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]

Overview

Liver transplantation remains to be the only definitive therapy in patients with acute liver failure who fail to regenerate enough liver tissue to maintain life. Whole organ liver transplantation (deceased liver) or a living donor liver transplantation (LDLT) are also possible options.

Surgery

• Drainage of ascites
• 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.
• Liver dialysis is evolving as a treatment modality and is gradually being introduced in the care of patients with liver failure.

Liver Transplantation

The patients candidacy for liver transplantation should be assessed based upon the patients 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.

King's College Criteria

The King's College criteria were described in a publication in 1989 by J.G. O'Grady and colleagues. 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

Patients with paracetamol toxicity pH <7.3 or Prothrombin time >100 seconds and serum creatinine level >3.4 mg/dL (>300 μmol/l) if in grade III or IV encephalopathy

Other patients 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)

2011 AASLD Recommendations : Liver Transplantation (DO NOT EDIT)

Class II-3

1. Urgent hepatic transplantation is indicated in acute liver failure where prognostic indicators suggest a high likelihood of death.

2. Living donor or auxiliary liver transplantation may be considered in the setting of limited organ supply, but its use remains controversial.

3. Hepatic vein thrombosis with acute hepatic failure is an indication for liver transplantation, provided underlying malignancy is excluded.

4. Short-acting barbiturates and the induction of hypothermia to a core body temperature of 34-35 0C may be considered for intracranial hypertension refractory to osmotic agents as a bridge to liver transplantation.

Class III

1. Contact with a transplant center and plans to transfer appropriate patients with ALF should be initiated early in the evaluation process.

2. Patients with acute liver failure secondary to mushroom poisoning should be listed for transplantation, as this procedure is often the only lifesaving option.

3. Patients with known or suspected herpes virus or varicella zoster as the cause of acute liver failure should be treated with acyclovir (5-10 mg/kg IV every 8 hours) and may be considered for transplantation.

4. Patients in whom Wilson disease is the likely cause of acute liver failure must be promptly considered for liver transplantation.

5. Patients with autoimmune hepatitis should be considered for transplantation even while corticosteroids are being administered.

6. For acute fatty liver of pregnancy or the HELLP syndrome, expeditious delivery of the infant is recommended. Transplantation may need to be considered if hepatic failure does not resolve quickly following delivery.

7. Intracranial pressure monitoring is recommended in ALF patients with high grade hepatic encephalopathy, in centers with expertise in ICP monitoring, in patients awaiting and undergoing liver transplantation.