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SURGICAL COMPLICATIONS OF LIVER

TRANSPLANTATION

Maher Osman, MD, Ph.D

National Liver Institute

Menoufiya University

INTRODUCTION

• Liver Tx has evolved over the past 4 decades to be the standard treatment for patients with a variety of acute and chronic liver diseases.

• The living donor procedure was developed as a result of:– The inevitable problem of organ shortage,– The obvious success of reduced-size and split-liver innovations,– Unacceptance of deceased donor transplantation because of

cultural difficulties with the concept of brain death.

INTRODUCTION

• The recipient operation for living donor procedures is identical to that of the deceased donor procedure, except that the recipient cava must be left in situ & a direct hepatic vein to vena caval anastomosis is used.

• Care must be taken to ensure that adequate recipient portal vein & hepatic artery are preserved.

• The biliary reconstruction can be either duct to duct or using a choledochojejunostomy.

• cadaveric

INTRODUCTION

• The technique of LDLTx has been hindered by three factors:

– The concern over donor safety (mortality ranges from 0.1 to 1% & morbidity from 10-20%).

– Inappropriate technique for profoundly ill patients (hepato-renal syndrome patients) or big body built recipients.

– Absence of backup re-transplantation whenever indicated.

• Despite these limitations, LDLTx has become a standard option for pediatric patients & for adult patients in areas where deceased donor livers are in short supply.

INTRODUCTION

• Postoperative complications following LTx are very common because of:– The degree of preoperative debilitation,– The complexity of the operative procedure,– The additional burden of immunosuppression

• These complications have a significant impact on:– Resource utilization– Cost– mortality

POSTOPERATIVE COMPLICATIONS

CLASSIFICATION

1. Extrahhepatic complications:• Pulmonary (atelectasis, pleural effusion, etc)• Neurologic (in about 12-20%)• Renal

2. Gastrointestinal complications:• Postoperative bleeding• Perforation

3. Infectious complications:• Bacterial• Fungal• viral


CLASSIFICATION

4. Surgical complications:– Hepatic artery stenosis– Hepatic artery thrombosis– Portal caval stenosis and thrombosis– Inferior vena cava stenosis and obstruction– Biliary complications (leak, stenosis, ampullary dysfunction)

5. Allograft-related complications:– Primary non-function– Acute cellular rejection


GRADES

Grade I: altered ideal postoperative course with recovery or easily controlled complications (ex. Steriod responsive rejection).

Grade II: any complication that is potentially life-threatening or results in ICU stay greater than 5 ds or a hospital stay greater than 4 ws but does not result in residual disability or permanent illness ( ex. Infection, bleeding or primary graft dysfunction)


GRADES

Grade III: complications with residual or lasting functional disability or development of malignant disease (ex. Renal failure).

Grade IV: complications that lead to retransplantation (IVa) or death (IVb).

SURGICAL COMPLICATIONS

Hepatic Artery Stenosis (HAS)

• Develops in 4-5% of cases.

• Sonographic findings include:– Resistive index of less than 0.5,– Systolic acceleration ,– Increase in focal peak velocity.

• Angiographic diagnosis of HAS is by reduction in caliber by greater than 50% of the normal lumen.

• Management is according to the time of diagnosis.


Hepatic Artery Stenosis (HAS)

• Early diagnosis:– Direct arterial reconstruction,– Reconstruction with placement of an infrarenal arterial

conduit.

• Late diagnosis (> 1 m):– Percutaneous hepatic angioplasty,– Complications of angioplasty include: intimal dissection,

arterial rupture, or pseudoaneurysm formation).

SURGICAL COMPLICATIONS Hepatic Artery Thrombosis (HAT)

• Occurs in 5-10% of liver transplants & is more common in children.

• Suspected clinically by:– Elevated transaminases,– Biliary problems.

• Diagnosed by:– Doppler US,– MRI– Angiography (the gold standard)


Hepatic Artery Thrombosis (HAT)

• Risk factors of HAT include:

– Anatomical Factors:• Poor inflow due to celiac trunk atherosclerosis,• Arcuate ligament compression,• The need for reconstructive angioplasty in the presence of non standard donor anatomy,

– Technical Factors:• Intimal dissection,• Anastomotic stenosis.

– Other important Factors:• Post-transplant acute rejection (within first week),• Placement of CMV+ve organ into CMV –ve recipient,• Donor smaller significantly than the recipient,• History of smoking.



• Routine ligation of the recipient gastroduodenal artery during implantation is important to prevent vascular steal phenomenon through the gastroduodenal artery away from the graft.

• The presentation of HAT is variable and depends on:– The timing of its occurrence,– The presence of collaterals.

• HAT in the 1st w post-transplant:– Complete biliary stenosis,– Graft failure,– Thrombectomy is the treatment (successful in ½ of cases), intrarterial

injection of urokinase & antibiotic for sepsis.•



• Late HAT( ms or ys) following LTx:– Does not always lead to graft failure,– Some patients develop biliary stricture &/or hepatic abscesses,– Approximately a 1/3 of patients do well without intervention.

• The association between rejection and HAT may be the result of:– Decrease in hepatic artery flow (the graft is swollen & edematous)– The release of procoagulants into the microcirculation (inflammatory injury).

• Most centers recommend prophylactic aspirin to prevent HAT in children


Portal Vein Thrombosis /Stenosis (PVT)

• Much less common than HAT, occurring in 1-3% ofcases

• Occurs more frequently in reduced-size LTx than in whole LTx because of the limited length of PV that can be obtained from the donor.

Risk Factors include:– Decreased PV inflow,– The presence of portosystemic shunt before Tx,– Previous splenectomy,– Twisting or kinking of the vascular conduit,– Tension in the PV interposition graft

• Previous splenorenal shunt should be disconnected at the time of LTx because it usually associated reduced flow through the PV.


Portal Vein Thrombosis /Stenosis (PVT)

• Presentation & diagnosis:– Symptoms & signs of portal hypertension,– Doppler US (the first diagnostic tool),– Mesenteric arteriography with portal phase view,– Direct percutaneous transhepatic portography (PTP) (stenosis or thrombosis).

• Portal vein stenosis: – PTP is useful to measure the pressure gradient across a stenotic area,– Balloon dilatation is done via the PTP catheter (angioplasty),– In case of restenosis & elastic stenosis a metallic stent can be used.

• Portal Vein thrombosis:– Can be effectively treated by continuous injection of urokinase via the balloon catheter

retained in the SMV.– If identified in the immediate postoperative period, reexploration & attempted

thrombectomy.

SURGICAL COMPLICATIONS Hepatic Vein Outflow Obstruction

• Occurs in 2-4% of patients.

• Restrictions of hepatic blood flow may result for kinking of the suprahepatic cava, which can be suspected when:

– the donor is small relative to the recipient,– the suprahepatic anastomosis is left long.

• Hepatic V obstruction can present with:– Ascites,– Renal dysfunction,– May be presented early in the 1st w after Tx or months later.

• The diagnosis can be suspected on the basis of:– Doppler US,– Inferior cavography.

• Hepatic vein stenosis responds very well to balloon dilatation


Biliary Leak or Obstruction

• Common surgical complication after LTx with an incidence of 10-30%, & mortality rate of 10%.

• Mortality continues to be a significant problem in patients with biliary tract complications because of delay in diagnosis.

• The laboratory diagnosis depends on elevation in serum bilirubin, gamma-glutamyltransferase, & alkaline phosphatase levels.


Biliary Leak or Obstruction

• Most biliary complications occur within the first 3 ms, with most leaks occurring in the 1st m after Tx & strictures developing later.

• The diff. diagnosis of elevations in the previous lab parameters include:– Sepsis,– Graft injury secondary to ischemia,– Rejection.

• Primary imaging modalities used in diagnosis include:– US to detect biliary dilatation,– Cholangiography to evaluate for leaks or strictures,– Cholescintigraphy using 99mTc-labelled hepatoiminodiacetic acid to look for

leaks from the cut surface of the liver or from anastomosis.


Bile Leaks

• Diagnosis:– PTC,– ERCP

• Etiologty:– Anastomotic complications,– Hepatic artery thrombosis,– T-tube exit-site leaks,– Leaks from the aberrant ducts,– Leaks from the cut liver surface

• Management:– T- tube exit-site leaks by endoscopic nasobiliary drainage,– Intraperitoneal biloma be percutaneous drainage,– Leaks after CD-J by operative intervention.

SURGICAL COMPLICATIONS Biliary Obstruction

• Etiology:– Anastomotic causes,

– Hepatic artery stenosis or thrombosis,

– Recurring cancer or recurrent disease,

– Sequelae of ischemic injury.

• Management:– Document hepatic artery patency

– Obstruction after CD-CD treated either by balloon dilatation & stenting or by conversion to CD-J.

– Stricture of CD-J treated by PTD or by surgical redo in refractory cases.

– Multiple diffuse IH strictures treated by PTC & drainage with either external or internal drainage and balloon dilatation or metallic stents.


Hemorrhage

• Postoperative bleeding occurs in 7-15% of patients, and requires exploration in 50% of cases.

• The most sensitive indication of bleeding is lack of urine output (oliguria).

• In many patients a specific bleeding point cannot be identified at reoperation (coagulopathy rather than failure of hemostasis).

• The bleeding will cease spontaneously due to:– Intrabdominal pressure,– Restoration of normal synthetic function by the new liver

• .


Hemorrhage

• Gastrointestinal bleeding can occur due to:– GI-Ulcers,– Viral enteritis,– Portal hypertensive lesions,– Roux-en-Y bleeds.

• Most episodes occur within the first 3 ms postoperatively.

• The occurrence of variceal bleeding after LTx is usually associated with PVT & mandates emergent US or angiography to document PV patency.

• Medical coagulopathy may worsen all episodes of bleeding and should be corrected.

• Thrombocytopenia is common after LTx and maybe due to:– Splenic sequestration,– Drug toxicity,– Immunologic factors


SUMMARY

• The cost and impact of early post-transplant complications continue to be high.

• Diagnosis and management involves a high index of suspicion, rapid diagnostic and therapeutic interventions, and eliminations of technical problems.

• Preoperative assessment of the donor and recipient medical condition and meticulous attention to detail during the performance of LTx are the mainstays in achieving a good outcome.