Dr sumer yadavDr sumer yadav

1955 – FIRST LIVER 1955 – FIRST LIVER TRANSPLANTTRANSPLANT

WELSH : EXPERIMENTAL WELSH : EXPERIMENTAL DOG MODELDOG MODEL

1963 – FIRST HUMAN 1963 – FIRST HUMAN LIVER TRANSPLANTLIVER TRANSPLANT

STARZL : PIONEERSTARZL : PIONEER

1960s & 1970s1960s & 1970s•TECHNICAL TECHNICAL

DEVELOPMENTDEVELOPMENT

•SURVIVAL RATES : <50% AT SURVIVAL RATES : <50% AT 1 YR.1 YR.

1980s1980s• CYCLOSPORINECYCLOSPORINE

• VENOVENOUS VENOVENOUS BYPASSBYPASS

• UW UW PRESERVATION PRESERVATION SOLUTION SOLUTION SURVIVAL RATES SURVIVAL RATES

IMPROVE IMPROVE MARKEDLYMARKEDLY

1991990s0s

EXPAND DONOR EXPAND DONOR LIVER POOLLIVER POOL

• LIVE DONOR LIVE DONOR (LDLT)(LDLT)

• SPLITSPLIT• REDUCED SIZE REDUCED SIZE

(RSLT)(RSLT)• NON HEART NON HEART

BEATINGBEATING

SURVIVAL RATES AT SURVIVAL RATES AT

01 YR. 01 YR. – – 90%90%10 YR.10 YR. – – 70% 70%

ENDEND STAGE LIVER DISEASE STAGE LIVER DISEASE

CHRONIC LIVER FAILURECHRONIC LIVER FAILURE

ACUTE FULMINANT LIVER FAILUREACUTE FULMINANT LIVER FAILURE

PRIMARY HEPATIC MALIGNANCYPRIMARY HEPATIC MALIGNANCY

INBORN ERRORS OF METABOLISMINBORN ERRORS OF METABOLISM

CHRONIC CHRONIC LIVER LIVER

FAILUREFAILURE•COMMONEST INDICATION COMMONEST INDICATION

(80%) : (80%) : END STAGE END STAGE CHRONIC LIVER DISEASESCHRONIC LIVER DISEASES

•GENERAL CRITERIA : GENERAL CRITERIA : CLINICAL + BIOCHEMICALCLINICAL + BIOCHEMICAL

AETIOLOGY AETIOLOGY DEPENDENTDEPENDENT

SPECIFIC SPECIFIC INDICATIONSINDICATIONS

A.A. CHOLESTATIC LIVER CHOLESTATIC LIVER DISEASE:DISEASE:

INTRACTABLE PRUTITUSINTRACTABLE PRUTITUS

INTERACTABLE BONE DISEASEINTERACTABLE BONE DISEASE

RECURRENT CHOLANGITISRECURRENT CHOLANGITIS

SPECIFIC INDICATIONS SPECIFIC INDICATIONS (Contd.)(Contd.)

A.A. HEPATO CELLULAR HEPATO CELLULAR DISEASE : DISEASE : WORSENING WORSENING SYNTHETIC FUNCTIONSSYNTHETIC FUNCTIONS

1.1. SERUM ALBUMIN <30.0G/lSERUM ALBUMIN <30.0G/l

2.2. PROTHROMBIN TIME >4 s PROTHROMBIN TIME >4 s THAN NORMALTHAN NORMAL

CLINICAL CLINICAL EVENTSEVENTS

MAY PRECIPITATE NEED FOR MAY PRECIPITATE NEED FOR TxTx

HEPATIC ENCEPHALOPATHYHEPATIC ENCEPHALOPATHY

REFRACTORY ASCITESREFRACTORY ASCITES

VARICEAL BLEEDINGVARICEAL BLEEDING

HEPATIC HEPATIC ENCEPHALOPATHENCEPHALOPATH

YY• EVEN MILD EVEN MILD

ENCEPHALOPATHY HAS ENCEPHALOPATHY HAS DETRIMENTAL EFFECT ON DETRIMENTAL EFFECT ON QUALITY OF LIFE QUALITY OF LIFE

CONSIDER CONSIDER TRANSPLANTATIONTRANSPLANTATION

ASCITESASCITES

• UNRESPONSIVE ASCITES : INDICATION UNRESPONSIVE ASCITES : INDICATION FOR Tx.FOR Tx.

• PERITONEOVENOUS SHUNTING NOT PERITONEOVENOUS SHUNTING NOT RECOMMENDED FOR Tx CANDIDATESRECOMMENDED FOR Tx CANDIDATES

• SPONTANEOUS BACTERIAL SPONTANEOUS BACTERIAL PERITONITIS (SBP) IS A STRONG PERITONITIS (SBP) IS A STRONG INDICATION FOR TxINDICATION FOR Tx

• SURGERY IN SBP DELAYED UNTIL SURGERY IN SBP DELAYED UNTIL AFTER FULL COURSE OF TREATMENTAFTER FULL COURSE OF TREATMENT

VARICEAL VARICEAL HEMORRHAGEHEMORRHAGE

•RECURRENT VARICEAL RECURRENT VARICEAL BLEEDING IS A CLEAR BLEEDING IS A CLEAR INDICATION FOR Tx.INDICATION FOR Tx.

•TIPS SHOULD BE CONSIDERED TIPS SHOULD BE CONSIDERED AS BRIDGING THERAPY IN AS BRIDGING THERAPY IN APPROPRIATE CASES.APPROPRIATE CASES.

FULMINANT HEPATIC FULMINANT HEPATIC FAILUREFAILURE

• ONSET OR HEPATIC ONSET OR HEPATIC ENCEPHALOPATHY WITH IN 8 ENCEPHALOPATHY WITH IN 8 WEEKS OF ONSET OF ACUTE WEEKS OF ONSET OF ACUTE LIVER FAILURE IN ABSENCE LIVER FAILURE IN ABSENCE OF PREEXISTING LIVER OF PREEXISTING LIVER DISEASE.DISEASE.

• BETWEEN 8 WEEKS & 6 BETWEEN 8 WEEKS & 6 MONTHS : LATER ONSET OR MONTHS : LATER ONSET OR SUBACUTESUBACUTE

FULMINANT HEPATIC FULMINANT HEPATIC FAILURE FAILURE (Contd.)(Contd.)

• COMMONER COMMONER CAUSES : CAUSES :

1.1.PARACETAMOL PARACETAMOL OVER DOSEOVER DOSE

2.2.VIRAL VIRAL HEPATITIS ESP HEPATITIS ESP : : NON A, NON B, NON A, NON B, NON C.NON C.

SPECIFIC CRITERIA FOR SPECIFIC CRITERIA FOR Tx : PUBLISHEDTx : PUBLISHED

•AETIOLOGICAL FACTORAETIOLOGICAL FACTOR•AGEAGE•ACIDOSISACIDOSIS•COAGULOPATHYCOAGULOPATHY•SERUM BILIRUBIN SERUM BILIRUBIN LEVEL LEVEL

CONTRA CONTRA INDICATIONSINDICATIONS

•BRAINSTEM DYSFUNCTIONBRAINSTEM DYSFUNCTION

•UNCONTROLLED SEPSISUNCONTROLLED SEPSIS

•REFRACTORY REFRACTORY HYPOTENSIONHYPOTENSION

PRIMARY PRIMARY HEPATIC HEPATIC

MALIGNANCY :MALIGNANCY :HCC

NON CIRRHOTICS

CIRRHOTICS (ESP, HEPATITIS C,

HAEMOCRIMROMATOSIS & ALCOHOLIC)

SPRORADICLARGE MASS

LATE RESULTS POOR(20%)

Tx NOT INDICATED

SINGLE TUMOR <5cm.3 TUMOR <3cm.

EXCELLENT RESULT

Tx INDICATED

CHILD’S A CIRRHOSISCHILD’S A CIRRHOSIS• LATE OCCURRENCE OF LATE OCCURRENCE OF

TUMOURS (OFTEN MULTIPLE)TUMOURS (OFTEN MULTIPLE)• POTENTIAL RESECTION v/s TxPOTENTIAL RESECTION v/s Tx

PRIMARY BILE DUCT PRIMARY BILE DUCT CANCERCANCER

(CHOLANGIO CARCINOMA)(CHOLANGIO CARCINOMA)• VERY HIGH RECURRENCE VERY HIGH RECURRENCE

RATERATE• UNSUITABLE FOR TxUNSUITABLE FOR Tx

INBORN ERRORS OF INBORN ERRORS OF METABOLISM:METABOLISM:

• WILSON’S DISEASEWILSON’S DISEASE• FAMILIAL HYPERCHOLESTROLAEMIAFAMILIAL HYPERCHOLESTROLAEMIA• PROTOPORPHYRIAPROTOPORPHYRIA• ANTITRYPSIN DEFICIENCYANTITRYPSIN DEFICIENCY

MAJORITY AFFECT PAEDIATRIC PATIENTSMAJORITY AFFECT PAEDIATRIC PATIENTS• INDICATIONS FOR Tx :INDICATIONS FOR Tx :1.1. LIVER FAILURELIVER FAILURE

2.2. EXTRA HEPATIC ORGAN FAILURE,EXTRA HEPATIC ORGAN FAILURE,

3.3. DEVELOPMENT OF HCCDEVELOPMENT OF HCC

4.4. SEVERE SYMPTOMS AFFECTING QUALITY OF SEVERE SYMPTOMS AFFECTING QUALITY OF LIFE.LIFE.

SELECTION & TIMINGSELECTION & TIMING

DONORDONOR :: RECIPIENT RECIPIENT

IN UKIN UK WL. 150WL. 150 :: ANNUAL Tx ANNUAL Tx 750750

WAITING LIST MORTALITY 10% per yr.WAITING LIST MORTALITY 10% per yr.MEDIAN WAITING TIME 3 TO 4 MONTHS MEDIAN WAITING TIME 3 TO 4 MONTHS

• EXPECTED LENGTH OF LIFE <1 YR.EXPECTED LENGTH OF LIFE <1 YR.• QUALITY OF LIFE UNACCEPTABLEQUALITY OF LIFE UNACCEPTABLE50% PROBABILITY OR MORE OF BEING ALIVE 5 Yrs. 50% PROBABILITY OR MORE OF BEING ALIVE 5 Yrs.

AFTER TRANSPLANTATION WITH ACCEPTABLE AFTER TRANSPLANTATION WITH ACCEPTABLE QUALITY OF LIFE.QUALITY OF LIFE.

INUSAINUSAWAITING LIST 18000 : ANNUAL WAITING LIST 18000 : ANNUAL CADAVERIC Tx 4500CADAVERIC Tx 4500

• MELD (MODEL FOR END MELD (MODEL FOR END STAGE LIVER DISEASE)STAGE LIVER DISEASE)

• PELD (FOR CHILDREN)PELD (FOR CHILDREN)•CREATININECREATININE•BILIRUBINBILIRUBIN•INRINR

•WELL VALIDATED TO PREDICT WELL VALIDATED TO PREDICT DEATH WITHIN 90 DAYSDEATH WITHIN 90 DAYS

•RESULTED IN REDUCTION IN RESULTED IN REDUCTION IN WL MORTALITY BUT DO NOT WL MORTALITY BUT DO NOT WELL PREDICT LONG TERM WELL PREDICT LONG TERM OUTCOMEOUTCOME

•ADDITIONAL MEASURES ADDITIONAL MEASURES NEEDEDNEEDED

SPECIFIC SPECIFIC INDICATIONSINDICATIONS

PRIMARY BILIARY CIRRHOSIS (PCB) :PRIMARY BILIARY CIRRHOSIS (PCB) : AUTO IMMUNE DISEASEAUTO IMMUNE DISEASE

SIMPLEST SIMPLEST : : SERUM BILIRUBINSERUM BILIRUBINOTHERS : OTHERS :

•AGEAGE•BILIRUBIN BILIRUBIN •ALBUMIN LEVELALBUMIN LEVEL•PROTHROMBIN TIMEPROTHROMBIN TIME

MEDICAL THERAPY : IMPROVES LIVER MEDICAL THERAPY : IMPROVES LIVER BIOCHEM. : DELAY/AVERT Tx? BIOCHEM. : DELAY/AVERT Tx?

PRIMARY PRIMARY SELEROSING SELEROSING

CHOLANGITIS (PSC)CHOLANGITIS (PSC)

PROGRESSIVE CHOLESTATIC DISEASE PROGRESSIVE CHOLESTATIC DISEASE ASSO. WITH CONCURRENT ASSO. WITH CONCURRENT INFLAMMATORY BOWEL DISEASE (70%).INFLAMMATORY BOWEL DISEASE (70%).

• HIGH RISK OF CHOLANGIOCARCINOMAHIGH RISK OF CHOLANGIOCARCINOMA• IF GRAFTED AFTER DEVELOPMENT OF IF GRAFTED AFTER DEVELOPMENT OF

MALIGNANCY : POOR OUT COMEMALIGNANCY : POOR OUT COME• CLINICAL DOUBT : GUIDED BIOPSY OF CLINICAL DOUBT : GUIDED BIOPSY OF

DOMINANT STRICTURE.DOMINANT STRICTURE.

CHRONIC VIRAL CHRONIC VIRAL HEPATITIS HEPATITIS

HEPATITIS C & B VIRUSESHEPATITIS C & B VIRUSES

– ANTIVIRAL DRUGS : MAJOR ANTIVIRAL DRUGS : MAJOR DEVELOPMENTS : CONTROL DEVELOPMENTS : CONTROL DISEASE/AVOID TxDISEASE/AVOID Tx

– MAJOR RISK OF HCC : IF MAJOR RISK OF HCC : IF DETECTED EARLY SIMILAR DETECTED EARLY SIMILAR SURVIVAL AS FOR BENIGN SURVIVAL AS FOR BENIGN DISEASE. DISEASE.

HEPATITIS CHEPATITIS C

• Rx : INTERFERON + RIBAVIRINRx : INTERFERON + RIBAVIRIN• HEPATIC DECOMPENSATION : Tx HEPATIC DECOMPENSATION : Tx

ONLY OPTION.ONLY OPTION.• DISEASE RECURRENCE IN NEW DISEASE RECURRENCE IN NEW

LIVER : OFTEN AT ACCELERATED LIVER : OFTEN AT ACCELERATED RATE : SIGNIFICANT RISK. RATE : SIGNIFICANT RISK.

• NO EFFECTIVE POST TRANSPLANT NO EFFECTIVE POST TRANSPLANT REGIME AVAILABLE : USE REGIME AVAILABLE : USE YOUNGER DONORS. YOUNGER DONORS.

HEPATITIS BHEPATITIS B

• ANTIVIRAL THERAPY USING ANTIVIRAL THERAPY USING NUCLEOSIDE ANALOGUES : PREVENT NUCLEOSIDE ANALOGUES : PREVENT PROGRESSIVE LIVER DAMAGEPROGRESSIVE LIVER DAMAGE

• UNRESPONSIVE OR ADVANCED UNRESPONSIVE OR ADVANCED DISEASE : Tx DISEASE : Tx

• Tx SUCCESSFUL DUE TO EFFECTIVE Tx SUCCESSFUL DUE TO EFFECTIVE ANTIVIRAL PROTOCOL UTILIZING ANTIVIRAL PROTOCOL UTILIZING HEPATITIS B IMMUNOGLOBULIN AND HEPATITIS B IMMUNOGLOBULIN AND LAMIVUDINE.LAMIVUDINE.

ALCOHOLIC LIVER ALCOHOLIC LIVER DISEASEDISEASE

END STAGE ALCOHOLIC LIVER DISEASE : END STAGE ALCOHOLIC LIVER DISEASE : ACCEPTED INDICATION FOR TxACCEPTED INDICATION FOR Tx

• CONTROVERSIAL : POSSIBLE RECIDIVISM CONTROVERSIAL : POSSIBLE RECIDIVISM & POOR COMPLIANCE& POOR COMPLIANCE

• OUT COME : SURVIVAL & QUALITY OF OUT COME : SURVIVAL & QUALITY OF LIFE SAME AS OTHERS.LIFE SAME AS OTHERS.– ABSTINENCE AT LEAST 6 MONTHSABSTINENCE AT LEAST 6 MONTHS– PSYCHIATRIC ASSESSMENT & FORMAL PSYCHIATRIC ASSESSMENT & FORMAL

ALCOHOL REHABILITATION PROGRAMMEALCOHOL REHABILITATION PROGRAMME– STABLE & SUPPORTIVE PSYCHOSOCIAL STABLE & SUPPORTIVE PSYCHOSOCIAL

ENVIRONMENTENVIRONMENT– RELAPSE RATE – FIRST FEW YEAR 40%. HEAVY RELAPSE RATE – FIRST FEW YEAR 40%. HEAVY

DRINK : 15% DRINK : 15%

AUTOIMMUNE AUTOIMMUNE HEPATITIS :HEPATITIS :

THREE FORMSTHREE FORMS• TYPE I : MOST COMMONTYPE I : MOST COMMON• IMMUNOSUPPRESSIVE THERAPY : PROLONGS IMMUNOSUPPRESSIVE THERAPY : PROLONGS

LIFE : LONG TERM TREATMENT DANGERS : LIFE : LONG TERM TREATMENT DANGERS : GREATEST CUMULATIVE DOSESGREATEST CUMULATIVE DOSES

• LIVER Tx – IMPROVES SURVIVAL BUT LIVER Tx – IMPROVES SURVIVAL BUT RECURRENCE CAN OCCURRECURRENCE CAN OCCUR

• MAY REQUIRE LONG TERM STEROIDSMAY REQUIRE LONG TERM STEROIDS

DISEASES THAT MIGHT RECUR IN THE DISEASES THAT MIGHT RECUR IN THE TRANSPLANTATION NOT ATRANSPLANTATION NOT A

CONTRA INDICATION FOR LIVER Tx.CONTRA INDICATION FOR LIVER Tx.

MANAGEMENT OF DONOR AND MANAGEMENT OF DONOR AND ORGAN RETRIEVALORGAN RETRIEVAL

EVALUATION OF DONOR : NO UPPER EVALUATION OF DONOR : NO UPPER AGE LIMITAGE LIMITNONO

• MALIGNANCY EXCEPT NON METASTATIC BRAIN & MALIGNANCY EXCEPT NON METASTATIC BRAIN & SKIN CANCERSKIN CANCER

• INTRA ABDOMINAL/SYSTEMIC SEFSISINTRA ABDOMINAL/SYSTEMIC SEFSIS• TRANSMISSIBLE DISEASES TRANSMISSIBLE DISEASES

YESYES• BACTERIAL MENINGITIS - BACTERIAL MENINGITIS - ANTI MICROBIAL ANTI MICROBIAL

THERAPY THERAPY TO DONOR & TO DONOR & RECIPIENTRECIPIENT

• -VE FOR HIV, HTLV – 1, HBs Ag, HBc Ab & -VE FOR HIV, HTLV – 1, HBs Ag, HBc Ab & HCVAb.HCVAb.

• HbcAb & HCVAb +VE DONOR CAN HbcAb & HCVAb +VE DONOR CAN DONATE TO RECIPIENTS OF SIMILAR DONATE TO RECIPIENTS OF SIMILAR SEROLOGY.SEROLOGY.

DONORDONOR• HEMODYNAMIC STABILITYHEMODYNAMIC STABILITY• EPISODES OF CARDIO RESPIRATORY EPISODES OF CARDIO RESPIRATORY

ARRESTARREST• INOTROPE REQUIREMENTSINOTROPE REQUIREMENTS• ELECTROLYTE IMBALANCESELECTROLYTE IMBALANCES• LFT INCLUDING PTLFT INCLUDING PT

FINAL JUDGMENT OF DONOR LIVER MADE FINAL JUDGMENT OF DONOR LIVER MADE AT RETRIEVAL OPERATIONAT RETRIEVAL OPERATION

- COLOR - COLOR - SIZE (SPLIT/PAED) - SIZE (SPLIT/PAED) - TEXTURE - TEXTURE - INTRA ABDOMINAL - INTRA ABDOMINAL PATHOLOGY EXCLUDEDPATHOLOGY EXCLUDED- CONSISTENCY - CONSISTENCY - QUALITY OF PERFUSION - QUALITY OF PERFUSION

OF ORGANOF ORGAN

MARGINAL LIVERS :MARGINAL LIVERS : STRESSED PRIOR TO STRESSED PRIOR TO

STORAGESTORAGEHYPOXIA

METABOLIC

DISTURBANCES OR

ISCHAEMIA

INCREASED RISK OF EARLY DYSFUNCTION

SECONDARY TO

HYPOTENSIVE EPISODES IN

DONOR

UNDERLYING LIVER

PATHOLOGY

HIGH VASOPRESSOR

REQUIREMENTS

APPEARANCE

LFT

TESTS : NOT TESTS : NOT PROVED SUPERIORPROVED SUPERIOR• MRGX/PHOSPHORUS – 31/MR MRGX/PHOSPHORUS – 31/MR

SPECTROMETRY/ HYALURONIC ACID SPECTROMETRY/ HYALURONIC ACID LEVEL IN GRAFT CAVAL EFFLUENT LEVEL IN GRAFT CAVAL EFFLUENT

• CAN BE SUCCESSFULLY USED : CAN BE SUCCESSFULLY USED : SIGNIFICANT RISE IN NO. OF TxSIGNIFICANT RISE IN NO. OF Tx

• NOT RECOMMENDED FOR HIGH NOT RECOMMENDED FOR HIGH RISK ‘MARGINAL RECIPIENTS.’RISK ‘MARGINAL RECIPIENTS.’

MARGINAL LIVERMARGINAL LIVER

DONOR HEPATECTOMYDONOR HEPATECTOMY

UNIVERSITY OF WISCONSIN SOLUTION UNIVERSITY OF WISCONSIN SOLUTION (UWS)(UWS)

• ALLOWS SAFE COLD STORAGE UPTO ALLOWS SAFE COLD STORAGE UPTO 24hrs. (PRACTICAL UPPER LIMIT 18hrs.)24hrs. (PRACTICAL UPPER LIMIT 18hrs.)

• EXPANDED DONOR POOL : TIME EXPANDED DONOR POOL : TIME ENVELOPE: SEMI ELECTIVE SURGERYENVELOPE: SEMI ELECTIVE SURGERY

BEATING BEATING HEART : HEART : ALMOST ALLALMOST ALL

NON BEATING NON BEATING HEART : DUE TO HEART : DUE TO

ORGAN ORGAN SHORTAGE SHORTAGE

STARTEDSTARTEDORGAN PRESERVATIONORGAN PRESERVATION

EVALUATION EVALUATION COMMITTEECOMMITTEE

• SURGEONSSURGEONS• HEPATOLOGISTSHEPATOLOGISTS• CARDIOLOGISTSCARDIOLOGISTS• PULMONOLOGISTSPULMONOLOGISTS• NEPHROLOGISTSNEPHROLOGISTS• NEUROLOGISTSNEUROLOGISTS• GASTROENTEROLOGIGASTROENTEROLOGI

STSSTS

• PAEDIATRICIANSPAEDIATRICIANS• PSYCHIATRISTSPSYCHIATRISTS• ANESTHESIOLOGISANESTHESIOLOGIS

TSTS• TRANSPLANT TRANSPLANT

COORDINATORSCOORDINATORS• SOCIAL WORKERSSOCIAL WORKERS

PERIOPERATIVE MANAGEMENT PERIOPERATIVE MANAGEMENT OF RECIPIENTOF RECIPIENT

• THROMBOELASTOGRAPHY (TEG) HAS THROMBOELASTOGRAPHY (TEG) HAS A SIGNIFICANT IMPACT BY A SIGNIFICANT IMPACT BY ENABLING THE ANESTHETIST TO ENABLING THE ANESTHETIST TO MONITOR & TREAT POST MONITOR & TREAT POST REPERFUSION COAGULOPATHY & TO REPERFUSION COAGULOPATHY & TO CONTROL THE EFFECTS OF CONTROL THE EFFECTS OF EXCESSIVE FIBRINOLYSIS BY THE EXCESSIVE FIBRINOLYSIS BY THE USE OF KALLIKREIN INHIBITORS, USE OF KALLIKREIN INHIBITORS, WITH REDUCTION IN BLOOD WITH REDUCTION IN BLOOD TRANSFUSION REQUIREMENTS.TRANSFUSION REQUIREMENTS.

ADULT WHOLE LIVER GRAFT :ADULT WHOLE LIVER GRAFT :GENEROUS BILATERAL SUBCOSTAL GENEROUS BILATERAL SUBCOSTAL

INCISIONINCISION

REMOVAL OF REMOVAL OF LIVER WITH INTRA LIVER WITH INTRA HEPATIC HEPATIC VENACAVAVENACAVA

• FULL CAVAL FULL CAVAL CLAMPING CLAMPING

• HEMODYNAMIC HEMODYNAMIC INSTABILITYINSTABILITY

• REQUIRES VENO REQUIRES VENO VENOUS BYPASSVENOUS BYPASS

PRESERVATION OF PRESERVATION OF RECIPIENT CAVARECIPIENT CAVA

• DONOR CAVA CAN DONOR CAVA CAN BE ANASTOMOSEDBE ANASTOMOSED

• STUMP OF HEPATIC STUMP OF HEPATIC VEINSVEINS

• SIDE TO SIDE CAVO SIDE TO SIDE CAVO CAVOSTOMY CAVOSTOMY (PIGGYBACK TECH.)(PIGGYBACK TECH.)

• PARTIAL CAVAL PARTIAL CAVAL CLAMPINGCLAMPING

• HEMODYNAMIC HEMODYNAMIC STABILITY STABILITY MAINTAINEDMAINTAINED

TEMPORARY END TO SIDE PORTO-CAVAL SHUNT TO MAINTAIN STABILITY &

PREVENT VENOUS CONGESTION OF BOWEL

BILIARY BILIARY RECONSTRUCTIONRECONSTRUCTION

• END TO END BETWEEN OBLIQUELY END TO END BETWEEN OBLIQUELY CUT DONOR & RECIPIENT DUCTCUT DONOR & RECIPIENT DUCT

• DO NOT OBSTRUCT LOWER END OF DO NOT OBSTRUCT LOWER END OF CYSTIC DUCT :CYSTIC DUCT :DILATEDILATEOBSTRUCTIONOBSTRUCTION

• T-TUBE NO LONGER ROUTINELY T-TUBE NO LONGER ROUTINELY USED, MAY BE USED IN SPLIT USED, MAY BE USED IN SPLIT GRAFTSGRAFTS

• BILIARY ATRSIAS OR PSC – ROUX-EN-BILIARY ATRSIAS OR PSC – ROUX-EN-Y-CHOLEDCHO-JEJUNOSTOMYY-CHOLEDCHO-JEJUNOSTOMY

REDUCED SIZE LIVER Tx REDUCED SIZE LIVER Tx (RSLT) :(RSLT) :

PERFORMED IN 1984PERFORMED IN 1984

TO INCREASE AVAILABILITY OF GRAFT TO INCREASE AVAILABILITY OF GRAFT IN PAEDIATRIC RECIPIENTSIN PAEDIATRIC RECIPIENTS

RSLT RSLT (CONTD.)(CONTD.)

• EX VIVO REDUCTION EX VIVO REDUCTION IN DONOR LIVERIN DONOR LIVER

• IMPLANTED IN IMPLANTED IN ORTHOTOPIC ORTHOTOPIC POSITION AFTER POSITION AFTER RECIPIENT RECIPIENT HEPATECTOMYHEPATECTOMY

• COMMONEST COMMONEST SEGMENTS USED :SEGMENTS USED :– LEFT LATERAL LEFT LATERAL

(SEGMENT II & III)(SEGMENT II & III)– FULL LEFT LOBEFULL LEFT LOBE

BASED ON SIZE BASED ON SIZE MATCHING OF MATCHING OF

DONOR & RECIPIENTS DONOR & RECIPIENTS ORGANS ORGANS

RSLT RSLT (CONTD.)(CONTD.)

• ORIGINAL TECHNIQUE : SEGMENT OF DONOR ORIGINAL TECHNIQUE : SEGMENT OF DONOR IVCIVC

• MODIFIED TECHNIQUE : DONOR LEFT HEPATIC MODIFIED TECHNIQUE : DONOR LEFT HEPATIC VEINVEIN

ANASTOMOSED WITH RECIPIENT IVC THROUGH ANASTOMOSED WITH RECIPIENT IVC THROUGH APPROPRIATE SIZED OSTIUMAPPROPRIATE SIZED OSTIUM

• REDUCED MORTALITY IN PAEDIATRIC WL. REDUCED MORTALITY IN PAEDIATRIC WL. • PATIENT SURVIVAL EQUAL/BETTER THAN PATIENT SURVIVAL EQUAL/BETTER THAN

WHOLE GRAFT PAEDIATRIC RECIPIENTSWHOLE GRAFT PAEDIATRIC RECIPIENTS

SPLIT LIVER SPLIT LIVER TRANSPLANTATIONTRANSPLANTATION

(IN VIVO & IN SITU) : (IN VIVO & IN SITU) : PERFORMED IN 1988 PERFORMED IN 1988

• NATURAL EXTENSION NATURAL EXTENSION OF RSLTOF RSLT

• FULL USE OF DONOR FULL USE OF DONOR LIVER – SMALLER LIVER – SMALLER LEFT – Tx IN CHILD.LEFT – Tx IN CHILD.

LARGE RIGHT – Tx IN LARGE RIGHT – Tx IN ADULT.ADULT.

• INCREASED THE INCREASED THE AVAILABILITY OF AVAILABILITY OF CADAVERIC LIVER CADAVERIC LIVER GRAFTS BY 25-28%GRAFTS BY 25-28%

SPLIT LIVER SPLIT LIVER TRANSPLANTATION TRANSPLANTATION

(IN VIVO & IN SITU) (IN VIVO & IN SITU) CONTD.CONTD.

•STRINGENT CRITERIA TO STRINGENT CRITERIA TO SELECT DONOR LIVERS SELECT DONOR LIVERS FOR SPLITTINGFOR SPLITTING

–INCREASED RISK OF INCREASED RISK OF PRESERVATION INJURY. PRESERVATION INJURY.

–COMPLICATIONS RELATED COMPLICATIONS RELATED TO CUT SURFACETO CUT SURFACE

• RECIPIENT SIZE : RECIPIENT SIZE : PLANE OF PLANE OF SEPARATION CAN SEPARATION CAN BE VARIEDBE VARIED

• ADULT : RIGHT LOBE ADULT : RIGHT LOBE GRAFT (SEGMENT IV GRAFT (SEGMENT IV OR V TO VIII)OR V TO VIII)

• LARGE CHILD OR LARGE CHILD OR SMALL ADULT : SMALL ADULT : COMPLETE LEFT COMPLETE LEFT LOBE (SEGMENT II, LOBE (SEGMENT II, III & IV)III & IV)

• INFANT : LEFT INFANT : LEFT LATERAL SEGMENTLATERAL SEGMENT

EX VIVOEX VIVO IN SITUIN SITU• GRAFT DIVIDED ON GRAFT DIVIDED ON

BACK TABLE AFTER BACK TABLE AFTER PROCUREMENTPROCUREMENT

• SLUSHED SALINE SLUSHED SALINE TO PREVENT TO PREVENT WARMINGWARMING

• BACK TABLE BACK TABLE CHOLAGIOGRAPHY CHOLAGIOGRAPHY (& (& ARTERIOGRAPHY) ARTERIOGRAPHY) TO DELINEATE TO DELINEATE BILIARY & BILIARY & VASCULAR VASCULAR ANATOMY PRIOR ANATOMY PRIOR TO SPLITTINGTO SPLITTING

• LEFT LATERAL LEFT LATERAL SEGMENTECTOMY OR SEGMENTECTOMY OR LEFT HEPATECTOMY IN LEFT HEPATECTOMY IN HEART BEATING HEART BEATING CADAVERIC DONORCADAVERIC DONOR

• RESECTED SEGMENT RESECTED SEGMENT PERFUSED ON BACK PERFUSED ON BACK TABLE FOLLOWED BY IN TABLE FOLLOWED BY IN SITU PERFUSION OF SITU PERFUSION OF RIGHT LOBERIGHT LOBE

• ADVANTAGE OF ADVANTAGE OF DECREASED COLD DECREASED COLD ISCHAEMIC TIME & ISCHAEMIC TIME & POTENTIAL WARMING POTENTIAL WARMING THAT MAY OCCUR THAT MAY OCCUR DURING EX VIVO DURING EX VIVO SPLITTINGSPLITTING

• DOES NOT DOES NOT SIGNIFICANTLY SIGNIFICANTLY PROLONG SURGERY AT PROLONG SURGERY AT DONOR HOSPITAL DONOR HOSPITAL

EARLY RESULTSEARLY RESULTS• INFERIOR C/F WHOLE ORGAN GRAFTINFERIOR C/F WHOLE ORGAN GRAFT• RIGOROUS SELECTION CRITERIA & RIGOROUS SELECTION CRITERIA &

ELECTIVE RECIPIENTS HAVE ELECTIVE RECIPIENTS HAVE IMPROVED OUTCOME TO IMPROVED OUTCOME TO COMPARABLE LEVELSCOMPARABLE LEVELS

• RESULTS COMPARABLE TO RSLT IN RESULTS COMPARABLE TO RSLT IN PAEDIATRIC RECIPIENT GROUPPAEDIATRIC RECIPIENT GROUP

• ULTIMATE OBJECTIVE : BOTH ULTIMATE OBJECTIVE : BOTH HEMIGRAFTS FOR TWO ADULTSHEMIGRAFTS FOR TWO ADULTS

• INITIAL EXPERIENCE : POOR INITIAL EXPERIENCE : POOR OUTCOME FOR LEFT LOBE OUTCOME FOR LEFT LOBE RECIPIENTS.RECIPIENTS.

LIVE DONOR LIVE DONOR LTx (LDLT) : LTx (LDLT) :

19891989• LEFT LATERAL SEGMENTAL LEFT LATERAL SEGMENTAL

RESECTIONRESECTION• SAFE, LOW MORBIDITY & SAFE, LOW MORBIDITY &

MORTALITY RATESMORTALITY RATES• ROUTINE ALTERNATIVE TO ROUTINE ALTERNATIVE TO

CADAVERIC Tx IN PAEDIATRIC CADAVERIC Tx IN PAEDIATRIC RECIPIENTSRECIPIENTS

• RECENTLY ADOPTED FOR ADULT RECENTLY ADOPTED FOR ADULT RECIPIENTS.RECIPIENTS.

• IMPEDIMENTS : IMPEDIMENTS : – SAFETY OF DONOR SAFETY OF DONOR – ADEQUACY OF HEPATIC MASSADEQUACY OF HEPATIC MASS

– ADEQUACY OF GRAFT VOLUME ADEQUACY OF GRAFT VOLUME (METHODS) :(METHODS) :GRAFT TO RECIPIENT WEIGHT RATIOGRAFT TO RECIPIENT WEIGHT RATIO

RATIO OF GRAFT VOLUME AS MEASURED RATIO OF GRAFT VOLUME AS MEASURED BY CT OR MRI VOLUMETRY WITH BY CT OR MRI VOLUMETRY WITH RECIPIENT’S ESTIMATED LIVER VOLUME RECIPIENT’S ESTIMATED LIVER VOLUME (ELV) OBTAINED USING STANDARD (ELV) OBTAINED USING STANDARD FORMULAFORMULA

• MINIMUM SAFE GRAFT VOLUME : 30%-MINIMUM SAFE GRAFT VOLUME : 30%-50%50%

• INSUFFICIENT GRAFT VOLUME : INSUFFICIENT GRAFT VOLUME : – SMALL FOR SIZE SYNDROME : SMALL FOR SIZE SYNDROME :

SECONDARY TO PORTAL SECONDARY TO PORTAL HYPERPERFUSION HYPERPERFUSION •CHOLESTASISCHOLESTASIS•ASCITESASCITES•POOR SYNTHETIC FUNCTIONPOOR SYNTHETIC FUNCTION

• DONOR SELECTION : RIGOROUS DONOR SELECTION : RIGOROUS – INFORMED CONSENTINFORMED CONSENT– EXCLUSION OF MEDICAL EXCLUSION OF MEDICAL

CONDITIONS THAT MAY CONDITIONS THAT MAY JEOPARDIZE DONOR OUTCOME.JEOPARDIZE DONOR OUTCOME.

RIGHT LOBE LDLTRIGHT LOBE LDLT

• NECESSITY FOR ADEQUATE SIZENECESSITY FOR ADEQUATE SIZE• FASTEST GROWING Tx TECHNIQUEFASTEST GROWING Tx TECHNIQUE• COMPLEX PROCEDURECOMPLEX PROCEDURE

MOBILIZATION OF LIVER FROM RETRO MOBILIZATION OF LIVER FROM RETRO HEPATIC IVC HEPATIC IVC HILAR DISSECTION IDENTIFIES RIGHT HILAR DISSECTION IDENTIFIES RIGHT HEPATIC ARTERY & PORTAL VEIN HEPATIC ARTERY & PORTAL VEIN WHILE AVOIDING AND EXPOSURE OF WHILE AVOIDING AND EXPOSURE OF LEFT HILAR STRUCTURES.LEFT HILAR STRUCTURES.

•USG : USG : – TO DELINEATE COURSE OF TO DELINEATE COURSE OF

MIDDLE & RIGHT HEPATIC VEINSMIDDLE & RIGHT HEPATIC VEINS

•CHOLANGIOGRAPHY : CHOLANGIOGRAPHY : – TO IDENTIFY BILIARY ANATOMYTO IDENTIFY BILIARY ANATOMY

•CUSA/HARMONIC SCALPEL :CUSA/HARMONIC SCALPEL :– PARENCHYMAL DISSECTION PARENCHYMAL DISSECTION

WITHOUT IN FLOW OCCLUSIONWITHOUT IN FLOW OCCLUSION

• IMPLANTATION : DIFFERENT IMPLANTATION : DIFFERENT FORM RSLT : NO IVC IN FORM RSLT : NO IVC IN RECIPIENTRECIPIENT

• DONOR RIGHT HEPATIC VEIN DONOR RIGHT HEPATIC VEIN ANASTOMOSED DIRECTLY TO ANASTOMOSED DIRECTLY TO RECIPIENT RIGHT HEPATIC RECIPIENT RIGHT HEPATIC VEIN VEIN

• BILIARY RECONSTRUCTION BILIARY RECONSTRUCTION USUALLY PERFORMED USING A USUALLY PERFORMED USING A ROUX –EN-Y HEPATICO ROUX –EN-Y HEPATICO JEJUNOSTOMY.JEJUNOSTOMY.

DISADVANTAGEDISADVANTAGE• GREATER DONOR RISK : MORTALITY GREATER DONOR RISK : MORTALITY

0.3%-0.5% (Cf 0.1-0.2% ON LEFT 0.3%-0.5% (Cf 0.1-0.2% ON LEFT LOBE LDLT FOR PAED. RECIPIENTS)LOBE LDLT FOR PAED. RECIPIENTS)

• TRANSIENT HYPERBILIRUBINAEMIA TRANSIENT HYPERBILIRUBINAEMIA ‘TRANSAMINITIS’ & ‘TRANSAMINITIS’ & COAGULOPATHY MORE FREQUENT COAGULOPATHY MORE FREQUENT

• BILIARY COMPLICATIONS MORE BILIARY COMPLICATIONS MORE COMMONCOMMON

ADVANTAGEADVANTAGE

• SHORT COLD ISCHAEMIA TIMESHORT COLD ISCHAEMIA TIME• HEALTHY DONORS WITH NORMAL HEALTHY DONORS WITH NORMAL

LIVER FUNCTIONLIVER FUNCTION• ABILITY TO PERFORM ABILITY TO PERFORM

TRANSPLANTATION PRIOR TO TRANSPLANTATION PRIOR TO RECIPIENT BECOMING RECIPIENT BECOMING CRITICALLY ILL.CRITICALLY ILL.

DOMINO PROCEDUREDOMINO PROCEDURERECIPIENT LIVER AS DONOR RECIPIENT LIVER AS DONOR

LIVERLIVER• LIVER FROM PATIENTS WITH HEPATIC LIVER FROM PATIENTS WITH HEPATIC

METABOLIC DISORDERS THAT CAUSE METABOLIC DISORDERS THAT CAUSE SYSTEMIC DISEASE WITHOUT SYSTEMIC DISEASE WITHOUT AFFECTING OTHER LIVER FUNCTIONSAFFECTING OTHER LIVER FUNCTIONS

• FAMILIAL AMYLOID FAMILIAL AMYLOID POLYNEUROPATHY (DUE TO SINGLE POLYNEUROPATHY (DUE TO SINGLE ENZYME DEFECT IN LIVER) : MAIN ENZYME DEFECT IN LIVER) : MAIN SOURCE SOURCE

• Tx IN OLDER RECIPIENT GROUP : ≤20 Tx IN OLDER RECIPIENT GROUP : ≤20 Yr. TO DEVELOP AMYLOIDOSIS IN Yr. TO DEVELOP AMYLOIDOSIS IN RECIPIENT PARTICULARLY IN AREAS RECIPIENT PARTICULARLY IN AREAS WHERE DISEASE IS PREVALENT. WHERE DISEASE IS PREVALENT.

AUXILIARY LIVER AUXILIARY LIVER TRANSPLANTATIONTRANSPLANTATION

– ALTERNATIVE TECHNIQUE INALTERNATIVE TECHNIQUE IN

FULMINANT HEPATIC FAILUREFULMINANT HEPATIC FAILURE

CERTAIN INBORN ERRORS OF CERTAIN INBORN ERRORS OF METABOLISM.METABOLISM.

CONCEPT :CONCEPT :A.A. TO TRANSPLANT ADEQUATE HEPATIC MASS TO TO TRANSPLANT ADEQUATE HEPATIC MASS TO

ALLOW RECOVERY OF NATIVE LIVER WITHOUT ALLOW RECOVERY OF NATIVE LIVER WITHOUT NEED FOR LONG TERM IMMUNOSUPPRESSION.NEED FOR LONG TERM IMMUNOSUPPRESSION.

B.B. ACUTE GRAFT FAILURE WOULD NOT BE FATAL.ACUTE GRAFT FAILURE WOULD NOT BE FATAL.

HETEROTOPIC – INITIALLYHETEROTOPIC – INITIALLYORTHOTOPIC – MORE RECENTLY ORTHOTOPIC – MORE RECENTLY WITH PARTIAL RESECTION OF WITH PARTIAL RESECTION OF HOST LIVER TO PROVIDE SPACE.HOST LIVER TO PROVIDE SPACE.SMALL SERIES : SMALL SERIES : IMMUNOSUPPRESSANT CAN BE IMMUNOSUPPRESSANT CAN BE WITHDRAWN IN MANY CASES.WITHDRAWN IN MANY CASES.LIMITED APPLICATION : LIMITED APPLICATION : TECHNICAL ISSUE OF SURGERY.TECHNICAL ISSUE OF SURGERY.RECENT : LIVING DONOR FOR RECENT : LIVING DONOR FOR AUXILIARY PARTIAL ORTHOTOPIC AUXILIARY PARTIAL ORTHOTOPIC LIVER TRANSPLANTS, LIVER TRANSPLANTS, PARTICULARLY FOR CHILDREN PARTICULARLY FOR CHILDREN WITH AFHF. WITH AFHF.

REPEAT ORTHOTOPIC LIVER REPEAT ORTHOTOPIC LIVER TxTx

• CONTROVERSIAL : CONTROVERSIAL : – PATIENT SELECTION PATIENT SELECTION – SHORTAGE OF DONOR ORGANSHORTAGE OF DONOR ORGAN

• OUTCOME :OUTCOME :– IMPROVED IN LAST TWO DECADESIMPROVED IN LAST TWO DECADES– PATIENT & GRAFT SURVIVAL RATES : PATIENT & GRAFT SURVIVAL RATES :

74% & 60% RESP74% & 60% RESP

• MAIN INDICATIONS : MAIN INDICATIONS : – CHRONIC REJECTIONCHRONIC REJECTION– HEPATIC ARTERY THROMBOSIS.HEPATIC ARTERY THROMBOSIS.

OTHER INDICATIONSOTHER INDICATIONS

• PRIMARY NON FUNCTIONPRIMARY NON FUNCTION• RECURRENT DISEASERECURRENT DISEASE• BILIARY COMPLICATIONSBILIARY COMPLICATIONS

EARLY v/s LATE EARLY v/s LATE RETRANSPLANTATION: WORSE v/s RETRANSPLANTATION: WORSE v/s SAME AS FIRST TxSAME AS FIRST Tx– OUTCOME REDUCES AS NUMBER OF OUTCOME REDUCES AS NUMBER OF

REPEAT TRANSPLANTS INCREASEREPEAT TRANSPLANTS INCREASE– III & IV GRAFT CANNOT USUALLY BE III & IV GRAFT CANNOT USUALLY BE

JUSTIFIED.JUSTIFIED.

IMMUNOSUPPRESSIOIMMUNOSUPPRESSIONN

• TRIPLE THERAPY : TRIPLE THERAPY : – PREDNISOLONEPREDNISOLONE– AZATHIOPRINEAZATHIOPRINE– CYCLOSPORINECYCLOSPORINE

• NEWER AGENTS : NEWER AGENTS : – SUPPLANTED CYCLOSPORINE WITH SUPPLANTED CYCLOSPORINE WITH

TACROLIMUS TACROLIMUS – BETTER LONG TERM OUTCOME.BETTER LONG TERM OUTCOME.

• PREDNISOLONE – PREDNISOLONE – – TO TREAT REJECTION EPISODESTO TREAT REJECTION EPISODES– EARLY MAINTENANCE THERAPYEARLY MAINTENANCE THERAPY– USUALLY CAN BE STOPPED WITHIN 3 MONTHUSUALLY CAN BE STOPPED WITHIN 3 MONTH

AZATHIOPRINE :AZATHIOPRINE :•STILL USED IN MANY CENTRESTILL USED IN MANY CENTRE• INCREASINGLY REPLACED BY INCREASINGLY REPLACED BY

MYCOPHENOLATE MOFETIL MYCOPHENOLATE MOFETIL (MMF)(MMF)

CALUNEURIN INHIBITORS CALUNEURIN INHIBITORS (CYCLOSPORINE + TACROLIMUS) :(CYCLOSPORINE + TACROLIMUS) :

•NEPHROTOXICITYNEPHROTOXICITY•LOW DOSE TACROLIMUS + MMF LOW DOSE TACROLIMUS + MMF

MAY PRESERVE RENAL RESERVE.MAY PRESERVE RENAL RESERVE.

RECENTRECENT• SIROLIMUS : MACROLYTIC SIROLIMUS : MACROLYTIC

LACTONELACTONE• EFFECTIVE SUBSTITUTE FOR EFFECTIVE SUBSTITUTE FOR

CALCINEURIN INHIBITORSCALCINEURIN INHIBITORS• NO NEPHROTOXICITYNO NEPHROTOXICITY• NEGATIVE IMPACT AN WOUND NEGATIVE IMPACT AN WOUND

HEALINGHEALING• MAY HAVE A ROLE IN LATER MAY HAVE A ROLE IN LATER

LONG TERM LONG TERM IMMUNOSUPPRESSIONIMMUNOSUPPRESSION

POLYCLONAL ANTIBODY POLYCLONAL ANTIBODY PREPARATIONSPREPARATIONS

DISAPPOINTING, HIGH INFECTIOUS DISAPPOINTING, HIGH INFECTIOUS COMPLICATION RATECOMPLICATION RATE

• CD 25 ANTIBODIES : GREATER PROMISE CD 25 ANTIBODIES : GREATER PROMISE AS CD 25 RECEPTORS PRESENT ONLY IN AS CD 25 RECEPTORS PRESENT ONLY IN ACTIVATED CELLS.ACTIVATED CELLS.

• MURINE HUMAN CHIMERIC PREPARATION MURINE HUMAN CHIMERIC PREPARATION BASILIXIMABBASILIXIMAB

• HUMANIZED MONOCLONAL ANTIBODY HUMANIZED MONOCLONAL ANTIBODY DACLIZUMABDACLIZUMAB

BOTH ARE CD 25 RECEPTOR BLOCKING BOTH ARE CD 25 RECEPTOR BLOCKING ANTIBODIES – UNDERGOING CLINICAL ANTIBODIES – UNDERGOING CLINICAL

EVALUATION.EVALUATION.

MANAGEMENT OF MANAGEMENT OF COMPLICATIONSCOMPLICATIONS

PRIMARY NON FUNCTION PRIMARY NON FUNCTION

PR. DYSFUNCTION :NON UNCOMMONPR. DYSFUNCTION :NON UNCOMMON

PR. NON FUNCTION :RARE 2-3%PR. NON FUNCTION :RARE 2-3%

MAY BE DUE TOMAY BE DUE TO• UNIDENTIFIED PREEXISTING UNIDENTIFIED PREEXISTING

DISEASE IN DONOR LIVERDISEASE IN DONOR LIVER• LIVER INJURY DURING RETRIEVAL LIVER INJURY DURING RETRIEVAL

& PRESERVATION& PRESERVATION• SECONDARY TO REPERFUSION SECONDARY TO REPERFUSION

INJURYINJURY

•EARLY Tx : ONLY EARLY Tx : ONLY SOLUTIONSOLUTION

•EARLY GRAFT EARLY GRAFT FUNCTION : LONG FUNCTION : LONG TERM GRAFT SURVIVALTERM GRAFT SURVIVAL

POST OPERATIVE POST OPERATIVE HEMORRHAGEHEMORRHAGE• LESS OF A PROBLEMLESS OF A PROBLEM

• SIGNIFICANT REDUCTION IN TRANSFUSION SIGNIFICANT REDUCTION IN TRANSFUSION REQUIREMENT REQUIREMENT

DUE TO :DUE TO :– METICULOUS SURGICAL TECHNIQUE.METICULOUS SURGICAL TECHNIQUE.– CONTINUOUS MONITORING OF COAGULATION CONTINUOUS MONITORING OF COAGULATION

PARAMETERS DURING SURGERY.PARAMETERS DURING SURGERY.– USE OF ANTIFIBRINOLYTIC AGENTSUSE OF ANTIFIBRINOLYTIC AGENTS– DECOMPRESSION OF SPENCHNIC CIRCULATION DECOMPRESSION OF SPENCHNIC CIRCULATION

BY VENO-VENOUS BYPASS OR TEMPORARY BY VENO-VENOUS BYPASS OR TEMPORARY PORTO-CAVAL SHUNT.PORTO-CAVAL SHUNT.

– MAINTENANCE OF RECIPIENT'S CORE MAINTENANCE OF RECIPIENT'S CORE TEMPERATURE TEMPERATURE

ACUTE RENAL FAILURE :ACUTE RENAL FAILURE :COMMON PROBLEMCOMMON PROBLEM

DUE TO DUE TO • PREEXISTING RENAL IMPAIRMENTPREEXISTING RENAL IMPAIRMENT• ISCHEMIA – REPERFUSION INJURYISCHEMIA – REPERFUSION INJURY• EFFECTS OF POST OPERATIVE SEPSISEFFECTS OF POST OPERATIVE SEPSIS• SIDE EFFECTS OF SIDE EFFECTS OF

IMMUNOSUPPRESSIVE THERAPYIMMUNOSUPPRESSIVE THERAPY

RENAL SUPPORT DURING 2 – 3 WEEKS RENAL SUPPORT DURING 2 – 3 WEEKS BEFORE RENAL FUNCTION BEFORE RENAL FUNCTION RECOVERS.RECOVERS.

1.1. VENO-VENOUS HAEMOFILTERATIONVENO-VENOUS HAEMOFILTERATION

2.2. HAEMODIALYSIS HAEMODIALYSIS

REJECTIONREJECTION

ACUTE CELLULAR :ACUTE CELLULAR :– WITHIN FIRST TWO WEEKS WITHIN FIRST TWO WEEKS – 75-80% H.P. EVIDENCE75-80% H.P. EVIDENCE– 30-40% BIOCHEMICAL EVIDENCE30-40% BIOCHEMICAL EVIDENCE– DIAGNOSED BY P.C. LIVER BIOPSYDIAGNOSED BY P.C. LIVER BIOPSY

•PORTAL VENOUS ENDOPHLEBITISPORTAL VENOUS ENDOPHLEBITIS•PORTAL INFILTRATIONPORTAL INFILTRATION•BILE DUCT INFLAMMATION & BILE DUCT INFLAMMATION &

INJURYINJURY

• SHORT COURSE OF HIGH DOSE SHORT COURSE OF HIGH DOSE STEROIDSTEROID

• OPTIMIZING LEVELS OF OPTIMIZING LEVELS OF CALINEUIRIN INHIBITORSCALINEUIRIN INHIBITORS

• SINGLE EPISODE :SINGLE EPISODE :• HAS NO IMPACT ON INCIDENCE HAS NO IMPACT ON INCIDENCE

OF CHRONIC REJECTIONOF CHRONIC REJECTION• MAY HAVE FAVORABLE LONG MAY HAVE FAVORABLE LONG

TERM OUTLOOKTERM OUTLOOK

•RESPONSE TO THERAPY : RESPONSE TO THERAPY : PROMPT IN MOST PATIENTSPROMPT IN MOST PATIENTS

•ONGOING ACUTE ONGOING ACUTE REJECTION :REJECTION :–REPEATED TREATMENTREPEATED TREATMENT–INCREASE IN BASELINE INCREASE IN BASELINE IMMUNO SUPPRESSION. IMMUNO SUPPRESSION.

CHRONIC CHRONIC REJECTION REJECTION

• DUCTOPENIC REJECTIONDUCTOPENIC REJECTION• FEW WEEKS OR MONTHS/YEARS FEW WEEKS OR MONTHS/YEARS

LATERLATER• DUE TO IMMUNOLOGICAL INJURY TO DUE TO IMMUNOLOGICAL INJURY TO

BILE DUCTBILE DUCT• VARIABLE RESPONSE TO TREATMENTVARIABLE RESPONSE TO TREATMENT• SEVERE : SEVERE :

– 10% 10% – RETRANSPLANTATION RETRANSPLANTATION

SEPSIS : MAJOR SEPSIS : MAJOR PROBLEMPROBLEM

• NOSOCOMIALNOSOCOMIAL• CYTO MEGALOVIRUSCYTO MEGALOVIRUS

1.1. 4-8 WEEKS AFTER Tx4-8 WEEKS AFTER Tx2.2. FEVER & LEUCOPENIAFEVER & LEUCOPENIA3.3. RAPID DIAGNOSIS WITH PCRRAPID DIAGNOSIS WITH PCR4.4. PROPHYLACTIC GANCICLOVIR UNDER STUDYPROPHYLACTIC GANCICLOVIR UNDER STUDY

• FUNGALFUNGAL

GIVING PROPHYLAXIS TO THOSE AT GIVING PROPHYLAXIS TO THOSE AT RISK CAN REDUCE INVASIVE FUNGAL RISK CAN REDUCE INVASIVE FUNGAL INFECTIONS INFECTIONS

BILIARY BILIARY COMPLICATIONSCOMPLICATIONS

• STRICTURESSTRICTURES– ANASTOMOTICANASTOMOTIC– NON ANASTOMOTICNON ANASTOMOTIC

• BILE LEAKSBILE LEAKS• USGUSG

– BILIARY DILATIONBILIARY DILATION– HEPATIC ARTERIAL PATENCY HEPATIC ARTERIAL PATENCY

• MANAGEMENTMANAGEMENT– ERCP & STENTINGERCP & STENTING– PERCUTANEOUS DRAINAGEPERCUTANEOUS DRAINAGE

LATE BILIARY STRICTURES MORE LIKELY TO LATE BILIARY STRICTURES MORE LIKELY TO RECUR AFTER RADIO LOGICAL OR RECUR AFTER RADIO LOGICAL OR

ENDOSCOPIC TREATMENT & USUALLY ENDOSCOPIC TREATMENT & USUALLY REQUIRES SURGICAL CORRECTION. REQUIRES SURGICAL CORRECTION.

HEPATIC ARTERY HEPATIC ARTERY THROMBOSISTHROMBOSIS

• DEVASTATING COMPLICATIONDEVASTATING COMPLICATION• PREDOMINANTLY IN FIRST MONTHPREDOMINANTLY IN FIRST MONTH• 2-3% IN ADULTS2-3% IN ADULTS• MASSIVE RISE IN SERUM MASSIVE RISE IN SERUM

AMINOTRANSFERASESAMINOTRANSFERASES• CAN PRESENT AS ACUTE CAN PRESENT AS ACUTE

FULMINANT HEPATIC OR BILIARY FULMINANT HEPATIC OR BILIARY SEPSIS & STRICTURESEPSIS & STRICTURE

TREATMENTTREATMENT

• THROMBECTOMY – FEWTHROMBECTOMY – FEW• URGENT RETRANPLANTATION – URGENT RETRANPLANTATION –

MOSTMOST

DELAYED : DELAYED : – UNCOMMONUNCOMMON– PRESENT WITH BILIARY SEPSIS PRESENT WITH BILIARY SEPSIS

OR OR – ASYMPTOMATICASYMPTOMATIC

1.1. REMAINS WELL 1/3REMAINS WELL 1/3rdrd

2.2. PROGRESSIVE GRAFT FAILURE 20%PROGRESSIVE GRAFT FAILURE 20%

HYBRID HYBRID BIOARTIFICIAL BIOARTIFICIAL

DEVISESDEVISES

EX VIVO EX VIVO PERFUSION PERFUSION TECHNIQUETECHNIQUE

SELECTIVE SELECTIVE IMMUNOSUPPRESSIIMMUNOSUPPRESSI

ON DRUGSON DRUGS

REFINEMENT REFINEMENT OF PRE EMPTIVE OF PRE EMPTIVE ANTIMICROBIAL ANTIMICROBIAL

THERAPYTHERAPY

NEW IMMUNO NEW IMMUNO SUPPRESSANTSSUPPRESSANTS

MONOCLONAL MONOCLONAL ANTIBODIESANTIBODIES

GENETIC GENETIC

ENGINEERINGENGINEERING