PRINCIPLES OF LIVER TRANSPLANTATION

Souvik Adhikari

TYPES OF LIVER TRANSPLANTS

Cadaveric liver transplants Living donor liver transplant

PRE-TRANSPLANT ASSESSMENT: PHASES

Phase 1: General assessment of patients medical state. Phase 2: Assessment of patients suitability for transplantation & identification of any problems. Phase 3: Logistics of the procedure are addressed: includes all necessary talks and visits.

TIMING OF LISTING

UNOS modification of MELD Score: MELD Score = 3.8 * loge(bilirubin in mg/dL) + 11.2 * loge(INR) + 9.6 * loge(creatinine mg/dL) + 6.4

* PELD Score: based on bilirubin, INR, albumin, growth failure, and age.

WORKUP: PHASE I

Full clinical and appropriate biochemical evaluation Other investigations: CXR, ECG, USG, review of liver histology and other investigations.

WORKUP: PHASE II

Hepatic & renal USG; MRI angiogram/CT imaging with contrast/angiography in few cases. Lung function tests. USG of great vessels of neck. Echocardiogram. Anesthetic opinion. Social worker.

PHASE II: OTHER TESTS

CMV, VZV, HCV, HBV status. Blood group. HLA typing & cross-matching. HIV. Serum creatinine >150 umol/l: full urinary evaluation, creatinine clearence, USG, renal biopsy, isotopic GFR. Diabetic: HbA2, fundoscopy, ECG before & after Valsalva. Dentition.

VACCINATION

Hepatitis A Hepatitis B

WORKUP: PHASE III: DISCUSSIONS

Nurses Dieticians Social worker Pharmacist Visit to ITU Final discussion with transplant coordinator

CARDIOPULMONARY ASSESSMENT: GROUPS

? Abnormal heart function ? Parenchymal chest disease Hepatopulmonary syndrome ? Portopulmonary hypertension Normal

DONOR OPERATION

Long midline laparotomy. Rapid cannulation/perfusion. Median Sternotomy. Warm phase dissection. Dissection by cardiac team. Cannulation, Perfusion & Bleed-out: removal of thoracic organs, aortic & portal perfusion.

DONOR OPERATION: CONTD.

Cold dissection. Back-table perfusion: removal of liver. Kidney removal. Vessels, spleen & lymph nodes: long splenic art. & SMA retrieval for SLT. Closure. Operation note.

SPLIT-LIVER TRANSPLANTATION

LIVE DONOR LIVER TRANSPLANTATION (LDLT)

Done because of shortage of cadaveric organs. Entails considerable risk to the donor. Donors with BMI >28 are excluded. Graft volume must be at least 1% of the recipients body weight. Results for LDLT probably not as good as cadaveric transplantation.

BENEFITS OF LDLT

Shorter waiting time. Performed as elective surgery. An organ from a healthy donor is of a better quality. Donor liver experiences minimal cold ischemic time. Allows a cadaveric liver to go to another recipient.

TRANSPLANT OPERATION

Induction of anesthesia. Laparotomy & dissection phase: venovenous bypass established. Anhepatic phase: IVC clamped, liver removed, IVC & portal vein anastomosed. Graft flushed, liver perfused, infrahepatic IVC & hepatic art anastomoses done. Gall bladder anastomosed/biliary drainage. Skin closure. Transfer to ITU.

POST-TRANSPLANT CARE: ITU

Sleep induction: Temazepam. Sedation: Propofol/Midazolam.

IMMUNOSUPPRESSION: TRIPLE THERAPY

Corticosteroids Azathioprine Tacrolimus Mycophenolate in those intolerant to azathioprine. Sirolimus in cases of recurrent acute rejection and chronic ductopenic rejection.

PROPHYLACTIC DRUGS

Perioperative antibiotics Pneumocystis & antifungal prophylaxis Peptic ulcer prophylaxis

COMMON PROBLEMS POST OLT

Hypokalemia High glucose levels Low ionised calcium levels Hypovolemia associated with rewarming Bleeding secondary to coagulopathy Oliguria associated with calcineurin inhibitors (Tacrolimus/Cyclosporin)

OTHER PROBLEMS POST OLT

Rejection Post-transplantation leucopenia Post Transplantation Lymphoproliferative Diseases (PTLD)