Reply: Severe preprocurement blunt trauma to the liver-Is there a need for back-table cutdown?

Abstract

We read with interest the letter by Oniscu et al. in response to our article published in the March issue of Liver Transplantation. In response to the question of whether there is a need for back-table cutdown, we can respond that at times the answer is yes. The strategy that we feel needs to be in place whenever there is known or occult damage, particularly to the right lobe of a donor liver, involves first ensuring that abdominal multiorgan procurement can be achieved even in the setting of ongoing hemorrhage from the right lobe of the liver or other solid organs. This may require packing of solid organs, including the right lobe of the liver; this was required on 3 occasions in our experience. On one occasion, packing of the right lobe of the liver facilitated in situ splitting to obtain a lateral segment graft for subsequent implantation into a pediatric recipient. Second, an assessment needs to be made, partly on the basis of the hemodynamic stability of the donor, concerning what may be possible in the setting of visible trauma to the liver. In the 2 cases in our report, in which back-table cutdown was ultimately required of the donor liver, it was decided to expedite multiorgan procurement and deal with the trauma to the liver on the back-table. It is of note that in both of these cases there was capsular damage (significant tears) as well as significant parenchymal trauma to the right lobe, in contrast to the case cited by Oniscu et al. However, we agree with Oniscu et al. that the meticulous back-table inspection of deceased donor liver allografts in the setting of blunt trauma is important and should include an examination of the vasculature, in which there may be occult injury as well.