SURGICAL COMPLCATIONS IN LIVER TRANSPLANTATON

S.VIVEKANANDANHEAD, LIVER TRANSPLANT SURGERY

KMCH, COIMBATORE

POST OP COMPLICATIONS

IMMEDIATE vs LATE

PEDIATRIC vs ADULT

LDLT vs CADAVERIC

Immediate post op

Bleeding

Arterial complications

Portal Venous Complications

Hepatic Venous Complications

Biliary Complications

Bleeding

Arterial Complications

Hepatic artery thrombosis 4-11%

Hepatic artery stenosis 5-13%

HA Aneuryms 0.3-1.2%

Hepatic artery rupture

Median arcuate ligament syndrome 1.5-10%

Early Vs Late HAT

EARLY <2%< 30 days

LATE 2-20%>30 days

Transminitis Fever

Bile Leaks Transminitis

Liver Abscess Cholangitis

PNF Liver Abscess

Hepatic Necrosis Biliary Stricture

Factors affecting HAT

Arterial complications

Resuscitation

Antibiotics, antifungals

Early HAT – exploration , thrombectomy, revision

IR-Catheter related thrombolysis – bleeding

Re Transplantation

Late HAT – IR – Plasty / Stenting

Retransplantation

Portal venous complications

Risk factors

Preexisting PVT

Small portal vein

Steal phenomenon

Prior shunt surgery

PVT – Presentation

Portal hypertension Variceal bleeding Ascitis Thrombocytopenia

Acute graft failure

PVT - Treatment

Surgical revision

Pharmacological – Portal Flow

Anticoagulation

Shunt surgery

Regular endoscopic surveillance

Outflow obstruction

Rare but serious problem

1% - 6%

Acute – technique / graft torsion

Chronic – peri anastamotic fibrosis

Outflow obstruction

Ascitis , congested Liver

Lower limb edema

Hepatic & Renal dysfunction

Investigations – CT, Cavogram- Pressure Studies

Trt – Stenting / plasty

5-7%

1%-17%

5%-10%

Treatment

Investigations – CT, MRCP, ERCP

Antibiotics

Antifungals

Controlled Fistula

Bile Recirculation

Bile Leaks

Bile leaks Depends on volume ERCP- sphincterotomy, stenting Controlled fistula Consequences – infection, HAT/PA, late

strictures

Anastamotic strictures

Within the first year

Technical issues , mismatch, fibrosis, HAT

Consequences – cholangitis, sepsis

ERCP / Surgery

Non anastamotic stictures

+ / - HAT

Ischemic and necrotic biliary tree

NHBD/> CIT

High mortality

Needs a Re transplant

Summary

A high degree of suspicion is required

Prevention is better – avoid technical errors

Interventional Radiology plays a major role these days

Multi Disciplinary team approach is required

Bile Duct Reconstruction

Duct to duct – preferred , no reflux, anatomical,

Roux – en-Y Hep J Insufficient length Ischemic duct PSC Pediatric Multiple ducts ( LDLT)