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Technical Problems: Biliary

Complications involving the biliary tract after orthotopic liver transplantation (OLT) have been a common problem since the beginning. Because of the limited number of donation after brain death (DBD) donors, alternative techniques and approaches such as living donor liver transplantation (LDLT) and split-liver transplantation have been developed, each of them being associated with new challenges with regard to biliary complications (BCs). In addition, the evolution of…

Graft Failure

Graft failure is a serious life-threatening condition for transplant recipients, and when left untreated, it results inevitably in death of the recipient. It is important to differentiate between acute and chronic graft failure. Although acute graft failure occurs early in the posttransplantation period and is mainly related to donor organ quality or less frequently to technical problems, chronic graft failure is caused by recurrent liver disease,…

Renal Failure in Adults

Orthotopic liver transplantation (OLT) is a well-established definitive treatment for patients with chronic advanced cirrhosis or acute fulminant hepatic failure and a viable therapeutic option for those with primary resectable hepatic malignancies with or without cirrhosis. Over the past decade more than 6000 such transplants were performed in the United States annually. Whereas the demand for liver transplantation has steadily increased, the supply of deceased donor…

Transition of Pediatric Patients to Adulthood

Late adolescence and young adulthood have long been seen as a time of increased risk in life across all populations and generations. Indeed, the overall mortality rate of young adults between 18 and 24 years of age is more than twice that of young adolescents, and the prevalence of many health behavior problems peaks during this time period. Adolescents and young adults with chronic medical conditions,…

Postoperative Care of Pediatric Transplant Recipients

Liver transplantation (LT) is the standard of care for children with end-stage liver disease (ESLD), acute liver failure, select patients with primary liver tumors, and certain inborn errors of metabolism. Patient survival after LT has improved significantly with advances in surgical techniques and anesthesia care. Now, with earlier referral to transplant centers, the medical and nutritional status of these children can be optimized by the time…

Postoperative Management Beyond the Intensive Care Unit: Adults

As discussed in Chapter 69 , there are various potential severe surgical and medical complications that may occur immediately after liver transplantation. Once a patient has been transferred out of the intensive care unit, the focus shifts more to rehabilitation, while a vigilant eye is maintained on graft function, renal function, and other relevant organ systems. Additionally, infectious complications, largely related to immunosuppression and immobility, can…

Postoperative Intensive Care Management in Children

The transition from the operating room after liver transplantation to the pediatric intensive care unit (ICU) and the subsequent 48 hours are a critical time for success of the procedure. During this time there is great potential for life-threatening problems to occur, and they must be anticipated and, it is hoped, prevented. This is a time of significant risk for morbidity and mortality; one series reported…

Postoperative Intensive Care Management in Adults

Nowhere else in the realm of liver transplantation have both the advances made in the field and the realities of the surgery been more evident than in the intensive care unit (ICU). The impact of the Model for End-Stage Liver Disease (MELD) system, with increasing MELD scores and waiting times, means sicker recipients before the transplant—more renal dysfunction, malnutrition, and moribund state. In response to this…

Auxiliary Transplantation

The first reported performance of auxiliary liver transplantation (ALT) was in a dog by Welch in 1955. The auxiliary liver was placed in a heterotopic position in the right paravertebral gutter, with portal venous inflow directed from the iliac vein. The idea of heterotopic ALT was attractive because it avoided the need for native hepatectomy and an anhepatic phase, with the idea that it would improve…

Transplantation: Situs Inversus and Polysplenia Syndrome

Although outcomes after liver transplantation (LT) have enjoyed unprecedented success, particularly in children, anatomical anomalies increase the complexity of the procedure. Situs inversus (SI) is one such anomaly that can be associated with intra-abdominal anatomical aberrations. At one time, patients with SI were not considered candidates for LT because of the high risk associated with these associated anomalies. Today, with advances in surgical techniques and experience…

Intestinal and Multivisceral Transplantation

Intestinal and multivisceral transplantation have evolved significantly over the last three decades. A better understanding of the pathophysiology, improvements in surgical techniques and perioperative management, availability of effective immunosuppression (IS), and above all the experience of the last few decades has resulted in fairly standardized management of these patients. The effect of these improvements is reflected in the overall outcomes of these patients, with many series…

Clinical Management of Necrotic Liver Before and After Transplantation

Necrotic liver tissue, whether before or after liver transplantation, is a serious condition that requires immediate attention, because it can result in considerable morbidity or mortality. Although the most effective treatment for a massively necrotic liver is liver replacement, the indications, the sequence, and the timing of procedures require considerable medical and surgical skills to achieve favorable outcomes. Liver infarction typically results in a sudden increase…

Retransplantation

The last 30 years have demonstrated dramatic improvements in survival outcomes following liver transplantation and thus have allowed liver transplantation to be established as the standard of care for adult and pediatric patients with end-stage liver disease or hepatic malignancy. Currently more than 50% of grafts survive 10 years or more, but in the absence of artificial hepatic support, such as dialysis for kidney failure, retransplantation…

Combined Liver-Kidney Transplantation

Irreversible kidney failure was once considered an absolute contraindication to liver transplantation alone. Three decades ago the first combined liver and kidney transplantation (CLKT) was performed by Margreiter et al. Interestingly, the recipient, a 32-year-old man with hepatitis B cirrhosis, had previously undergone a kidney transplantation 6 years earlier, making this first case both a subsequent and simultaneous transplant. Thirty years later, this patient remains alive and…

Portal Vein Thrombosis and Other Venous Anomalies

Portal vein thrombosis (PVT) is defined as a partial or complete occlusion of the blood flow within the portal vein by an intraluminal thrombus. Balfour and Stewart first described this process in the literature in 1868 in a patient who presented with splenomegaly, ascites and variceal dilation. Since that initial report it has been thought to be a rare condition, though its reported prevalence varies widely.…

Arterial Reconstruction: Pitfalls

Reconstruction of the hepatic artery is one of the principal technical challenges in orthotopic liver transplantation, and successful patient and allograft outcomes depend on robust, uninterrupted arterial flow into the newly implanted liver. Because oxygen is delivered to the allograft's biliary ductal system almost solely through the hepatic artery, and because recipient collaterals to the liver are divided during the hepatectomy, the technical aspects of arterial…

Ethics in Living Donor Transplantation

Liver transplantation has become the standard of care for many types of end-stage liver disease. Dr. Thomas Starzl performed the first successful deceased donor liver transplantations (DDLTs) in the 1960s, but DDLT would not move from experimental to therapeutic status until 1983, following the introduction of cyclosporine as an immunosuppressive agent. In the ensuing 30 years the success of liver transplantation has led to great expansion…

Outcomes of Living Donor Transplantation: The Eastern Perspective

Historical Background The first attempted and successful living donor liver transplants were undertaken in 1989 in the in Brazil and Australia. In the face of a scarcity of deceased donor liver grafts, living donor liver transplantation (LDLT) took a preeminent position in Asia. In the early series the recipients were children and the parents donated their left livers for the transplant. Brain death was legislated in…

Outcomes of Living Donor Transplantation: The Western Perspective

The benefit of liver transplantation among patients with end-stage liver disease cannot be disputed in the modern era. However, access to a deceased donor liver allograft remains an extremely challenging problem that has prevented expansion of this medical advance to all patients in need. The persistent disparity between patients in need and the availability of deceased donor livers has forced the transplant community to expand the…

Dual Grafts for Transplantation

The shortage of cadaveric liver grafts has stimulated the development of innovative surgical procedures with various forms of living donor liver transplantation (LDLT), especially in adult patients, which produce satisfactory results comparable to whole-liver deceased donor liver transplantation (DDLT). For adult LDLT, insufficient graft size has been a major obstacle for an expansion of this procedure when the liver graft is confined to the left lobe…