Transthoracic open window hepatostomy: A salvage approach to right lobe abscesses after liver transplantation

Abstract

Pyogenic abscesses in grafts after liver transplantation (LT) are observed in 0.5% to 1% of patients, with mortality rates up to 45%. Predisposing factors are hepatic artery thrombosis, presence of hepaticojejunostomy, biliary obstruction, ascendant cholangitis, bacteremia, and percutaneous procedures (liver biopsy and biliary drainage). Therapeutic options include antibiotics, immunosuppression withdrawal, percutaneous or surgical drainage, liver resection, and retransplantation. However, in extreme situations, treatments can fail and retransplantation can be contraindicated because of sepsis, a complex surgical history, or both. In this setting, a salvage approach to abscesses located in the right hepatic area was devised, inspired by the open window thoracostomy described by Clagett in 1963 for postpneumonectomy empyema. Similar to the Clagett procedure, the so-called open window hepatostomy (OWH) is based on transthoracic surgical drainage of the septic cavity and secondary wound healing. With over 1820 consecutive LT procedures performed from 1990 to 2008, the technique was applied in only 3 cases (0.2%), always resulting in control of infection and preservation of life. Repeated dressings and further interventions were needed without exception because an external biliary fistula invariably appeared. Complete skin closure was obtained in 2 cases in 12 years and 7 months, respectively. The most recent patient, whose case is illustrated here, is now at an advanced stage of the healing process. CASE REPORT