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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

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