Relevance of two-stage total hepatectomy and liver transplantation in acute liver failure and severe liver trauma

Emergency liver transplantation frequently is the only lifesaving procedure in cases of acute liver failure. It remains unclear whether emergency hepa tectomy with portocaval shunt followed by liver transplantation as a two-st age procedure should be performed in cases in which a donor organ is not ye t available. It has been stated that "toxic liver syndrome" could be treate d by means of this strategy. From 1990 to 1995 we performed emergency hepat ectomies in eight cases of acute liver failure or traumatic liver rupture w ith exsanguinating bleeding. In six cases we were able to perform a subsequ ent liver transplantation. Five of the six patients who underwent an emerge ncy hepatectomy died. Emergency hepatectomy led to a significant increase i n epinephrine dosage until the transplantation was performed. Only after tr ansplantation did the need for epinephrine therapy decrease. The need for o xygen support did not change during the entire observation period. Plasmati c coagulation was stabilized by substitution, showing significantly higher values at 24 h after transplantation than at 48 h before transplantation. F ibrinogen increased significantly after transplantation in this group of pa tients. The experiences gathered at our clinic, however, do not show advant ages that would allow a recommendation of emergency hepatectomy and subsequ ent liver transplantation as a two-stage procedure except for situations of severe and uncontrollable hepatic bleeding. Considering the progressive de stabilization of our patients, fast procurement of donor organs seems to be of imminent importance for the outcome.