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7/30/2019 Principles of Liver Transplantation
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PRINCIPLES OF LIVER
TRANSPLANTATIONSouvik Adhikari
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TYPES OF LIVER TRANSPLANTS
Cadaveric liver transplants
Living donor liver transplant
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PRE-TRANSPLANT
ASSESSMENT: PHASES
Phase 1: General assessment ofpatients medical state.
Phase 2: Assessment of patientssuitability for transplantation &identification of any problems.
Phase 3: Logistics of the procedureare addressed: includes all necessarytalks and visits.
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TIMING OF LISTING
UNOS modification of MELD Score:
MELD Score = 3.8 * loge(bilirubin inmg/dL) + 11.2 * loge(INR) + 9.6 *loge(creatinine mg/dL) + 6.4
* PELD Score: based on bilirubin, INR,albumin, growth failure, and age.
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WORKUP: PHASE I
Full clinical and appropriatebiochemical evaluation
Other investigations: CXR, ECG,USG, review of liver histology andother investigations.
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WORKUP: PHASE II
Hepatic & renal USG; MRIangiogram/CT imaging withcontrast/angiography in few cases.
Lung function tests.
USG of great vessels of neck.
Echocardiogram. Anesthetic opinion.
Social worker.
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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.
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VACCINATION
Hepatitis A
Hepatitis B
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WORKUP: PHASE III:
DISCUSSIONS
Nurses
Dieticians
Social worker Pharmacist
Visit to ITU
Final discussion with transplant co-ordinator
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CARDIOPULMONARY
ASSESSMENT: GROUPS
? Abnormal heart function
? Parenchymal chest disease
Hepatopulmonary syndrome ? Portopulmonary hypertension
Normal
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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.
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DONOR OPERATION: CONTD.
Cold dissection.
Back-table perfusion: removal ofliver.
Kidney removal.
Vessels, spleen & lymph nodes: long
splenic art. & SMA retrieval for SLT. Closure.
Operation note.
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SPLIT-LIVER
TRANSPLANTATION
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LIVE DONOR LIVER
TRANSPLANTATION (LDLT)
Done because of shortage ofcadaveric 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.
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BENEFITS OF LDLT
Shorter waiting time.
Performed as elective surgery.
An organ from a healthy donor is of abetter quality.
Donor liver experiences minimal cold
ischemic time. Allows a cadaveric liver to go to
another recipient.
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TRANSPLANT OPERATION
Induction of anesthesia. Laparotomy & dissection phase: veno-
venous 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.
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POST-TRANSPLANT CARE: ITU
Sleep induction: Temazepam.
Sedation: Propofol/Midazolam.
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IMMUNOSUPPRESSION: TRIPLE
THERAPY
Corticosteroids
Azathioprine
Tacrolimus Mycophenolate in those intolerant to
azathioprine.
Sirolimus in cases of recurrent acuterejection and chronic ductopenicrejection.
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PROPHYLACTIC DRUGS
Perioperative antibiotics
Pneumocystis & antifungalprophylaxis
Peptic ulcer prophylaxis
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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)
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OTHER PROBLEMS POST OLT
Rejection
Post-transplantation leucopenia
Post TransplantationLymphoproliferative Diseases (PTLD)
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