Liver Transplantation

Transcription

1 1 Liver Transplantation Department of Surgery Yonsei University Wonju College of Medicine Kim Myoung Soo M.D. History Development of Liver transplantation

2 2 Change of survival rate after liver Tx Rationale for liver transplantation Child-Pugh Score Albumin

3 3 Indications of liver transplantation Adult Pediatric Absolute contraindication Sepsis outside the hepatobiliary system Extrahepatic malignancy Metastatic hepatobiliary malignancy Active alcoholic disease or drug abuse Severe hypoxemia secondary to right to left shunt Non-compliance Advanced cardiopulmonary disease AIDS

4 4 Donor Selection Criteria 1. Patient size 2. Blood type (ABO) 3. Prior substance or alcohol abuse 4. Prior episodes of hepatobiliary disease 5. Hospital course including episodes of cardiac/pulmonary arrest, vasoactive drugs and stability of the blood pressure 6. Pulmonary status including blood gas measurements 7. Donor s age 8. Presence of infection 9. History of malignancy 10. Level of transaminases and bilirubin Criteria for Liver Size Matching Large or Small DONOR Recipient height weight chest circumference physical exam (liver size) costal angle height weight chest circumference liver volume vy US, CT or MRI costal angle presence of ascites or previous surgery

5 5 Multiple Organ Procument in situ hypothermic perfusion for core cooling of multiple organs in situ hypothermic perfusion - cold Ringer s lactate --> UW solution by aorta and portal vein

6 6 Liver Harvest Liver and Pancreas combination Harvest artery vein Liver hepatic a. Portal v. or celiac axis pancreas SMA SMV splenic a.

7 7 Skin incision and Veno-venous shunt Recipient Hepatectomy

8 8 Post-hepatectomy status Venous anastomosis - hepatic vein or vena cava Infrahepatic Superahepatic

9 9 Venous anastomosis - Portal vein Hepatic artery anastomosis

10 10 Biliary Drainage End-to-end anastomosis Choledochojejunostomy Overview of Liver transplantation

11 11 Intra-operative Signs of Good Hepatic Function 1. Restoration of hemodynamic stability 2. Good renal function as evidenced by adequate urine output 3. Stabilization of acid-base status 4. Normalization of the coagulation system 5. Normalization of body temperature 6. Maintenance of proper glucose metabolism 7. Adequate bile production 8. Good texture and color of the liver Post-operative Signs of Good Hepatic Function 1. Improving coagulation profile 2. Bile of sufficient quantity and golden brown in color 3. Hemodynamic stability 4. Awakening from anesthesia 5. Good renal function as evidenced by adequate urine output

12 12 Liver rejection treatment Type of Rejection Mild, mild-to-moderate Moderate Severe Recurrent mild Recurrent severe, or steroid-resistant Persistent mild Therapy Steroid bolus(1 g methylprednisolone) Steroid bolus and recycle OKT3 Repetition of the steroid bolus with or without a recycle OKT3 Add Azathioprine, mg/kg/day Technical Causes of Hepatic Allograft Dysfunction 1. Hepatic artery thrombosis 2. Portal vein thrombosis 3. Biliary tract obstruction 4. Bile duct leak 5. Hepatic vein/ caval thrombosis

13 13 Risk Factors in Liver transplantation Pre-operative patient status (medical urgency) Primary disease : Recurrence Age : < 1 year old and > 50 yrs old OLT after Portosystemic shunt in patients with portal thrombosis Retransplantation Protracted ascites and spontaneous bacterial peritonitis Prior abdominal surgery Operative blood loss Risk Factors - Recipient age

14 14 Risk Factors - Original liver disease Risk Factors - Original liver disease Etiology N= 3 mos. 1yr. 5yrs 8yrs HBV 61 81% 54% 33% 33% HCV 93 89% 87% 73% 73% Hepatoma HBV % 73% % Hepatoma HBV % 40% 11% 11% Alcoholic cirrhosis 75 81% 77% 65% 52% Cryptogenic cirrhosis 92 78% 74% 65% 59% Sclersing cholangitis 52 90% 86% 71% 60% Biliary cirrhosis 74 86% 84% 72% 72% Autoimmune 17 94% 94% 94% 94%

15 15 Risk Factors - preoperative patient status Thank You Myoung Soo Kim M.D. Department of Surgery Yonsei University Wonju College of Medicine ysms91@wonju.yonsei.ac.kr