There are basically two main types of severe iatrogenic liver injury requiring urgent LT: Biliary or vascular injuries, or a combination of the two. Some patients were indicated for LT due to acute liver failure (ALF) resulting from vascular injury secondary to a first biliary injury or other less common severe iatrogenic liver injuries.
BDI and vasculobiliary injuries during cholecystectomy
The incidence of BDI during cholecystectomy varies from 0.1% to 0.3%, rising to 0.6% when considering the laparoscopic approach[5,6]. The type and extent of BDI play an important role in surgical planning for appropriate timing and treatment.
Different systems have been proposed to classify and grade the severity of BDI. In 1982, Professor Bismuth first classified postoperative bile duct strictures in a chapter of the “Blumgart book”. He subsequently proposed a useful classification of biliary strictures based on the principles of surgical treatments. Like the Bismuth classification, Strasberg’s scale incorporates other biliary injuries commonly encountered after laparoscopic cholecystectomy. To prevent bile duct injury, the Stewart-Way classification incorporates the mechanism of injury as well as its anatomy, separating resectional damage from stricture and providing a guide to pre-operative evaluation and biliary reconstruction. Although other classifications of BDI after laparoscopic cholecystectomy have been reported and recently reviewed by Chun, the Strasberg scale remains the classification of choice for defining the types of BDI.
Some recently reported series on LT for cholecystectomy-induced BDI provide important insights. In 2011, Ardiles et al analyzed their experience using LT as a definitive treatment for BDI, reporting data from a retrospective national survey performed in 18 LT centers over 20 years in Argentina. Among 2766 LT performed from 1990 to 2009, 19 (0.7%) were secondary to BDI arising during 16 cholecystectomies (open in 10, and laparoscopic in 6), two hydatid cyst resections, and one right hepatectomy. Seven patients had associated vascular injuries. The indication for LT was liver cirrhosis in 18 cases and ALF in the remaining one. No intraoperative mortality was reported but four patients died during the first month after LT, and another four died in the late postoperative period. The remaining 11 patients showed a good quality of life in the long-term follow-up and recipient survival rates at one, three, five and ten years were 73%, 68%, 68% and 45% respectively. The authors reported a higher rate of major post-operative complications (52%), according to the Clavien classification, compared with other etiologies and secondary biliary cirrhosis. Interestingly, the significant decrease over time in the incidence of LT for this indication in their cohorts (3.1% of all LT in the period 1990-1994; and 0.2% in the period 2005-2009 - P < 0.001) reflects improvements in the prevention and management of BDI related to a multidisciplinary and specialized approach to injury-related complications.
In 2013, Parilla et al, on behalf of the Spanish Liver Transplantation Study Group, reviewed the indications and outcome of 27 patients with BDI after cholecystectomy and listed for LT in Spain over a 24-year period. Emergency LT for ALF was indicated in seven patients all after laparoscopic cholecystectomy. Two of them died while on the waiting list, one from multiorgan failure (MOF) secondary to BDI-related sepsis, and the other was anhepatic after a total hepatectomy required for massive liver necrosis. Another 20 patients underwent elective LT for secondary biliary cirrhosis after BDI (13 after open and 7 after laparoscopic cholecystectomy). Four of the five recipients who underwent emergency LT for ALF died within 30 d after LT, and the estimated overall five-year survival rate was 68%. The Spanish study confirms that BDI after laparoscopic cholecystectomy tends to be more severe than that after the open approach.
Very recently, an Italian group from Genoa reviewed the literature and reported another two cases of LT for iatrogenic injuries among 12 patients referred to their tertiary center for the management of complicated cholecystectomy. The timing for LT differed in this series. The first patient was transplanted after several endoscopic and radiological attempts to solve recurrent cholangitis that led to secondary biliary cirrhosis five years after BDI. He initially underwent open cholecystectomy with a biliary lesion described as type E2 (according to the Strasberg-Bismuth classification), and referred to the tertiary center five years after the first injury. Conversely, the second patient was listed for an emergency LT after a laparoscopic cholecystectomy converted to the open approach because of bleeding from the liver parenchyma. Eight days after surgery the patient had bile leaks and underwent endoscopic biliary stent placement complicated by a large intrahepatic hematoma and bleeding initially treated by right hepatic embolization. The patient required emergency surgical exploration and a total hepatectomy with temporary portocaval shunt (TPCS) was required to overcome the bleeding after a right hepatectomy. The intraoperative field showed a massive liver hematoma involving the right lobe, deep parenchyma lacerations, and a type D injury. After a two-day anhepatic bridging period the patient was successfully transplanted and underwent long-term follow-up. The same authors also described another patient with chronic cirrhosis who underwent LT after acute liver decompensation caused by open cholecystectomy for common bile duct lithiasis.
In addition to biliary damage, severe vascular iatrogenic injuries during HPB surgery can result in devastating complications. While the BDI rate after cholecystectomy is estimated up to 0.6% (6), and concomitant hepatic artery damage has been reported in 12%-47% of patients, isolated portal vein (PV) injury is uncommon. In 2011, Strasberg et al published an analytical review of vasculobiliary injury in cholecystectomy, evaluating frequencies, causes clinical implications, and their management. A year later, the same team addressed the pathogenesis of “extreme” vasculobiliary injury and reported on outcomes after cholecystectomy for severely inflamed gallbladders in eight patients. Unfortunately, one patient developed infarction of the bile ducts after injury to the proper hepatic artery and died of sepsis in the postoperative period after urgent LT. In author’s opinion, in presence of inflammation a fundus-down cholecistectomy should be avoided for the prevention of extreme vasculobiliary injuries.
In 2013, Wang et al analyzed the therapeutic strategies for iatrogenic PV injury after cholecystectomy, reporting their experience of 11 patients with vascular injuries in the absence of biliary damage. One of these patients, a 50-year-old woman, underwent LT due to chronic liver failure four months after the initial injury to the right branch of PV after an open cholecystectomy. In the authors’ opinion, delayed diagnosis and treatment may have led to difficult vein repair and liver revascularization resulting in PV thrombosis and hepatic necrosis. They highlighted the major role of thrombolytic and anticoagulation therapy in the treatment of acute massive thrombus. We agree with them that an immediate attempt to repair severe PV injury should be preferred in a hemodynamically stable patient.
Other causes of severe iatrogenic liver injuries
Indications for LT to treat severe iatrogenic liver injuries after abdominal surgery or causes other than injuries during cholecystectomy are certainly less common, and very few cases have been reported.
In 2006, Huerta et al described three lethal complications resulting from severe iatrogenic injuries during bariatric surgery performed in a high-volume bariatric center. They also described details of three cases of PV thrombosis that led to LT after two Roux-en-Y gastric bypass (RYGBP) procedures and one vertical banded gastroplasty. In the two cases of RYGBP, the porta hepatis was inadvertently stapled, while in the patient who underwent vertical banded gastroplasty the PV was divided and promptly reconstructed, but caused irreversible ischemic liver damage. Although the iatrogenic injuries were immediately recognized, a transplant surgeon consulted, and patients referred for emergency LT, the postoperative course was complicated by sepsis, MOF, and other severe medical complications resulting in the deaths of the patients. The authors claimed that PV ligation with immediate patient referral to a LT center for emergency transplant may improve the outcome in case of severe PV injury.
In 2009, the group from the University Medical Center, Nashville, Tennessee (United States) reported two cases of iatrogenic porta hepatis transection requiring an urgent two-stage liver LT. In the first case, severe porta hepatis transection occurred during an open adrenalectomy in a 39-year-old woman with a history of cholecystectomy. Before transferring the patient to the authors’ tertiary LT center, primary PV repair was attempted, and a Roux-en-Y hepaticojejunostomy performed, while the hepatic artery was left divided. Due to progression of the hepatic dysfunction and worsening hemodynamics, the patient underwent urgent total hepatectomy and portocaval shunt, and was listed for an emergency LT. In the other case, severe iatrogenic injury occurred during a laparoscopic cholecystectomy converted to an open operation to control a massive bleed and complete cholecystectomy before emergency transfer of the patient to the authors’ tertiary center. A computed tomography (CT) scan showed infarction of the right hepatic lobe, transection of the right hepatic artery and right PV. Arterial perfusion of the left lobe was provided through a replaced left hepatic artery. A right hepatic lobectomy was planned and an urgent surgical re-exploration performed. Unfortunately, the extent of the left PV injury precluded successful reconstruction of the PV flow and a total hepatectomy with a portocaval shunt was performed. The patient underwent LT 20 h later. We agree with the author that patients presenting with severe portal transection cannot be treated expectantly, and prompt radiological evaluation and surgical intervention are mandatory to attempt to restore hepatic flow. Hepatic resections should not be the only options entertained and LT should be promptly evaluated on a case-by-case basis.
Another case of severe hepatic injury resulting from an open right adrenalectomy was reported in the same year by Tessier et al in a review of high-grade complications after adrenalectomy. The surgical procedure was complicated by an unrecognized injury to and ligation of the proper hepatic artery. Three months after adrenalectomy, the patient underwent a Roux-en-Y hepaticojejunostomy for the treatment of multiple liver abscesses, recurrent episodes of cholangitis and later a bleeding cholecysto-enteric fistula. The patient was ultimately referred to a tertiary center where LT was performed because of recurrent cholangitis and bile duct sclerosis.
Interestingly, in 2010 Di Benedetto et al, reported details of their experience in the treatment of severe injuries after transjugular intrahepatic portosystemic shunt placements in two cirrhotic patients where surgical and radiological attempts had failed to stop the bleeding after parenchymal and vascular rupture. Although the indications for LT were liver failure after artery embolization, and uncontrollable hemobilia, this experience highlights the ability of a tertiary referral center to offer LT as the only curative option.