July 13, 2009 | In: TRANSPLANTATION
89 LIVER TRANSPLANTATION
Thomas E. Bak M.D., Michael E. Wachs M.D., Igal Kam M.D.
1. When and where was the first liver transplant performed?
Show answer
Dr. Thomas Starzl performed the first operation on March 1, 1963, at the University of Colorado in Denver.
2. Is liver transplantation considered a safe and effective operation?
Show answer
Yes. Although still a major operation with significant risks, patient and graft survival have continuously improved. One-year survival should be well over 90% in major centers.
3. What are the most common indications for liver transplantation in the United States?
Show answer
Noncholestatic cirrhosis characterizes > 50% of the recipients. This group includes those with viral hepatitis, alcoholic cirrhosis (Laennec’s), and Budd-Chiari syndrome. Cholestatic cirrhosis makes up an additional 15%, with primary sclerosing cholangitis (PSC) and primary biliary cirrhosis heading this group. Other indications include biliary atresia, acute hepatic necrosis, malignant neoplasms, and metabolic disease.
4. Has the most common disease requiring transplantation shifted over the years?
Show answer
Yes. The largest percentage of people now being transplanted have hepatitis C. There are also more retransplants performed because some diseases such as hepatits C and PSC can recur in transplanted livers.
5. How is the waiting list run?
Show answer
Changes have been made to the list so that the sickest patients get transplanted first. New scoring systems (Mayo End-stage Liver Disease [MELD] score) have been devised to give more weight to objective markers of illness rather than the more subjective medical criteria used in the past. This point system has also minimized the importance of time spent on the waiting list. The goal of these changes is to reduce waiting list mortality.
6. What are some of the recent advances in liver transplant surgery?
Show answer
Operative techniques have improved such that some liver transplant recipients do not require a stay in the intensive care unit, venovenous bypass, or external biliary drainage, and operative times are shorter (4-5 hours). Improved immunosuppression medications have reduced rejection rates and side effects.
7. How long can a liver be kept “on ice”?
Show answer
Optimal cold ischemia should be < 12 hours.
8. What are some common postoperative complications of liver transplantation?
Show answer
Postoperative bleeding, infection, and biliary complications are the most common. Primary nonfunction (< 5%) and early hepatic artery thrombosis (5%) are less common, but they usually require an urgent retransplant.
9. What is the “piggy-back” technique?
Show answer
This is a technique in which the recipient’s sick liver is carefully resected off of his or her vena cava, which is left in situ. The upper donor cava is then sewn to a common cuff of native hepatic veins. The donor’s lower cava is ligated. Using this method, it is possible to do the complete transplant with minimal if any vena caval occlusion, resulting in less intraoperative hemodynamic instability.
10. Is living-donor liver transplantation an option?
Show answer
Yes. Initially used in the pediatric population using an adult left lateral segment graft, this procedure has evolved into fairly common practice. The Far East has had a large number of adult-to-adult left lobe graft series. Elsewhere, this has been replaced with a right lobe donor operation. Both the donor and recipient liver lobes quickly regenerate to normal size. Results in experienced centers mimic those of cadaveric transplant with similar patient survival, albeit at higher complication and retransplant rates.
KEY POINTS: LIVER TRANSPLANTATION
1. The most common indication for liver transplantation in the United States is noncholestatic cirrhosis.
2. Optimal cold ischemia time for the liver is < 12 hours.
3. Transjugular intrahepatic portosystemic shunts can be used in potential transplant recipients as a bridge to transplantation.
11. How have transjugular intrahepatic portosystemic shunts (TIPS) improved this field of surgery?
Show answer
TIPS can be used in potential transplant recipients as a bridge to transplantation. This procedure is very effective in controlling portal hypertension without the need for a major abdominal operative shunt. A prior portocaval shunt does complicate a liver transplant, but it is not a contraindication to liver transplantation.
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