Salvage Hepatectomy in Toxic Liver Syndrome as a Bridge to Orthotopic Liver Retransplantation—Case Series and Structured Narrative Review

Background/Objectives: Salvage hepatectomy with a prolonged anhepatic phase represents a potential life-saving strategy in patients with toxic liver syndrome (TLS) following orthotopic liver transplantation (OLT). Available evidence is limited to small case series. Methods: We retrospectively analyzed all patients undergoing OLT between 2014 and 2024 at a German transplant center. Among 497 patients, 33 required retransplantation, including four patients who underwent salvage hepatectomy due to refractory TLS. Clinical trajectories were analyzed descriptively. Additionally, a structured narrative review of the literature was performed. Results: Median age was 63 years (range 62–67), and median anhepatic time was 38.4 h (range 14.39–71.55). No patient died during the anhepatic phase. One patient died during retransplantation, and another during the postoperative course. Two patients survived long-term without neurological impairment. A literature review identified 30 relevant studies with reported mortality rates exceeding 50%. Conclusions: Salvage hepatectomy with subsequent retransplantation may serve as a life-saving bridge in selected patients with TLS. However, outcomes remain heterogeneous, and evidence is limited. This study provides detailed insights into perioperative physiological trajectories and clinical decision-making, which are insufficiently described in the current literature.