title: Damage Control as a Strategy to Manage Postreperfusion Hemodynamic Instability and Coagulopathy in Liver Transplant.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  We performed a retrospective analysis of adults undergoing liver transplant at a large transplant center from February 1, 2002, through July 31, 2012.
  
  
  METHODS
  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
  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.
authors: Division of Hepatopancreatobiliary Surgery and Abdominal Organ Transplantation, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles.
authors: Joseph
authors: J
authors: DiNorcia
authors: Dumont-UCLA Liver Cancer and Transplant Centers, Pfleger Liver Institute, Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles.
authors: Minna K
authors: MK
authors: Lee
authors: Dumont-UCLA Liver Cancer and Transplant Centers, Pfleger Liver Institute, Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles.
authors: Michael P
authors: MP
authors: Harlander-Locke
authors: Department of Anesthesiology, David Geffen School of Medicine at University of California, Los Angeles.
authors: Victor
authors: V
authors: Xia
authors: Dumont-UCLA Liver Cancer and Transplant Centers, Pfleger Liver Institute, Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles.
authors: Fady M
authors: FM
authors: Kaldas
authors: Dumont-UCLA Liver Cancer and Transplant Centers, Pfleger Liver Institute, Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles.
authors: Ali
authors: A
authors: Zarrinpar
authors: Dumont-UCLA Liver Cancer and Transplant Centers, Pfleger Liver Institute, Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles.
authors: Douglas G
authors: DG
authors: Farmer
authors: Dumont-UCLA Liver Cancer and Transplant Centers, Pfleger Liver Institute, Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles.
authors: Hasan
authors: H
authors: Yersiz
authors: Dumont-UCLA Liver Cancer and Transplant Centers, Pfleger Liver Institute, Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles.
authors: Jonathan R
authors: JR
authors: Hiatt
authors: Dumont-UCLA Liver Cancer and Transplant Centers, Pfleger Liver Institute, Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles.
authors: Ronald W
authors: RW
authors: Busuttil
authors: Dumont-UCLA Liver Cancer and Transplant Centers, Pfleger Liver Institute, Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles.
authors: Vatche G
authors: VG
authors: Agopian
mesh_terms: D015331:Cohort Studies; D016001:Confidence Intervals; D016208:Databases, Factual; D005260:Female; D005500:Follow-Up Studies; D006084:Graft Rejection; D006085:Graft Survival; D006439:Hemodynamics / Q000502:physiology*; D006801:Humans; D053208:Kaplan-Meier Estimate; D017093:Liver Failure / Q000175:diagnosis / Q000401:mortality / Q000601:surgery; D016031:Liver Transplantation / Q000009:adverse effects / Q000379:methods* / Q000401:mortality*; D016015:Logistic Models; D008297:Male; D008390:Markov Chains; D015999:Multivariate Analysis; D016017:Odds Ratio; D011183:Postoperative Complications / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D012016:Reference Values; D012086:Reoperation / Q000379:methods; D015427:Reperfusion Injury / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D012189:Retrospective Studies; D015996:Survival Rate; D013997:Time Factors; D016896:Treatment Outcome