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Original Investigation | Pacific Coast Surgical Association

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

Joseph DiNorcia, MD1; Minna K. Lee, MD2; Michael P. Harlander-Locke, BS2; Victor Xia, MD3; Fady M. Kaldas, MD2; Ali Zarrinpar, MD, PhD2; Douglas G. Farmer, MD2; Hasan Yersiz, MD2; Jonathan R. Hiatt, MD2; Ronald W. Busuttil, MD, PhD2; Vatche G. Agopian, MD2
[+] Author Affiliations
1Division of Hepatopancreatobiliary Surgery and Abdominal Organ Transplantation, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles
2Dumont-UCLA Liver Cancer and Transplant Centers, Pfleger Liver Institute, Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles
3Department of Anesthesiology, David Geffen School of Medicine at University of California, Los Angeles
JAMA Surg. 2015;150(11):1066-1072. doi:10.1001/jamasurg.2015.1853.
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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.

Figures in this Article

Figures

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Figure 1.
Flow Diagram of Study Patients

Of 150 patients who underwent damage control (DC), 58 had a single, planned additional operation for delayed biliary reconstruction (DBR), 26 had a single, unplanned additional operation during which the bile duct was reconstructed, and 57 had multiple additional operations for various complications. Five patients died before any additional operation, and 4 patients underwent additional transplant at the first additional operation. OLT indicates orthotopic liver transplant.

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Figure 2.
Kaplan-Meier Graft and Patient Survival Curves With 1-, 3-, and 5-Year Estimates Comparing Recipients With and Without Damage Control (DC)
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Figure 3.
Kaplan-Meier Graft and Patient Survival Curves With 1-, 3-, and 5-Year Estimates Comparing Recipients Who Underwent No Damage Control (DC), DC With a Single Additional Operation for Delayed Biliary Reconstruction (DBR), and DC With Multiple Complications (MCs)
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Figure 4.
Kaplan-Meier Graft Survival Curves With 1-, 3-, and 5-Year Estimates Comparing Recipients With and Without Damage Control (DC) Stratified by Single and Multiple Additional Operations
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