Acute liver failure surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Aditya Govindavarjhulla, M.B.B.S. [2] Husnain Shaukat, M.D [3]

Overview

The candidates for liver transplantation should be identified as quickly as possible because the progression to multiorgan failure results in deterioration in many patients who are awaiting liver transplantation. While many people who develop acute liver failure recover with supportive treatment, liver transplantation is often required in people who continue to deteriorate or have poor prognostic factors. The patient's candidacy for liver transplantation should be assessed based on the patient's clinical scenario, as well as upon social and financial factors. Patient evaluation for liver transplantation should be done as soon as possible and before encephalopathy occurs. The key common feature among various prognostic evaluation systems is the presence of encephalopathy. Other common features are patient's age and severity of the liver injury which is assessed by coagulopathy or jaundice. To address the limitations, a wide variety of prognostic systems have been proposed but none has universal acceptance. King's college criteria is the most well-characterized evaluation system. Common absolute contraindications for liver transplantation include untreated sepsis, uncontrolled extra-hepatobiliary infection, alcohol abuse, uncontrolled cardiopulmonary disease, cholangiocarcinoma, metastatic malignancy to the liver and life-threatening systemic illness. Common postoperative complications for liver transplantation include infections, graft failure, vascular compromise, biliary stricture or stenosis, anastomosis leakage, thrombosis of hepatic artery and portal vein and depression.

Liver Transplantation

• The candidates for liver transplantation should be identified as quickly as possible because the progression of multiorgan failure results in deterioration in many patients who are awaiting liver transplantation.
• While many people who develop acute liver failure recover with supportive treatment, liver transplantation is often required in people who continue to deteriorate or have poor prognostic factors.
• The patient's candidacy for liver transplantation should be assessed based on the patient's clinical scenario, as well as upon social and financial factors. Patient evaluation for liver transplantation should be done as soon as possible and before encephalopathy occurs.
• The key common feature among various prognostic evaluation systems is the presence of encephalopathy. Other common features are patient's age and severity of the liver injury which is assessed by coagulopathy or jaundice. To address the limitations, a wide variety of prognostic systems have been proposed but none has universal acceptance. King's college criteria is the most well-characterized evaluation system.Ostapowicz G, Fontana RJ, Schiødt FV, Larson A, Davern TJ, Han SH, McCashland TM, Shakil AO, Hay JE, Hynan L, Crippin JS, Blei AT, Samuel G, Reisch J, Lee WM (2002). "Results of a prospective study of acute liver failure at 17 tertiary care centers in the United States". Ann. Intern. Med. 137 (12): 947–54. PMID 12484709.

King's College Criteria

• The King’s College criteria are from O’Grady et al. The criteria were stratified into acetaminophen and non-acetaminophen causes of acute liver failure, due to the different mechanisms of damage correlating with prognosis in each of the causes.

King's College Hospital Criteria for Liver Transplantation in Acute Liver Failure

Acute Liver Failure with Acetaminophen Toxicity pH <7.3 or Prothrombin time >100 seconds and Serum creatinine level >3.4 mg/dL (>300 μmol/l) Grade III or IV encephalopathy

Acute Liver Failure without Acetaminophen Toxicity Prothrombin time >100 seconds or Three of the following variables: Age <10 yr or >40 yr Cause: Non-A, non-B hepatitis Halothane hepatitis Idiosyncratic drug reaction Duration of jaundice before encephalopathy >7 days Prothrombin time >50 seconds Serum bilirubin level >17.6 mg/dL (>300 μmol/l)

Absolute contraindications for liver transplantation

• Untreated sepsis
• Uncontrolled extrahepatobillary infection
• Alcohol abuse
• Uncontrolled cardiopulmonary disease
• Cholangiocarcinoma
• Metastatic malignancy to the liver
• Life-threatening systemic illness

Relative contraindications for liver transplantation

• Age >70
• Uncontrolled psychiatric disorder
• Intrahepatic sepsis
• HIV seropositivity with failure to control HIV viremia or CD4 <100/μL
• Severe malnutrition/wasting
• Portal vein thrombosis
• Renal failure not attributable to liver disease
• Severe hypoxemia secondary to right-to-left intrapulmonary shunts (Po2 <50 mmHg)

Common complications for liver transplantation

• Infections
  • Bacterial: early, common postoperative infections
  • Fungal/parasitic: late, opportunistic infections
  • Viral: late, opportunistic infections, recurrent hepatitis
  • Infections from donor
• Primary graft failure
• vascular compromise
• stricture, stenosis or leakage of the biliary anastomoses
• Recurrence of primary hepatic disorder
• Ischemic injury during harvesting
• Portal vein obstruction
• Hepatic artery thrombosis
• Difficult psychosocial adjustment
• Depression