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Complications and Management after

Liver Resection or Transplantation

Po-Huang Lee, MD PH D

Department of Surgery, E-Da Hospital

• Suggested Readings:

• Liver surgery: operative techniques and

• avoidance of complications.

• F.Koeckerling, S.I. Schwartz (edited)• F.Koeckerling, S.I. Schwartz (edited)

• J.A.Barth ,2001.

• Journal of Hepato-biliary-Pancreatic

• Surgery: current status and future of

• laparoscopic liver resection. 2009; 16(4).

Contents

• Liver anatomy and physiology

• Refinements of surgical technique

• Conventional open liver resection

• The application of minimal invasive surgery• The application of minimal invasive surgery

• Liver transplantation

• Postoperative care

Variations in the confluence of the extrahepatic bile ducts(after Smadja and Blumgart, after Couinaud 1957)

Blood Supply

1. Hepatic artery: 25%

30-40% O2 requirement

2. Portal vein: 75%2. Portal vein: 75%

60-70% O2 requirement

5-10 mmHg

Contents







Hepatic Resection, Resectability and Operation Mortality

for HCC Patients in NTUH (1954.05 – 2012.12)

60.0%

80.0%

100.0%

120.0%

500

600

700

800

900

1000

1954~2012： total resection cases 7089 ; total operated cases 7728

0.0%

20.0%

40.0%

0

100

200

300

400

total resection(人) total cases operated(人) resectability*(%) operative mortality(%)

• Progress in the early detection of hepatocellular carcinomaserum AFPreal-time ultrasonography

• Technique refinement in hepatic surgerynon-anatomical techniqueanatomical techniquetotal vascular exclusionminimal invasive surgerytransplantationtransplantation

• The aids of surgical instrumentsintraoperative echographyLin’s clampMicrowave tissue coagulatorCavitron ultrasonic surgical aspirator (CUSA)Argon bean coagulatorLaparoscopic instruments

Ligation of the Hilar Structure(before resection)

Advantages Disadvantages

-Little intraoperative blood loss

-no impairment of liver function

-clear demarcation between the

tissue to be resected and the well-

perfused residual liver

-anatomical variations must be

rigorously searched for

-errors of identification in the hilum

lead to additional necrosis

-difficult dissection of theperfused residual liver

-technical facilitation of parenchymal

transection and time gain for inflow

occlusion and reperfusion phase

-no damage to structures in the

hepatoduodenal ligament through

clamping or tournuquet

-elimination of haemodynamic

consequences of clamping the portal

vein and hepatic artery

-difficult dissection of the

suprahepatic veins

-bleeding from intrahepatic

collaterals

Pringle’s Manoeuvre(temporary occlusion of the hepatoduodenal ligament)

Advantages Disadvantages

-simple, safe, and easy to camy out

-the response of the otherwise

healthy liver to 15 minutes of

normothermic ischaemia normalizes

within 6 days

-anatomical variations(left hepatic

artery arising in the gastric artery)

are not identified

-hepatic veins are not occluded

-with high CVP(central venous within 6 days

-clamping up to 4*15 minutes

-control of bleeding is achieved

-with high CVP(central venous

pressure) bleeding is to be expected

( incl. return flow bleeding)

-danger of air embolism

1954 Left hepatic lobectomy with finger

fracture dissection

1959 Right hepatic lobectomy

1973 Hepatic resection with Lin’s clamp

1974 Hepatic resection with crush

method

1978 Sonography

1979 Resection for small Hcc

1981 Intraoperative echography

台灣醫學會雜誌 1958;57:472 Ann Surg 1973;177:413-21

J Formosan Med Assoc. 1994;93(8):686-90

Cryotherapy

• Cryogenes: liquid nitrogen, helium, argon

• Various-sized probe for different locations

• Large bore probe is needed for liver tumor

Cryotherapy： Complications

• Intraoperative hypothermia

• Cardiac arrhythmia

• Cracking of tissue

• Postoperative fever• Postoperative fever

• Subphrenic or liver abscess

• Biloma or bile fistula

• Myoglobulinuria and renal failure

• Cryoshock

CUSA (1977發明, 1991引進台大, 1994開始用於肝臟切除)

• ultrasonic vibration: tissue differentiation

• coagulation: hemostasis

• irrigation

• Aspiration

1. Bloodless and clear 1. Bloodless and clear operation field

2. Less unexpected bleeding

CUSA-200 CUSA EXcel

Contents







Complications of liver resection

• Intraoperative bleeding

• Postoperative hepatic insufficiency

• Local complications ( liver necrosis, biliary fistula,

postoperative bleeding, subphrenic abscess)postoperative bleeding, subphrenic abscess)

Preoperative Evaluation for Liver Resection

1. Anatomical evaluation

2. Functional evaluation

3. Prognostic evaluation

General assessment

Aims of the pre-operative diagnostic work-up

A Liver parenchyma

1. Topography of the segments

2. Nodular / parenchymal transformation processes

3. Volumetric data or combined procedure

4. Topographic identification of liver lesions

B Arterial System

1. Variations

2. Vessel infiltration2. Vessel infiltration

3. Stenosis of the coeliac trunk ( functional, fixed)

4. Aneurysm

C Hepatoportal System

1. Variations

2. Portal hypertension

3. Portal vein thrombosis

4. Hepatopedal / hepatofugal flow characteristics

D Biliary System

1. Normal topography Hepatic bifurcation , accessory ductal system

2. Pathological changes

Measures aimed at avoiding complications

in liver resections

• Adequate access

• Complete mobilization of the liver

• Occlusion of the hepatoduodenal ligament (pringle manoeuvre)

• Total vascular isolation

• Ligation/division of the main portal vessel branches prior to • Ligation/division of the main portal vessel branches prior to

resection

• Preliminary division of the hepatic vein

• Use of staplers

• Reduction of PEEP

• Transection in anatomical planes

• Incision of parenchyma with the ultrasonic dissector

• Use of fibrin sealant

Current Hemostasis Method

Mechanical Thermal Chemical Physiological

• Compression

• Clamps

• Clips

• Suture

• Collagen

• Cauterization

• Diathermia

• Bipolar

• Laser

• Freezing

• Hydrogen

peroxide

• Other antiseptic

means

• Thrombin

• Fibrin

• Coagulation

factors

• Thrombocytes

• Gelatin sponges

• Cellulose

• Full blood

• Fresh frozen

plasma

Category FlowableHemostatic Hemostat

Fibrin Sealant

Mechanism of Action

Contact activation + final stage of clotting cascade

Replicates end stage of clotting cascade

Field Conditions Wet Moist

Baxter Portfolio for Surgeon

Field Conditions Wet Moist

Pressure Tolerance High Medium

Requires active

bleedingYes No

LimitationsDoes not seal. Creates gelatin-

reinforced blood clot

Will not strongly adhere to graft

material

Uses Control Localized bleeding Support Sealing

The Use of Tissucol Duo (TDQ) and Floseal

in Liver Surgery

Liver Resection

TDQ: Liver resection surface oozing ( prevent postoperative

bleeding )

Floseal: Local site bleedingFloseal: Local site bleeding

Liver Transplantation

TDQ: Hepatic artery- anastomatic sealing and proper

fixation

TDQ: Bile duct- anastomotic sealing and reduce adhesion

Repeat Resection for Patients with Hepatocellular Carcinoma (1987-1995)

Operation time Patients No. Resection No. 2 55 110 3 7 21 3 7 21 4 2 8 5 1 5 Total 65 144

Total patients 408 Total resections 480 Resection rate 15.9% 30%

Post Recurrence Survival in Patients Received

Primary Resection for Hepatocellular Carcinoma

Su

rviv

al

1.0

0.8

0.6

0.4

TACE

RFA

Re-resection

P = 0.56

P = 0.014

Log-rank test

RFA 50 36 23 15 7 4 3 2 1

Reresection 54 44 30 21 14 8 2 0 0

TACE 254 157 97 52 28 16 11 3 1

Supportive

treatment

77 10 2 1 0 0 0 0 0

9876543210

0.2

0.0

Supportive Treatment

P < 0.001

Number at riskTime after recurrence (years)

Local ablation and re-

resection have comparable

effect in the treatment of

recurrent HCC

Surgery. 2012; 151(5):700-9,

Extended Surgery for Hepatoma

• Hepatic vascular exclusion for liver resection

using veno-venous bypass

• Liver resection and removal of tumor thrombi

in the major portal veinin the major portal vein

Perioperative Complications for Hepatocellular Carcinoma Patients Receiving Liver Resection

1987-1991 1992-1995 (n=184) (n=296) TotalInternal bleeding 3 1 4G-I bleeding 2 2 4 Bile leakage 8 7 15 Wound infection 2 4 6Intrabdominal abscess 7 5 12Pneumonia 1 0 1Pleural effusion 14 12 26Pleural effusion 14 12 26Ascites 4 5 9CBD amputation 0 1 1Intestinal perforation 0 2 2Liver failure 9 6 15

Total 50 45 95

Reoperation 3 1Mortality (within 30 days) 3 0(0%) 3(0.74%)*

* 480 liver resections in 408 patients

Prophylaxis of Hepatic Decompensation

�Adequate blood volume

�Adequate nutrition

�Reduction of intestinal flora

�Prophylaxis of gastrointestinal bleeding�Prophylaxis of gastrointestinal bleeding

Operative Techniques to Minimize Infection

Eliminate hair, if indicated, just prior to incision time

Effective skin preparation, i.e., iodophor chlorhexidine

Gentle tissue handling

Effective hemostasisEffective hemostasis

Eradicate dead spaces

Operation lasting less than 2 hours

Closed suction drainage, if indicated, at a distance from

the incision

Contents







Minimally Invasive Surgery for Liver Diseases

Laparoscopic liver resection

Hand-assisted laparoscopic liver resection

Total laparoscopic liver resection

RFA-assisted laparoscopic liver resectionRFA-assisted laparoscopic liver resection

Laparoscopic RFA

Robotic liver resection

What’s the difference between

robotic surgery and laparoscopic surgery?1. 3D HD surgical version with 10~12 magnification

Laparoscopic surgery:2D image

Robotic Hepatobiliary Surgery in NTUH Indications (2012 ~Jul, 2013)

Total cases : 76

Robotic liver resection: 69 (91%)

Malignant : 76%

** most of the reported cases of right

hepatectomy (33/51) were contributed by

a single surgeon (Giulianotti et al.)conversion rate: 4.6% (10/217)

morbidity: 20.3%

Clinical Data & Surgical Results in HCC PatientsRobotic(n=38) Laparoscopy(n=41) p Value

Age(years) 60.9 ±14.9 54.1 ±14 0.04

Sex (M：F) 32:6 28:13 NS

Tumor size (cm) 3.4±1.7 2.5 ±1.6 0.02

Operative method

(≧ 2 segments)

28(74%) 15(36.58%) 0.05

Operating time (min) 380 166 227 80 0.04Operating time (min) 380±166 227 ±80 0.04

Blood loss(ml) 325 ±480 173 ±165 0.03

Conversion (rate) 2(5%) 5(12.2%) NS

Post-operative stay (days) 7.9 ±4.7 7.2 ±4.4 NS

Morbidity 3 (8%) 4(10%) NS

Mortality 0 0 NS

Follow up(month) 5.1±2.8 26.6 ±13.3

(150 ~ 720) (40 ~210)(65 ~340)

** complications:

Robotic: transient bile leak

Laparoscopic: transient bile leak, bleeding need transfusion.

Open: w’d infection, ascites, transient hepatic decompensation, bile leakage

** Oncology outcome: margin negative; no recurrence or metastasis noted

Important Key Points for Laparoscopic

Hepatectomy

． Adequate exposure of operative field

． Precise localization of tumor

． Control of bleeding during parenchymal． Control of bleeding during parenchymal

transections

Strategies to Avoid Gas Emboli

Reduced pneumoperitoneum pressure,

below 12 mmHg.

Precise ultrasonographic localization of the Precise ultrasonographic localization of the

hepatic vein and its tributaries.

Positive pressure ventilation.

Contents







Liver Transplantation in National Taiwan University Hospital (NTUH) (1989 Oct.~ 2013Dec.)

30

35

40

All patients

Others218 44%

HBV 104 21%

HCV 46 9%

HBV+HCC 71 14%

HCV+HCC 37 8%

HCC 10 2%

HBV+HCV 11 2%Number : 497

CLT : 125LRLT : 372

0

5

10

15

20

25

1989199019911992199319941995199619971998

199920002001200220032004200520062007200820092010201120122013

CLTCLTCLTCLTLRLTLRLTLRLTLRLT All patients 497

Adult patients 358

Others 79 22%

HBV 104 29%

HCV 46 12%HBV+HCC 71 20%

HCV+HCC37 11%

HCC 10 3% HBV+HCV 11 3%

16/Dec./2013

肝移植方式

• 正位肝臟移植

• 部分肝臟移植

– 活體肝臟移植

– 屍肝移植

– 輔助肝臟移植– 輔助肝臟移植

Hepatic Vein Reconstruction (Ⅱ)

THE PIGGYBACK TECHNIQUE WITHOUT PORTOCAVAL SHUNT IS SUPERIOR TO

STANDARD VENO-VENO BYPASS TECHNIQUE FOR LIVER TRANSPLANTATION.

Piggy Back IVCPiggy Back IVC--cavalcaval (end to Side) (end to Side) AnastomosisAnastomosis in Deceased in Deceased

Donor Liver TransplantationDonor Liver Transplantation

Fernandez, et al. Transplantation 1998;66(8):S52

Polak WG, et al. Clin Transplant 2006;20:609-616

Side-to-Side Cavo-cavostomy

A useful aid in “complicated” piggyback LTx

Hepatic Vein reconstruction (ⅢⅢⅢⅢ)

Belghiti J, et al. Surg Gynecol Obstet 1992;175:270-272

Lerut J, et al. Transplant Int 1993;6:299-301

% 3-Month Mortality as a Function of MELD

100

Allocation by MELD Score

Based on 3 parameters: - INR

- Bilirubin

- Creatinine

3 months mortality according to MELD score

0

10

20

30

40

50

60

70

80

90

100

-20 -10 0 10 20 30 40 50 60 70 80

MELD Score

% M

ort

ali

ty

MELD

%%

Causes

• Recipient factor

1. High MELD score; high >35

2. Advanced recipient age

• Graft factor

1. Advanced donor age

• Operative factor

1. Bile duct reconstruction type

2. Cold ischemic time

3. Warm ischemic time

• Post-operative factor

2. Graft type

3. Bile duct diameter and

multiplicity

1. Immunosuppression

2. CMV infection

3. Hepatic artery thrombosis

Akamatsu et al Transpl Int. (2011) 379-372

MELD Score = (0.957 * ln(Serum Cr) + 0.378 * ln(Serum Bilirubin) + 1.120 * ln(INR) + 0.643 )

* 10 (if hemodialysis, value for Creatinine is automatically set to 4.0)

Survey of liver donor complications

21% ：ELTR

death

need for rehospitalization

bile stricture or leak

liver insufficiency

pulmonary emboli

major infection

14% ：Brown et al.

death (0.2%)

rehospitalization(8.5%)

bile stricture or leak(6%)

blood transfusion (4.9%)

need for reoperation(4.5%)

major infection (1.1%)

20% ：Lo CM

Bile leakage

Hyperbilirubinemia

intraabdominal collection

small bowel obstruction

biliary stricture

portal vein thrombosis

pulmonary embolipulmonary emboli

intraabdominal bleeding

Pancreatitis

bleeding duodenal ulcer

incisional hernia

renal failure

gastric perforation

wound infection

gastric outlet obstruction

pleural effusion and pneumonia

pressure sore

peroneal nerve palsyTransplantation 2006; 81: 10, 1373-1385.

Estimated Worldwide Operative Donor Mortality

• 6000-7000 live donor hepatic resection• Two donors have undergone liver transplantation secondary to

operative complications from right lobe donation

• One donor is in a persistent vegetative state after donation

• Catastrophic complications (0.4-0.6%): 14 deaths, 2 required liver transplant, 1 vegetative state14 deaths, 2 required liver transplant, 1 vegetative state

3 left liver 11 right liver

US 1 US 2 Japan 1

Brazil 1 Brazil 2 Egypt 1

Germany 1 Germany 2 China(HK) 1

France 1 India 1

• The mortality is up to 0.5% for right liver donor and 0.1% for left liver

Transplantation 2006; 81: 10, 1373-1385.

Evaluation of Fatty Liver

● MRI:

○ magnetic resonance spectroscopy (MRS)■ MRS> 9%: moderate■ MRS> 18%: severe

Milan vs UCSF Criteria

• 479 HCC+OLT

– pre-op stage 5yrSR p<0.001

– within Milan 279 60.1%

– between Milan & UCSF 44 45.6%

– beyond UCSF 145 34.7%

P=0.10

– beyond UCSF 145 34.7%

– Post op stage p<0.001

– within Milan 184 70.4%

– between Milan & UCSF 39 63.6%

– beyond UCSF 238 34.1

Liver Transplantation. 2006;12(12):1761-9

P=0.33

A lot of patients go beyond UCSF criteria after operation

Favor Milan criteria than UCSF criteria !

Liver transplantation for HCC at NTUH

Since 1996 (all LTx since 1989)

Reasonable morbidityLow recurrence rateBetter long term survivalBut shortage of donor

patient survival disease free survival

Ann Surg Oncol 2012;19(3):826-33

9 yr 75.9% 9 yr 65.0%

Survival, Recurrence, and Mortality of HCC Patients

Receiving Liver Resection or Transplantation

Resection (n=746) Tx (n=54)

Mortality 1.47% 3.7%

Patient survival 5-year 80.5% 77.2%

9-year 75.9% 77.2%

Recurrence rate

2-year 33.9% 16.8%2-year 33.9% 16.8%

5-year 56.3% 27.1%

7-year 61.9% 34.4%

9-year 65.0% 34.4%

Recurrence free

2-year 66.1%

5-year 43.7%

9-year 35.0%

Ann Surg Oncol 2012; 19(3):826-33,

Recurrence Pattern after Surgical Treatment

for HCC

Resection (n = 746) Liver Transplantation (n = 54)

Intra-hepatic 283 (37.9%) 2 (3.7%)

Loco-regional 4 (0.5%) 2 (3.7%)

Lung 10 (1.3%) 5 (9.3%)

Brain 1 (0.1%) 1 (1.9%)

Bone 3 (0.4%) 2 (3.7%)

66

Ann Surg Oncol. 2012;19:826-33

Portocaval Anastomosis

Cheuan xx, M 59 y/o

Tx date : 1998-07-01 (CLTx)

No PV or SMV found during

dissection

10Y8M, Live with frequent

attacks of encephalopathy

Chen xx, M 58 y/o

Tx date : 2007-01-10 (LRLTx) PV

thrombosis noted preoperatively.

Vascular graft from cadaver

Died on POD10 due to PNF

Ko x x, F 37y/o Neuroendocrine tumor

Tx date : 2007-12-24 (LRLTx)

1Y3M, L&W

Wang xx, M 58y/o HCV+HCC

Tx date : 2008-05-05 (LRLTx)Tx date : 2008-05-05 (LRLTx)

Portal vein stricture

PV Balloom dilatation and stenting on 2008-06-16

10M, L&W

Causes of Poor Portal Flow in Recipient

• Anastomotic stenosis

• Occluded or a partially removed thrombus in

the recipient portal system

• Steal phenomena due to native portosystemic• Steal phenomena due to native portosystemic

communications

Strategy of portal vein reconstruction for

patients with PVT

1.Preoperative evaluation on CT angiography

2.Original portal vein is ideal for reconstruction, if

possiblepossible

3.Interception of collateral veins

→ increasing portal blood flow

4.Possible alternative in the case without original

portal vein reconstruction

The Importance of Adequate Hepatic Venous Drainage

• In adult-adult LDLT, right lobe grafts are usually needed

for the recipients

• If the blood from S5 & S8 are not drained well

– Lobular congestion

– Catastrophic bleeding

– Effective functional size decreased

Impaired liver graft function

Causes of Early Hepatic Venous Outflow

Obstruction

• Mostly technical complications

• Tight suture line causing anastomotic stenosis

• Twisting of the HV anastomosis by displacement of

• the graft to right hepatic fossa• the graft to right hepatic fossa

• Caval compression from a large graft squeezing the

• liver in the abdomen despite closure of the skin

Sayers RD, et al. Eur J Vasc Surg 1992;6:354

Zaiko AB, et al. Radiology 1989;170:763

Someda H, et al. J Hepatol 1995;22:623

Causes of Late Hepatic Venous Outflow

Obstruction

• Neointimal fibrous hyperplasia

• Fibrosis around the anastomotic site/suprahepatic

anastomosis

Compression of the anastomosis from the • Compression of the anastomosis from the

hypertrophic graft

Sayers RD, et al. Eur J Vasc Surg 1992;6:354

Zaiko AB, et al. Radiology 1989;170:763

Someda H, et al. J Hepatol 1995;22:623

Choices of Drainage Preservation

• Ensure the well-draining of S5&8 graft:

– with MHV

– w/o MHV but need additional vascular reconstruction

– Inferior hepatic vein (s) (IHV)

• Donor safety• Donor safety

– Graft with MHV is beneficial to the recipient, but the donor suffers

We use graft without MHV but with reconstruction of S5&8 drainage

Hepatic Drainage Reconstruction Considering

S4,5 &8 in 122 LDLT (1)

• With MHV drainage reconstruction (n=52, 42.6%)

– One greater saphenous vein graft for S4

– Right lobe graft (n=51)

• Recipient greater saphenous vein: n=48 (94.1%)• Recipient greater saphenous vein: n=48 (94.1%)

• Recipient umbilical vein: n=1

• Live donor IMV: n=1

• Iliac vein graft from tissue bank: n=1

– S5 & S8 drainage vein reconstruction: n=15 (29.4%)

– S5 or S8 drainage vein reconstruction: n=36 (70.6%)

– Combined IHV reconstruction: n=17

Hepatic Drainage Reconstruction Considering

S4,5 &8 in 122 LDLT (2)

• IHV reconstruction: n=25

– Vascular conduit: n=4 (16%)

• Recipient greater saphenous vein graft (2),• Recipient greater saphenous vein graft (2),

left portal vein (1), umbilical vein (1)

Examples of Drainage Reconstruction

Hwang Wu x x, F 54y/o HCV+HCC

Tx date : 2005-05-02

3Y10M, L&W

Hsu x x, M 48y/o Alcoholic LC+HCV

Tx date : 2007-05-28

1Y10M, L&W

Biliary reconstructions

1. Duct to duct (DD) anastomosis

1. Shorter operation time

2. More physiological enteric functions

3. Preservation of function of the sphincter of Oddi

2. Roux-en-Y (RY): Hepatojejunostomy

Hwang et al. Liver transpl 2006:12:831-838

Feng XN et al. Hepatobiliary Pancreat Dis Int. (2011); 10: 136-142

Stent insertion

• Advantage:

1. Prevent anastomotic stricture

2. Maintenance of biliary flow

3. Monitoring the quality of output bile

4. Cholangiographic for biliary anatomy

5. Lowering the biliary pressure5. Lowering the biliary pressure

• Biliary decompression with a splinting tube may be more

indicated in DD reconstruction with a partial-liver graft

transplant. (80% of center)

Wojcicki M et al. Dig Surg 2008;25: 245.

Lerut J et al. Transplantation 1987; 43: 47.

Stent insertion

• Stent insertion was reported to increase complication

– Narrowing of the bile duct lumen

– Spontaneous dislodgment or accidental early removal

– Bile leak frequently following removal (5-33%)

• There is no clear evidence in favor of using a stent during DDLT • There is no clear evidence in favor of using a stent during DDLT

in terms of overall biliary complications.

Akamatsu et al Transpl Int. (2011) 379-372

StrictureStrictureStrictureStricture LeakageLeakageLeakageLeakage BiliaryBiliaryBiliaryBiliary complicationscomplicationscomplicationscomplications

StentStentStentStent NonNonNonNon----SSSS PPPP----valuevaluevaluevalue StentStentStentStent NonNonNonNon----SSSS PPPP----valuevaluevaluevalue StentStentStentStent NonNonNonNon----SSSS PPPP----valuevaluevaluevalue

NTUH 4/50(8.0%)

7/43(16.3%)

0.1785 6/50(12%)

3/43(7%)

0.4977 10/50(20%)

10/43(23%)

0.5419

Critical Liver Mass for Liver Resection

and Partial Liver Transplantation

Normal liver(%) Cirrhotic

liver(%)

Donor volume

in LRLT(%)

Graft-body-

weight-ratio

Europe 28(15-40) 50(30-80) 35(30-50) 0.8(0.6-1.2)

North America 25(15-30) 50(25-90) 35(30-45) 0.8(0.8-1.0)

Asia 30(20-40) 50(30-80) 35(30-45) 0.8(0.6-0.8)Asia 30(20-40) 50(30-80) 35(30-45) 0.8(0.6-0.8)

Australia 28(25-30) 50(40-50) 35 -

South America 28(25-40) 45(40-80) 38(35-40) 0.8(0.8-1.2)

Overall 28(15-40) 50(25-90) 40(30-50) 0.8(0.6-1.2)

World J. Surg (2009) 33:797-803

Controlled Portal Pressure is Key for Better Outcome

100

50

Pa

tie

nt

Su

rviv

al

(%)

Portal pressure <20mmHg (n=98)Portal pressure <15mmHg (n=57)

Portal pressure ≥15mmHg (n=43)

100

50

76.0%

91.4%

50.0%

85.4%

50

0

Post-operative years

Pa

tie

nt

Su

rviv

al

(%)

Portal pressure ≥20mmHg (n=2)

p = 0.1

1 20

Post-operative years

50

0p = 0.0162

1 20

50.0%

Decrease

・・・・splenectomy →3-5mmHg

・・・・distal spleno-renal shunt (rare)

How to modulate portal blood flow?

・・・・distal spleno-renal shunt (rare)

Increase

・・・・interception of collateral veins

Trend of graft selection for adult LDLT in KUHP

60

70

80

90

100

60%

70%

80%

90%

100%

Left LobeRight Lobe

79%

90%

95%98% 98% 97%

100% 96%

78%

64%65%

Ad

ult

LD

LT

cases/

year

Pro

po

rtio

n o

f ri

gh

t-lo

be g

raft

100%

80%

60%

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 20080

10

20

30

40

50

60

0%

10%

20%

30%

40%

50%

64%65%

Ad

ult

LD

LT

cases/

year

Pro

po

rtio

n o

f ri

gh

t

40%

20%

0%

46%

2009

PV pressure controlIndication limit of GRWR

≥0.8 ≥0.7 ≥0.6

10

15

20

CG

(m

mH

g)

Impact of splenectomy on PCG

p < 0.0001

2008.3-2010.12 Adult-LDLT 125cases

Pre-s

plen

ecto

my

Final

0

5

PC

PCG ≤ 5mmHg

(n=70)

PCG > 5mmHg (n=55) P-value

4 (5.7%) 19 (34.5%) < 0.0001

Early (within 3M) patients death


4 (5.7%) 19 (34.5%) < 0.0001

Chi-square test

Patients survival Graft survival


Log-rank (Mantle Cox) test

p = 0.0007 p = 0.0004

Contents







Postoperative Liver Dysfunction

Extrahepatic ( postthepatic) causes:Blockage of bile ducts (bile stone, papillary stenosis)

Injury to bile ducts

ligation of hepatic artery

pancreatitis ( papillary stenosis)

Acalculous cholecystitis

Hepatocellular dysfunction:Liver ischaemia (hepatitis, medication, arterial occlusion, portal vein thrombosis)

medication

Parenteral feeding

Fatty liver

Viral hepatitisViral hepatitis

transfusion

Cholestasis:ischaemia

sepsis

medication

Parenteral feeding

Prehepatic causes and bilirubin overproduction:haemolytic anaemia

Blood transfusion

sepsis

Absorption of blood

Goal of Intensive Care for Patients with Impaired

Liver Function

Prevent further deterioration in liver function

Reverse precipitating factors

Support failing organsSupport failing organs

Support of the Failing Liver

Medical therapy

Plasma exchange-plasmaphresis

Blood purification

hemofiltration

hemoadsorption

charcoal hemoperfusioncharcoal hemoperfusion

hemofiltration with plasma exchange

molecular absorbent recirculaition system(MARS)

Biological liver support system

ex vivo liver perfusion

hepatocyte transplantation

extracorporeal hepatocyte systems (Bio-artificial liver ,BAL)

LATE COMPLICATIONS ASSOCIATED

MORTALITY

De novo malignancies

InfectionsInfections

Chronic renal failure

Cardiovascular disease

Clinical Experience with Elective IS

Clinicopathological Features

Associated with Successful Weaning

Longer interval between transplantation and

weaning (preferably >3 years);

An absence of humoral sensitization, as

determined by donor-specific antibody (DSA)

determinations

A paucity of previous cellular rejection episodes

Non-autoimmune primary liver diseases

Already minimized immunosuppression

Lower recipient age at time of transplantation

(microsoft powerpoint

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