Urgent liver retransplantation in patient with sepsis, multiple organ failure and unstable hemodynamics

Abstract

In the presented case, the patient after orthotopic liver transplantation from an optimal cadaveric donor against the background of a smooth postoperative period and satisfactory graft function was followed by a series of biliary complications in the form of ongoing necrosis of the bile ducts of the graft, which required repeated surgical interventions, which led to the formation of a separate bicholangiostomy. The patient was put on the waiting list for a repeated liver transplantation. The developed complications led to sepsis, multiple organ failure and unstable hemodynamics, that required using of substitution therapy and high doses of inotropic, vasopressor drugs. A decision was made to assign the patient a «high-urgency» status with priority graft obtaining, and the coordination centers of St. Petersburg, Moscow, Leningrad and Moscow Regions and FMBA were notified. From the assignment of the «high urgency» status to receiving an organ has passed 10 hours. Hepatectomy with the formation of a temporary portocaval shunt began in advance of the donor liver’s admission to the clinic, which made it possible to stabilize the hemodynamic parameters and the recipient’s condition. However, against the background of massive blood loss, at the stage of graft revascularization, two episodes of cardiac arrest occurred, requiring indirect heart massage with chest and diaphragm compressions. Due to severe peripheral circulatory insufficiency, dry gangrene of the nail phalanx of the right forefinger was developed. Nevertheless, from the first postoperative day and thereafter, the graft demonstrated satisfactory function. Two months after the repeated transplantation, the patient was discharged in satisfactory condition. Subsequently, the index finger was amputated. Six months after the second operation, the patient returned to the work of a teacher.

Keywords

• liver retransplantation
• bile duct necrosis
• sepsis
• multiple organ failure
• unstable hemodynamics
• vasopressors
• dry gangrene
• vacuum-assisted closure