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Liver transplantation

Dileep Thakur
Introduction
• 1st by T. Starzl in 1963

Post transplant 1yr survival increased from 30


to 85%
• Refined surgery
• Better preservation
• Better immunosupression
• early diagnosis & management of complications
Indications
• Chronic liver failure

• Acute liver failure

• Metabolic diseases

• Hepatic tumours
Chronic liver failure
• Alcoholic liver disease (complicated)

• Primary biliary cirrhosis

• Biliary atresia

• Post hepatitic cirrhosis

• Autoimmune chronic hepatitis

• Primary sclerosing cholangitis

• Budd Chiari syndrome / venoocclusive


Acute liver failure
• Paracetamol toxicity

• Viral hepatitis

• Idiosyncratic reactions
Kings college Criteria for OLT in
ALF
Paracetamol toxicity
• pH < 7.3
• PT > 100 sec
• S. Creat > 3.4mg/dl
• Hepatic encephalopathy

No paracetamol toxicity
• PT > 50 sec
• Age < 10 yrs or >40yrs
• Duration of jaundice before encephalopathy >7days
• S. Bil > 300 micromol/dl
• Non A or B hepatitis
Metabolic Disease
• Primary oxalosis

• Alpha 1 antitrypsin deficiency

• Hemochromatosis

• Wilson's Disease

• Gauchers disease

• Glycogen Storage disorder


Hepatic tumours
• HCC

Milan criteria (Mazzaferro)


• Size of lesion <5cm
• Upto 3 lesion maximum <3cm
• Fibrolamellar variant
• No microvascular invasion
Absolute
Contraindications
• Advanced uncorrectable cardiopulmonary
disorders
• Severe irreversible pulmonary hypertension
• Hypotension requiring vasopressor support
• Recent intracranial hemorrhage
• AIDS
• Uncontrolled sepsis
• Extrahepatic malignancy
• Active substance abuse
• Irreversible neurological impairment
Relative Contraindications
• HCC stage III or IV

• HIV positive

• Age > 70yrs

• Cholangiocarcinoma

• Secondaries liver
Waiting list criteria
• Child Turcot Pugh

• MELD score

• PELD score
Pre operative assessment
• Already done before pt on waiting list

• Hematologic tests

• Coagulation profile

• Biochemical studies

• 20 pints of blood arranged


Operative technique
Anastomotic sequence
• Suprahepatic IVC

• Infrahepatic IVC

• Portal vein

• Hepatic artery

• Bile ducts
Piggy back OLT
• Improved hemodynamic stability

• Improved renal perfusion

• Avoidance of venovenous bypass


Living Donor Transplant
• Avoids lengthy waiting period

• Usually right lobe used

• Donor complications an issue

• Outflow problems commoner


Complications
• Biliary anastomotic complications – most common

• Hemorrhage

• Vascular complications – hepatic artery thrombosis

• Opportunistic infections

• Graft rejection

• Primary graft non function


Conclusion
• Routine procedure in many centres

• Post transplant survival improving

• Ultimate survival depends on underlying


disease