheter arterial embolization, and propagation of inflammation caused by hepatic necrosis and cholecystitis.

Liver transplant is rarely performed for liver injury; most of the available evidence is from case reports or series.^5,12,13 A literature review of 46 patients revealed a mortality rate of 37% among those who underwent liver transplant after a liver injury.⁸ The authors suggested liver transplant as a treatment option for severe liver injury but could not provide specific indications for the same. Marek and colleagues performed a large-scale retrospective study on 73 patients who underwent liver transplant for a liver injury¹⁴ and were registered in the European Liver Transplant Registry. They noted a slightly higher mortality rate (approximately 42%) and cautiously suggested an Injury Severity Score of <33 and a grade of <5 as indications for liver transplant in patients with severe liver injury.

Liver failure is a possible complication after transcatheter arterial embolization for liver trauma. Surgeons should focus on patients who undergo repetitive transcatheter arterial embolization for high-grade liver injury. Liver transplant for liver trauma is technically demanding and risky but should be considered a viable treatment option in selected cases. Our report has a limitation; because this was a case study, our observations may not be generalizable. Further studies are needed to elucidate the appropriate indications and optimal timing for liver transplant for liver trauma.

Volume: 21 Issue: 7 July 2023

FULL TEXT