liver transplant

3. 1955 – FIRST LIVER1955 – FIRST LIVER
TRANSPLANTTRANSPLANT
WELSH : EXPERIMENTALWELSH : EXPERIMENTAL
DOG MODELDOG MODEL
1963 – FIRST HUMAN1963 – FIRST HUMAN
LIVER TRANSPLANTLIVER TRANSPLANT
STARZL : PIONEERSTARZL : PIONEER

4. 1960s & 1970s1960s & 1970s
• TECHNICAL DEVELOPMENTTECHNICAL DEVELOPMENT
• SURVIVAL RATES : <50% AT 1SURVIVAL RATES : <50% AT 1
YR.YR.

5. 1980s1980s
• CYCLOSPORINECYCLOSPORINE
• VENOVENOUSVENOVENOUS
BYPASSBYPASS
• UWUW
PRESERVATIONPRESERVATION
SOLUTIONSOLUTION
SURVIVAL RATESSURVIVAL RATES

6. 1990s1990s
EXPAND DONOREXPAND DONOR
LIVER POOLLIVER POOL
• LIVE DONORLIVE DONOR
(LDLT)(LDLT)
• SPLITSPLIT
• REDUCED SIZEREDUCED SIZE
(RSLT)(RSLT)
• NON HEARTNON HEART
BEATINGBEATING
SURVIVAL RATES ATSURVIVAL RATES AT
01 YR.01 YR. –– 90%90%
10 YR.10 YR. –– 70%70%

8. ENDEND STAGE LIVERSTAGE LIVER
DISEASEDISEASE
CHRONIC LIVER FAILURECHRONIC LIVER FAILURE
ACUTE FULMINANT LIVER FAILUREACUTE FULMINANT LIVER FAILURE
PRIMARY HEPATIC MALIGNANCYPRIMARY HEPATIC MALIGNANCY
INBORN ERRORS OF METABOLISMINBORN ERRORS OF METABOLISM

9. CHRONIC LIVERCHRONIC LIVER
FAILUREFAILURE
• COMMONEST INDICATIONCOMMONEST INDICATION
(80%) :(80%) : END STAGE CHRONICEND STAGE CHRONIC
LIVER DISEASESLIVER DISEASES
• GENERAL CRITERIA :GENERAL CRITERIA :
CLINICAL + BIOCHEMICALCLINICAL + BIOCHEMICAL
AETIOLOGY DEPENDENTAETIOLOGY DEPENDENT

10. SPECIFIC INDICATIONSSPECIFIC INDICATIONS
A.A. CHOLESTATIC LIVERCHOLESTATIC LIVER
DISEASE:DISEASE:
INTRACTABLE PRUTITUSINTRACTABLE PRUTITUS
INTERACTABLE BONE DISEASEINTERACTABLE BONE DISEASE
RECURRENT CHOLANGITISRECURRENT CHOLANGITIS

11. SPECIFIC INDICATIONSSPECIFIC INDICATIONS (Contd.)(Contd.)
A.A. HEPATO CELLULARHEPATO CELLULAR
DISEASE :DISEASE : WORSENINGWORSENING
SYNTHETIC FUNCTIONSSYNTHETIC FUNCTIONS
1.1. SERUM ALBUMIN <30.0G/lSERUM ALBUMIN <30.0G/l
2.2. PROTHROMBIN TIME >4 sPROTHROMBIN TIME >4 s
THAN NORMALTHAN NORMAL

12. CLINICAL EVENTSCLINICAL EVENTS
MAY PRECIPITATE NEED FOR TxMAY PRECIPITATE NEED FOR Tx
HEPATIC ENCEPHALOPATHYHEPATIC ENCEPHALOPATHY
REFRACTORY ASCITESREFRACTORY ASCITES
VARICEAL BLEEDINGVARICEAL BLEEDING

13. HEPATICHEPATIC
ENCEPHALOPATHYENCEPHALOPATHY
• EVEN MILD ENCEPHALOPATHYEVEN MILD ENCEPHALOPATHY
HAS DETRIMENTAL EFFECT ONHAS DETRIMENTAL EFFECT ON
QUALITY OF LIFEQUALITY OF LIFE
CONSIDERCONSIDER
TRANSPLANTATIONTRANSPLANTATION

14. ASCITESASCITES
• UNRESPONSIVE ASCITES : INDICATIONUNRESPONSIVE ASCITES : INDICATION
FOR Tx.FOR Tx.
• PERITONEOVENOUS SHUNTING NOTPERITONEOVENOUS SHUNTING NOT
RECOMMENDED FOR Tx CANDIDATESRECOMMENDED FOR Tx CANDIDATES
• SPONTANEOUS BACTERIALSPONTANEOUS BACTERIAL
PERITONITIS (SBP) IS A STRONGPERITONITIS (SBP) IS A STRONG
INDICATION FOR TxINDICATION FOR Tx
• SURGERY IN SBP DELAYED UNTILSURGERY IN SBP DELAYED UNTIL
AFTER FULL COURSE OF TREATMENTAFTER FULL COURSE OF TREATMENT

15. VARICEALVARICEAL
HEMORRHAGEHEMORRHAGE
• RECURRENT VARICEALRECURRENT VARICEAL
BLEEDING IS A CLEARBLEEDING IS A CLEAR
INDICATION FOR Tx.INDICATION FOR Tx.
• TIPS SHOULD BE CONSIDEREDTIPS SHOULD BE CONSIDERED
AS BRIDGING THERAPY INAS BRIDGING THERAPY IN
APPROPRIATE CASES.APPROPRIATE CASES.

16. FULMINANT HEPATICFULMINANT HEPATIC
FAILUREFAILURE
• ONSET OR HEPATICONSET OR HEPATIC
ENCEPHALOPATHY WITH IN 8ENCEPHALOPATHY WITH IN 8
WEEKS OF ONSET OF ACUTEWEEKS OF ONSET OF ACUTE
LIVER FAILURE IN ABSENCE OFLIVER FAILURE IN ABSENCE OF
PREEXISTING LIVER DISEASE.PREEXISTING LIVER DISEASE.
• BETWEEN 8 WEEKS & 6BETWEEN 8 WEEKS & 6
MONTHS : LATER ONSET ORMONTHS : LATER ONSET OR
SUBACUTESUBACUTE

17. FULMINANT HEPATICFULMINANT HEPATIC
FAILUREFAILURE (Contd.)(Contd.)
• COMMONERCOMMONER
CAUSES :CAUSES :
1.1.PARACETAMOLPARACETAMOL
OVER DOSEOVER DOSE
2.2.VIRAL HEPATITISVIRAL HEPATITIS
ESP :ESP :
NON A, NON B,NON A, NON B,
NON C.NON C.

18. SPECIFIC CRITERIA FOR Tx :SPECIFIC CRITERIA FOR Tx :
PUBLISHEDPUBLISHED
• AETIOLOGICAL FACTORAETIOLOGICAL FACTOR
• AGEAGE
• ACIDOSISACIDOSIS
• COAGULOPATHYCOAGULOPATHY
• SERUM BILIRUBIN LEVELSERUM BILIRUBIN LEVEL

19. CONTRA INDICATIONSCONTRA INDICATIONS
• BRAINSTEM DYSFUNCTIONBRAINSTEM DYSFUNCTION
• UNCONTROLLED SEPSISUNCONTROLLED SEPSIS
• REFRACTORY HYPOTENSIONREFRACTORY HYPOTENSION

20. PRIMARY HEPATICPRIMARY HEPATIC
MALIGNANCY :MALIGNANCY :HCC
NON
CIRRHOTICS
CIRRHOTICS
(ESP, HEPATITIS C,
HAEMOCRIMROMATOSIS
& ALCOHOLIC)
SPRORADIC
LARGE MASS
LATE RESULTS
POOR(20%)
Tx NOT
INDICATED
SINGLE TUMOR
<5cm.3 TUMOR <3cm.
EXCELLENT
RESULT
Tx INDICATED

21. CHILD’S A CIRRHOSISCHILD’S A CIRRHOSIS
• LATE OCCURRENCE OF TUMOURSLATE OCCURRENCE OF TUMOURS
(OFTEN MULTIPLE)(OFTEN MULTIPLE)
• POTENTIAL RESECTION v/s TxPOTENTIAL RESECTION v/s Tx
PRIMARY BILE DUCT CANCERPRIMARY BILE DUCT CANCER
(CHOLANGIO CARCINOMA)(CHOLANGIO CARCINOMA)• VERY HIGH RECURRENCE RATEVERY HIGH RECURRENCE RATE
• UNSUITABLE FOR TxUNSUITABLE FOR Tx

22. INBORN ERRORS OFINBORN ERRORS OF
METABOLISM:METABOLISM:
• WILSON’S DISEASEWILSON’S DISEASE
• FAMILIAL HYPERCHOLESTROLAEMIAFAMILIAL HYPERCHOLESTROLAEMIA
• PROTOPORPHYRIAPROTOPORPHYRIA
• ANTITRYPSIN DEFICIENCYANTITRYPSIN DEFICIENCY
MAJORITY AFFECT PAEDIATRIC PATIENTSMAJORITY AFFECT PAEDIATRIC PATIENTS
• INDICATIONS FOR Tx :INDICATIONS FOR Tx :
1.1. LIVER FAILURELIVER FAILURE
2.2. EXTRA HEPATIC ORGAN FAILURE,EXTRA HEPATIC ORGAN FAILURE,
3.3. DEVELOPMENT OF HCCDEVELOPMENT OF HCC
4.4. SEVERE SYMPTOMS AFFECTING QUALITY OFSEVERE SYMPTOMS AFFECTING QUALITY OF
LIFE.LIFE.

23. SELECTION & TIMINGSELECTION & TIMING
DONORDONOR :: RECIPIENTRECIPIENT
IN UKIN UK WL. 150WL. 150 :: ANNUAL Tx 750ANNUAL Tx 750
WAITING LIST MORTALITY 10% per yr.WAITING LIST MORTALITY 10% per yr.
MEDIAN WAITING TIME 3 TO 4 MONTHSMEDIAN WAITING TIME 3 TO 4 MONTHS
• EXPECTED LENGTH OF LIFE <1 YR.EXPECTED LENGTH OF LIFE <1 YR.
• QUALITY OF LIFE UNACCEPTABLEQUALITY OF LIFE UNACCEPTABLE
50% PROBABILITY OR MORE OF BEING ALIVE50% PROBABILITY OR MORE OF BEING ALIVE
5 Yrs. AFTER TRANSPLANTATION WITH5 Yrs. AFTER TRANSPLANTATION WITH
ACCEPTABLE QUALITY OF LIFE.ACCEPTABLE QUALITY OF LIFE.

24. INUSAINUSA
WAITING LIST 18000 : ANNUALWAITING LIST 18000 : ANNUAL
CADAVERIC Tx 4500CADAVERIC Tx 4500
• MELD (MODEL FOR END STAGEMELD (MODEL FOR END STAGE
LIVER DISEASE)LIVER DISEASE)
• PELD (FOR CHILDREN)PELD (FOR CHILDREN)
• CREATININECREATININE
• BILIRUBINBILIRUBIN
• INRINR

25. • WELL VALIDATED TOWELL VALIDATED TO
PREDICT DEATH WITHIN 90PREDICT DEATH WITHIN 90
DAYSDAYS
• RESULTED IN REDUCTION INRESULTED IN REDUCTION IN
WL MORTALITY BUT DO NOTWL MORTALITY BUT DO NOT
WELL PREDICT LONG TERMWELL PREDICT LONG TERM
OUTCOMEOUTCOME
• ADDITIONAL MEASURESADDITIONAL MEASURES
NEEDEDNEEDED

26. SPECIFIC INDICATIONSSPECIFIC INDICATIONS
PRIMARY BILIARY CIRRHOSIS (PCB) :PRIMARY BILIARY CIRRHOSIS (PCB) :
AUTO IMMUNE DISEASEAUTO IMMUNE DISEASE
SIMPLESTSIMPLEST :: SERUM BILIRUBINSERUM BILIRUBIN
OTHERS :OTHERS :
• AGEAGE
• BILIRUBINBILIRUBIN
• ALBUMIN LEVELALBUMIN LEVEL
• PROTHROMBIN TIMEPROTHROMBIN TIME
MEDICAL THERAPY : IMPROVES LIVERMEDICAL THERAPY : IMPROVES LIVER
BIOCHEM. : DELAY/AVERT Tx?BIOCHEM. : DELAY/AVERT Tx?

27. PRIMARY SELEROSINGPRIMARY SELEROSING
CHOLANGITIS (PSC)CHOLANGITIS (PSC)
PROGRESSIVE CHOLESTATIC DISEASEPROGRESSIVE CHOLESTATIC DISEASE
ASSO. WITH CONCURRENTASSO. WITH CONCURRENT
INFLAMMATORY BOWEL DISEASE (70%).INFLAMMATORY BOWEL DISEASE (70%).
• HIGH RISK OF CHOLANGIOCARCINOMAHIGH RISK OF CHOLANGIOCARCINOMA
• IF GRAFTED AFTER DEVELOPMENT OFIF GRAFTED AFTER DEVELOPMENT OF
MALIGNANCY : POOR OUT COMEMALIGNANCY : POOR OUT COME
• CLINICAL DOUBT : GUIDED BIOPSY OFCLINICAL DOUBT : GUIDED BIOPSY OF
DOMINANT STRICTURE.DOMINANT STRICTURE.

28. CHRONIC VIRALCHRONIC VIRAL
HEPATITISHEPATITIS
HEPATITIS C & B VIRUSESHEPATITIS C & B VIRUSES
– ANTIVIRAL DRUGS : MAJORANTIVIRAL DRUGS : MAJOR
DEVELOPMENTS : CONTROLDEVELOPMENTS : CONTROL
DISEASE/AVOID TxDISEASE/AVOID Tx
– MAJOR RISK OF HCC : IFMAJOR RISK OF HCC : IF
DETECTED EARLY SIMILARDETECTED EARLY SIMILAR
SURVIVAL AS FOR BENIGNSURVIVAL AS FOR BENIGN
DISEASE.DISEASE.

29. HEPATITIS CHEPATITIS C
• Rx : INTERFERON + RIBAVIRINRx : INTERFERON + RIBAVIRIN
• HEPATIC DECOMPENSATION : TxHEPATIC DECOMPENSATION : Tx
ONLY OPTION.ONLY OPTION.
• DISEASE RECURRENCE IN NEWDISEASE RECURRENCE IN NEW
LIVER : OFTEN AT ACCELERATEDLIVER : OFTEN AT ACCELERATED
RATE : SIGNIFICANT RISK.RATE : SIGNIFICANT RISK.
• NO EFFECTIVE POST TRANSPLANTNO EFFECTIVE POST TRANSPLANT
REGIME AVAILABLE : USEREGIME AVAILABLE : USE
YOUNGER DONORS.YOUNGER DONORS.

30. HEPATITIS BHEPATITIS B
• ANTIVIRAL THERAPY USINGANTIVIRAL THERAPY USING
NUCLEOSIDE ANALOGUES : PREVENTNUCLEOSIDE ANALOGUES : PREVENT
PROGRESSIVE LIVER DAMAGEPROGRESSIVE LIVER DAMAGE
• UNRESPONSIVE OR ADVANCEDUNRESPONSIVE OR ADVANCED
DISEASE : TxDISEASE : Tx
• Tx SUCCESSFUL DUE TO EFFECTIVETx SUCCESSFUL DUE TO EFFECTIVE
ANTIVIRAL PROTOCOL UTILIZINGANTIVIRAL PROTOCOL UTILIZING
HEPATITIS B IMMUNOGLOBULIN ANDHEPATITIS B IMMUNOGLOBULIN AND
LAMIVUDINE.LAMIVUDINE.

31. ALCOHOLIC LIVERALCOHOLIC LIVER
DISEASEDISEASE
END STAGE ALCOHOLIC LIVER DISEASE :END STAGE ALCOHOLIC LIVER DISEASE :
ACCEPTED INDICATION FOR TxACCEPTED INDICATION FOR Tx
• CONTROVERSIAL : POSSIBLE RECIDIVISMCONTROVERSIAL : POSSIBLE RECIDIVISM
& POOR COMPLIANCE& POOR COMPLIANCE
• OUT COME : SURVIVAL & QUALITY OF LIFEOUT COME : SURVIVAL & QUALITY OF LIFE
SAME AS OTHERS.SAME AS OTHERS.
– ABSTINENCE AT LEAST 6 MONTHSABSTINENCE AT LEAST 6 MONTHS
– PSYCHIATRIC ASSESSMENT & FORMALPSYCHIATRIC ASSESSMENT & FORMAL
ALCOHOL REHABILITATION PROGRAMMEALCOHOL REHABILITATION PROGRAMME
– STABLE & SUPPORTIVE PSYCHOSOCIALSTABLE & SUPPORTIVE PSYCHOSOCIAL
ENVIRONMENTENVIRONMENT
– RELAPSE RATE – FIRST FEW YEAR 40%. HEAVYRELAPSE RATE – FIRST FEW YEAR 40%. HEAVY
DRINK : 15%DRINK : 15%

32. AUTOIMMUNE HEPATITIS :AUTOIMMUNE HEPATITIS :
THREE FORMSTHREE FORMS
• TYPE I : MOST COMMONTYPE I : MOST COMMON
• IMMUNOSUPPRESSIVE THERAPY : PROLONGS LIFE :IMMUNOSUPPRESSIVE THERAPY : PROLONGS LIFE :
LONG TERM TREATMENT DANGERS : GREATESTLONG TERM TREATMENT DANGERS : GREATEST
CUMULATIVE DOSESCUMULATIVE DOSES
• LIVER Tx – IMPROVES SURVIVAL BUT RECURRENCELIVER Tx – IMPROVES SURVIVAL BUT RECURRENCE
CAN OCCURCAN OCCUR
• MAY REQUIRE LONG TERM STEROIDSMAY REQUIRE LONG TERM STEROIDS
DISEASES THAT MIGHT RECUR IN THEDISEASES THAT MIGHT RECUR IN THE
TRANSPLANTATION NOT ATRANSPLANTATION NOT A
CONTRA INDICATION FOR LIVER Tx.CONTRA INDICATION FOR LIVER Tx.

33. MANAGEMENT OF DONOR ANDMANAGEMENT OF DONOR AND
ORGAN RETRIEVALORGAN RETRIEVAL
EVALUATION OF DONOR : NO UPPEREVALUATION OF DONOR : NO UPPER
AGE LIMITAGE LIMIT
NONO
• MALIGNANCY EXCEPT NON METASTATIC BRAIN & SKINMALIGNANCY EXCEPT NON METASTATIC BRAIN & SKIN
CANCERCANCER
• INTRA ABDOMINAL/SYSTEMIC SEFSISINTRA ABDOMINAL/SYSTEMIC SEFSIS
• TRANSMISSIBLE DISEASESTRANSMISSIBLE DISEASES
YESYES
• BACTERIAL MENINGITIS -BACTERIAL MENINGITIS - ANTI MICROBIAL THERAPYANTI MICROBIAL THERAPY
TO DONOR & RECIPIENTTO DONOR & RECIPIENT
• -VE FOR HIV, HTLV – 1, HBs Ag, HBc Ab &-VE FOR HIV, HTLV – 1, HBs Ag, HBc Ab &
HCVAb.HCVAb.
• HbcAb & HCVAb +VE DONOR CAN DONATEHbcAb & HCVAb +VE DONOR CAN DONATE
TO RECIPIENTS OF SIMILAR SEROLOGY.TO RECIPIENTS OF SIMILAR SEROLOGY.

34. DONORDONOR
• HEMODYNAMIC STABILITYHEMODYNAMIC STABILITY
• EPISODES OF CARDIO RESPIRATORY ARRESTEPISODES OF CARDIO RESPIRATORY ARREST
• INOTROPE REQUIREMENTSINOTROPE REQUIREMENTS
• ELECTROLYTE IMBALANCESELECTROLYTE IMBALANCES
• LFT INCLUDING PTLFT INCLUDING PT
FINAL JUDGMENT OF DONOR LIVER MADE ATFINAL JUDGMENT OF DONOR LIVER MADE AT
RETRIEVAL OPERATIONRETRIEVAL OPERATION
- COLOR- COLOR - SIZE (SPLIT/PAED)- SIZE (SPLIT/PAED)
- TEXTURE- TEXTURE - INTRA ABDOMINAL- INTRA ABDOMINAL
PATHOLOGY EXCLUDEDPATHOLOGY EXCLUDED
- CONSISTENCY- CONSISTENCY - QUALITY OF PERFUSION- QUALITY OF PERFUSION
OF ORGANOF ORGAN

35. MARGINAL LIVERS :MARGINAL LIVERS :
STRESSED PRIOR TOSTRESSED PRIOR TO
STORAGESTORAGE
HYPOXIA METABOLIC
DISTURBANCES OR
ISCHAEMIA
INCREASED RISK
OF EARLY
DYSFUNCTION
SECONDARY TO
HYPOTENSIVE
EPISODES IN
DONOR
UNDERLYING
LIVER PATHOLOGY
HIGH
VASOPRESSOR
REQUIREMENTS
APPEARANCE
LFT

36. TESTS : NOT PROVEDTESTS : NOT PROVED
SUPERIORSUPERIOR
• MRGX/PHOSPHORUS – 31/MRMRGX/PHOSPHORUS – 31/MR
SPECTROMETRY/ HYALURONIC ACIDSPECTROMETRY/ HYALURONIC ACID
LEVEL IN GRAFT CAVAL EFFLUENTLEVEL IN GRAFT CAVAL EFFLUENT
• CAN BE SUCCESSFULLY USED :CAN BE SUCCESSFULLY USED :
SIGNIFICANT RISE IN NO. OF TxSIGNIFICANT RISE IN NO. OF Tx
• NOT RECOMMENDED FOR HIGH RISKNOT RECOMMENDED FOR HIGH RISK
‘MARGINAL RECIPIENTS.’‘MARGINAL RECIPIENTS.’
MARGINAL LIVERMARGINAL LIVER

37. DONOR HEPATECTOMYDONOR HEPATECTOMY
UNIVERSITY OF WISCONSIN SOLUTION (UWS)UNIVERSITY OF WISCONSIN SOLUTION (UWS)
• ALLOWS SAFE COLD STORAGE UPTO 24hrs.ALLOWS SAFE COLD STORAGE UPTO 24hrs.
(PRACTICAL UPPER LIMIT 18hrs.)(PRACTICAL UPPER LIMIT 18hrs.)
• EXPANDED DONOR POOL : TIME ENVELOPE:EXPANDED DONOR POOL : TIME ENVELOPE:
SEMI ELECTIVE SURGERYSEMI ELECTIVE SURGERY
BEATING HEARTBEATING HEART
: ALMOST ALL: ALMOST ALL
NON BEATING HEART :NON BEATING HEART :
DUE TO ORGANDUE TO ORGAN
SHORTAGE STARTEDSHORTAGE STARTED
ORGAN PRESERVATIONORGAN PRESERVATION

38. EVALUATION COMMITTEEEVALUATION COMMITTEE
• SURGEONSSURGEONS
• HEPATOLOGISTSHEPATOLOGISTS
• CARDIOLOGISTSCARDIOLOGISTS
• PULMONOLOGISTSPULMONOLOGISTS
• NEPHROLOGISTSNEPHROLOGISTS
• NEUROLOGISTSNEUROLOGISTS
• GASTROENTEROLOGISTSGASTROENTEROLOGISTS
• PAEDIATRICIANSPAEDIATRICIANS
• PSYCHIATRISTSPSYCHIATRISTS
• ANESTHESIOLOGISTSANESTHESIOLOGISTS
• TRANSPLANTTRANSPLANT
COORDINATORSCOORDINATORS
• SOCIAL WORKERSSOCIAL WORKERS

39. PERIOPERATIVE MANAGEMENT OFPERIOPERATIVE MANAGEMENT OF
RECIPIENTRECIPIENT
• THROMBOELASTOGRAPHY (TEG) HAS ATHROMBOELASTOGRAPHY (TEG) HAS A
SIGNIFICANT IMPACT BY ENABLINGSIGNIFICANT IMPACT BY ENABLING
THE ANESTHETIST TO MONITOR &THE ANESTHETIST TO MONITOR &
TREAT POST REPERFUSIONTREAT POST REPERFUSION
COAGULOPATHY & TO CONTROL THECOAGULOPATHY & TO CONTROL THE
EFFECTS OF EXCESSIVE FIBRINOLYSISEFFECTS OF EXCESSIVE FIBRINOLYSIS
BY THE USE OF KALLIKREINBY THE USE OF KALLIKREIN
INHIBITORS, WITH REDUCTION ININHIBITORS, WITH REDUCTION IN
BLOOD TRANSFUSION REQUIREMENTS.BLOOD TRANSFUSION REQUIREMENTS.

40. ADULT WHOLE LIVER GRAFT :ADULT WHOLE LIVER GRAFT :
GENEROUS BILATERAL SUBCOSTAL INCISIONGENEROUS BILATERAL SUBCOSTAL INCISION
REMOVAL OF LIVERREMOVAL OF LIVER
WITH INTRA HEPATICWITH INTRA HEPATIC
VENACAVAVENACAVA
• FULL CAVAL CLAMPINGFULL CAVAL CLAMPING
• HEMODYNAMICHEMODYNAMIC
INSTABILITYINSTABILITY
• REQUIRES VENOREQUIRES VENO
VENOUS BYPASSVENOUS BYPASS
PRESERVATION OFPRESERVATION OF
RECIPIENT CAVARECIPIENT CAVA
• DONOR CAVA CAN BEDONOR CAVA CAN BE
ANASTOMOSEDANASTOMOSED
• STUMP OF HEPATICSTUMP OF HEPATIC
VEINSVEINS
• SIDE TO SIDE CAVOSIDE TO SIDE CAVO
CAVOSTOMYCAVOSTOMY
(PIGGYBACK TECH.)(PIGGYBACK TECH.)
• PARTIAL CAVALPARTIAL CAVAL
CLAMPINGCLAMPING
• HEMODYNAMICHEMODYNAMIC
STABILITYSTABILITY
MAINTAINEDMAINTAINED
TEMPORARY END TO SIDE
PORTO-CAVAL SHUNT TO
MAINTAIN STABILITY &
PREVENT VENOUS
CONGESTION OF BOWEL

41. BILIARY RECONSTRUCTIONBILIARY RECONSTRUCTION
• END TO END BETWEEN OBLIQUELYEND TO END BETWEEN OBLIQUELY
CUT DONOR & RECIPIENT DUCTCUT DONOR & RECIPIENT DUCT
• DO NOT OBSTRUCT LOWER END OFDO NOT OBSTRUCT LOWER END OF
CYSTIC DUCT :CYSTIC DUCT : DILATEDILATE
OBSTRUCTIONOBSTRUCTION
• T-TUBE NO LONGER ROUTINELYT-TUBE NO LONGER ROUTINELY
USED, MAY BE USED IN SPLIT GRAFTSUSED, MAY BE USED IN SPLIT GRAFTS
• BILIARY ATRSIAS OR PSC – ROUX-EN-BILIARY ATRSIAS OR PSC – ROUX-EN-
Y-CHOLEDCHO-JEJUNOSTOMYY-CHOLEDCHO-JEJUNOSTOMY

42. REDUCED SIZE LIVER Tx (RSLT) :REDUCED SIZE LIVER Tx (RSLT) :
PERFORMED IN 1984PERFORMED IN 1984
TO INCREASE AVAILABILITY OF GRAFT INTO INCREASE AVAILABILITY OF GRAFT IN
PAEDIATRIC RECIPIENTSPAEDIATRIC RECIPIENTS

43. RSLTRSLT (CONTD.)(CONTD.)
• EX VIVO REDUCTIONEX VIVO REDUCTION
IN DONOR LIVERIN DONOR LIVER
• IMPLANTED INIMPLANTED IN
ORTHOTOPICORTHOTOPIC
POSITION AFTERPOSITION AFTER
RECIPIENTRECIPIENT
HEPATECTOMYHEPATECTOMY
• COMMONESTCOMMONEST
SEGMENTS USED :SEGMENTS USED :
– LEFT LATERALLEFT LATERAL
(SEGMENT II & III)(SEGMENT II & III)
– FULL LEFT LOBEFULL LEFT LOBE
BASED ON SIZE MATCHING OFBASED ON SIZE MATCHING OF
DONOR & RECIPIENTSDONOR & RECIPIENTS

44. RSLTRSLT (CONTD.)(CONTD.)
• ORIGINAL TECHNIQUE : SEGMENT OF DONORORIGINAL TECHNIQUE : SEGMENT OF DONOR
IVCIVC
• MODIFIED TECHNIQUE : DONOR LEFT HEPATICMODIFIED TECHNIQUE : DONOR LEFT HEPATIC
VEINVEIN
ANASTOMOSED WITH RECIPIENT IVC THROUGHANASTOMOSED WITH RECIPIENT IVC THROUGH
APPROPRIATE SIZED OSTIUMAPPROPRIATE SIZED OSTIUM
• REDUCED MORTALITY IN PAEDIATRIC WL.REDUCED MORTALITY IN PAEDIATRIC WL.
• PATIENT SURVIVAL EQUAL/BETTER THANPATIENT SURVIVAL EQUAL/BETTER THAN
WHOLE GRAFT PAEDIATRIC RECIPIENTSWHOLE GRAFT PAEDIATRIC RECIPIENTS

45. SPLIT LIVER TRANSPLANTATIONSPLIT LIVER TRANSPLANTATION
(IN VIVO & IN SITU) :(IN VIVO & IN SITU) :
PERFORMED IN 1988PERFORMED IN 1988
• NATURAL EXTENSIONNATURAL EXTENSION
OF RSLTOF RSLT
• FULL USE OF DONORFULL USE OF DONOR
LIVER – SMALLERLIVER – SMALLER
LEFT – Tx IN CHILD.LEFT – Tx IN CHILD.
LARGE RIGHT – Tx INLARGE RIGHT – Tx IN
ADULT.ADULT.
• INCREASED THEINCREASED THE
AVAILABILITY OFAVAILABILITY OF
CADAVERIC LIVERCADAVERIC LIVER
GRAFTS BY 25-28%GRAFTS BY 25-28%

46. SPLIT LIVER TRANSPLANTATIONSPLIT LIVER TRANSPLANTATION
(IN VIVO & IN SITU)(IN VIVO & IN SITU) CONTD.CONTD.
• STRINGENT CRITERIA TOSTRINGENT CRITERIA TO
SELECT DONOR LIVERS FORSELECT DONOR LIVERS FOR
SPLITTINGSPLITTING
–INCREASED RISK OFINCREASED RISK OF
PRESERVATION INJURY.PRESERVATION INJURY.
–COMPLICATIONS RELATED TOCOMPLICATIONS RELATED TO
CUT SURFACECUT SURFACE

47. • RECIPIENT SIZE :RECIPIENT SIZE :
PLANE OF SEPARATIONPLANE OF SEPARATION
CAN BE VARIEDCAN BE VARIED
• ADULT : RIGHT LOBEADULT : RIGHT LOBE
GRAFT (SEGMENT IVGRAFT (SEGMENT IV
OR V TO VIII)OR V TO VIII)
• LARGE CHILD ORLARGE CHILD OR
SMALL ADULT :SMALL ADULT :
COMPLETE LEFT LOBECOMPLETE LEFT LOBE
(SEGMENT II, III & IV)(SEGMENT II, III & IV)
• INFANT : LEFTINFANT : LEFT
LATERAL SEGMENTLATERAL SEGMENT

48. EX VIVOEX VIVO IN SITUIN SITU
• GRAFT DIVIDED ONGRAFT DIVIDED ON
BACK TABLE AFTERBACK TABLE AFTER
PROCUREMENTPROCUREMENT
• SLUSHED SALINE TOSLUSHED SALINE TO
PREVENT WARMINGPREVENT WARMING
• BACK TABLEBACK TABLE
CHOLAGIOGRAPHYCHOLAGIOGRAPHY
(&(&
ARTERIOGRAPHY)ARTERIOGRAPHY)
TO DELINEATETO DELINEATE
BILIARY &BILIARY &
VASCULARVASCULAR
ANATOMY PRIOR TOANATOMY PRIOR TO
SPLITTINGSPLITTING
• LEFT LATERALLEFT LATERAL
SEGMENTECTOMY ORSEGMENTECTOMY OR
LEFT HEPATECTOMY INLEFT HEPATECTOMY IN
HEART BEATINGHEART BEATING
CADAVERIC DONORCADAVERIC DONOR
• RESECTED SEGMENTRESECTED SEGMENT
PERFUSED ON BACK TABLEPERFUSED ON BACK TABLE
FOLLOWED BY IN SITUFOLLOWED BY IN SITU
PERFUSION OF RIGHTPERFUSION OF RIGHT
LOBELOBE
• ADVANTAGE OFADVANTAGE OF
DECREASED COLDDECREASED COLD
ISCHAEMIC TIME &ISCHAEMIC TIME &
POTENTIAL WARMINGPOTENTIAL WARMING
THAT MAY OCCUR DURINGTHAT MAY OCCUR DURING
EX VIVO SPLITTINGEX VIVO SPLITTING
• DOES NOT SIGNIFICANTLYDOES NOT SIGNIFICANTLY
PROLONG SURGERY ATPROLONG SURGERY AT
DONOR HOSPITALDONOR HOSPITAL

49. EARLY RESULTSEARLY RESULTS
• INFERIOR C/F WHOLE ORGAN GRAFTINFERIOR C/F WHOLE ORGAN GRAFT
• RIGOROUS SELECTION CRITERIA &RIGOROUS SELECTION CRITERIA &
ELECTIVE RECIPIENTS HAVEELECTIVE RECIPIENTS HAVE
IMPROVED OUTCOME TOIMPROVED OUTCOME TO
COMPARABLE LEVELSCOMPARABLE LEVELS
• RESULTS COMPARABLE TO RSLT INRESULTS COMPARABLE TO RSLT IN
PAEDIATRIC RECIPIENT GROUPPAEDIATRIC RECIPIENT GROUP
• ULTIMATE OBJECTIVE : BOTHULTIMATE OBJECTIVE : BOTH
HEMIGRAFTS FOR TWO ADULTSHEMIGRAFTS FOR TWO ADULTS
• INITIAL EXPERIENCE : POORINITIAL EXPERIENCE : POOR
OUTCOME FOR LEFT LOBEOUTCOME FOR LEFT LOBE
RECIPIENTS.

50. LIVE DONORLIVE DONOR
LTx (LDLT) : 1989LTx (LDLT) : 1989
• LEFT LATERAL SEGMENTALLEFT LATERAL SEGMENTAL
RESECTIONRESECTION
• SAFE, LOW MORBIDITY &SAFE, LOW MORBIDITY &
MORTALITY RATESMORTALITY RATES
• ROUTINE ALTERNATIVE TOROUTINE ALTERNATIVE TO
CADAVERIC Tx IN PAEDIATRICCADAVERIC Tx IN PAEDIATRIC
RECIPIENTSRECIPIENTS
• RECENTLY ADOPTED FOR ADULTRECENTLY ADOPTED FOR ADULT
RECIPIENTS.RECIPIENTS.

51. • IMPEDIMENTS :IMPEDIMENTS :
– SAFETY OF DONORSAFETY OF DONOR
– ADEQUACY OF HEPATIC MASSADEQUACY OF HEPATIC MASS
– ADEQUACY OF GRAFT VOLUMEADEQUACY OF GRAFT VOLUME
(METHODS) :(METHODS) :
GRAFT TO RECIPIENT WEIGHT RATIOGRAFT TO RECIPIENT WEIGHT RATIO
RATIO OF GRAFT VOLUME AS MEASURED BYRATIO OF GRAFT VOLUME AS MEASURED BY
CT OR MRI VOLUMETRY WITH RECIPIENT’SCT OR MRI VOLUMETRY WITH RECIPIENT’S
ESTIMATED LIVER VOLUME (ELV)ESTIMATED LIVER VOLUME (ELV)
OBTAINED USING STANDARD FORMULAOBTAINED USING STANDARD FORMULA
• MINIMUM SAFE GRAFT VOLUME : 30%-50%MINIMUM SAFE GRAFT VOLUME : 30%-50%

52. • INSUFFICIENT GRAFT VOLUME :INSUFFICIENT GRAFT VOLUME :
– SMALL FOR SIZE SYNDROME :SMALL FOR SIZE SYNDROME :
SECONDARY TO PORTALSECONDARY TO PORTAL
HYPERPERFUSIONHYPERPERFUSION
• CHOLESTASISCHOLESTASIS
• ASCITESASCITES
• POOR SYNTHETIC FUNCTIONPOOR SYNTHETIC FUNCTION
• DONOR SELECTION : RIGOROUSDONOR SELECTION : RIGOROUS
– INFORMED CONSENTINFORMED CONSENT
– EXCLUSION OF MEDICALEXCLUSION OF MEDICAL
CONDITIONS THAT MAYCONDITIONS THAT MAY
JEOPARDIZE DONOR OUTCOME.JEOPARDIZE DONOR OUTCOME.

53. RIGHT LOBE LDLTRIGHT LOBE LDLT
• NECESSITY FOR ADEQUATE SIZENECESSITY FOR ADEQUATE SIZE
• FASTEST GROWING Tx TECHNIQUEFASTEST GROWING Tx TECHNIQUE
• COMPLEX PROCEDURECOMPLEX PROCEDURE
MOBILIZATION OF LIVER FROM RETROMOBILIZATION OF LIVER FROM RETRO
HEPATIC IVCHEPATIC IVC
HILAR DISSECTION IDENTIFIES RIGHTHILAR DISSECTION IDENTIFIES RIGHT
HEPATIC ARTERY & PORTAL VEINHEPATIC ARTERY & PORTAL VEIN
WHILE AVOIDING AND EXPOSURE OFWHILE AVOIDING AND EXPOSURE OF
LEFT HILAR STRUCTURES.LEFT HILAR STRUCTURES.

54. • USG :USG :
– TO DELINEATE COURSE OFTO DELINEATE COURSE OF
MIDDLE & RIGHT HEPATICMIDDLE & RIGHT HEPATIC
VEINSVEINS
• CHOLANGIOGRAPHY :CHOLANGIOGRAPHY :
– TO IDENTIFY BILIARY ANATOMYTO IDENTIFY BILIARY ANATOMY
• CUSA/HARMONIC SCALPEL :CUSA/HARMONIC SCALPEL :
– PARENCHYMAL DISSECTIONPARENCHYMAL DISSECTION
WITHOUT IN FLOW OCCLUSIONWITHOUT IN FLOW OCCLUSION

55. • IMPLANTATION : DIFFERENTIMPLANTATION : DIFFERENT
FORM RSLT : NO IVC INFORM RSLT : NO IVC IN
RECIPIENTRECIPIENT
• DONOR RIGHT HEPATIC VEINDONOR RIGHT HEPATIC VEIN
ANASTOMOSED DIRECTLY TOANASTOMOSED DIRECTLY TO
RECIPIENT RIGHT HEPATIC VEINRECIPIENT RIGHT HEPATIC VEIN
• BILIARY RECONSTRUCTIONBILIARY RECONSTRUCTION
USUALLY PERFORMED USING AUSUALLY PERFORMED USING A
ROUX –EN-Y HEPATICOROUX –EN-Y HEPATICO
JEJUNOSTOMY.JEJUNOSTOMY.

56. DISADVANTAGEDISADVANTAGE
• GREATER DONOR RISK :GREATER DONOR RISK :
MORTALITY 0.3%-0.5% (Cf 0.1-0.2% ONMORTALITY 0.3%-0.5% (Cf 0.1-0.2% ON
LEFT LOBE LDLT FOR PAED.LEFT LOBE LDLT FOR PAED.
RECIPIENTS)RECIPIENTS)
• TRANSIENT HYPERBILIRUBINAEMIATRANSIENT HYPERBILIRUBINAEMIA
‘TRANSAMINITIS’ &‘TRANSAMINITIS’ &
COAGULOPATHY MORE FREQUENTCOAGULOPATHY MORE FREQUENT
• BILIARY COMPLICATIONS MOREBILIARY COMPLICATIONS MORE
COMMONCOMMON

57. ADVANTAGEADVANTAGE
• SHORT COLD ISCHAEMIA TIMESHORT COLD ISCHAEMIA TIME
• HEALTHY DONORS WITH NORMALHEALTHY DONORS WITH NORMAL
LIVER FUNCTIONLIVER FUNCTION
• ABILITY TO PERFORMABILITY TO PERFORM
TRANSPLANTATION PRIOR TOTRANSPLANTATION PRIOR TO
RECIPIENT BECOMING CRITICALLY ILL.RECIPIENT BECOMING CRITICALLY ILL.

58. DOMINO PROCEDUREDOMINO PROCEDURE
RECIPIENT LIVER AS DONOR LIVERRECIPIENT LIVER AS DONOR LIVER
• LIVER FROM PATIENTS WITH HEPATICLIVER FROM PATIENTS WITH HEPATIC
METABOLIC DISORDERS THAT CAUSEMETABOLIC DISORDERS THAT CAUSE
SYSTEMIC DISEASE WITHOUT AFFECTINGSYSTEMIC DISEASE WITHOUT AFFECTING
OTHER LIVER FUNCTIONSOTHER LIVER FUNCTIONS
• FAMILIAL AMYLOID POLYNEUROPATHYFAMILIAL AMYLOID POLYNEUROPATHY
(DUE TO SINGLE ENZYME DEFECT IN(DUE TO SINGLE ENZYME DEFECT IN
LIVER) : MAIN SOURCELIVER) : MAIN SOURCE
• Tx IN OLDER RECIPIENT GROUP : ≤20 Yr.Tx IN OLDER RECIPIENT GROUP : ≤20 Yr.
TO DEVELOP AMYLOIDOSIS IN RECIPIENTTO DEVELOP AMYLOIDOSIS IN RECIPIENT
PARTICULARLY IN AREAS WHERE DISEASEPARTICULARLY IN AREAS WHERE DISEASE
IS PREVALENT.IS PREVALENT.

59. AUXILIARY LIVERAUXILIARY LIVER
TRANSPLANTATIONTRANSPLANTATION
– ALTERNATIVE TECHNIQUE INALTERNATIVE TECHNIQUE IN
FULMINANT HEPATIC FAILUREFULMINANT HEPATIC FAILURE
CERTAIN INBORN ERRORS OF METABOLISM.CERTAIN INBORN ERRORS OF METABOLISM.
CONCEPT :CONCEPT :
A.A. TO TRANSPLANT ADEQUATE HEPATIC MASS TOTO TRANSPLANT ADEQUATE HEPATIC MASS TO
ALLOW RECOVERY OF NATIVE LIVER WITHOUTALLOW RECOVERY OF NATIVE LIVER WITHOUT
NEED FOR LONG TERM IMMUNOSUPPRESSION.NEED FOR LONG TERM IMMUNOSUPPRESSION.
B.B. ACUTE GRAFT FAILURE WOULD NOT BE FATAL.ACUTE GRAFT FAILURE WOULD NOT BE FATAL.

60. HETEROTOPIC – INITIALLYHETEROTOPIC – INITIALLY
ORTHOTOPIC – MORE RECENTLYORTHOTOPIC – MORE RECENTLY
WITH PARTIAL RESECTION OF HOSTWITH PARTIAL RESECTION OF HOST
LIVER TO PROVIDE SPACE.LIVER TO PROVIDE SPACE.
SMALL SERIES :SMALL SERIES :
IMMUNOSUPPRESSANT CAN BEIMMUNOSUPPRESSANT CAN BE
WITHDRAWN IN MANY CASES.WITHDRAWN IN MANY CASES.
LIMITED APPLICATION : TECHNICALLIMITED APPLICATION : TECHNICAL
ISSUE OF SURGERY.ISSUE OF SURGERY.
RECENT : LIVING DONOR FORRECENT : LIVING DONOR FOR
AUXILIARY PARTIAL ORTHOTOPICAUXILIARY PARTIAL ORTHOTOPIC
LIVER TRANSPLANTS, PARTICULARLYLIVER TRANSPLANTS, PARTICULARLY
FOR CHILDREN WITH AFHF.FOR CHILDREN WITH AFHF.

61. REPEAT ORTHOTOPIC LIVER TxREPEAT ORTHOTOPIC LIVER Tx
• CONTROVERSIAL :CONTROVERSIAL :
– PATIENT SELECTIONPATIENT SELECTION
– SHORTAGE OF DONOR ORGANSHORTAGE OF DONOR ORGAN
• OUTCOME :OUTCOME :
– IMPROVED IN LAST TWO DECADESIMPROVED IN LAST TWO DECADES
– PATIENT & GRAFT SURVIVAL RATES : 74% &PATIENT & GRAFT SURVIVAL RATES : 74% &
60% RESP60% RESP
• MAIN INDICATIONS :MAIN INDICATIONS :
– CHRONIC REJECTIONCHRONIC REJECTION
– HEPATIC ARTERY THROMBOSIS.HEPATIC ARTERY THROMBOSIS.

62. OTHER INDICATIONSOTHER INDICATIONS
• PRIMARY NON FUNCTIONPRIMARY NON FUNCTION
• RECURRENT DISEASERECURRENT DISEASE
• BILIARY COMPLICATIONSBILIARY COMPLICATIONS
EARLY v/s LATEEARLY v/s LATE
RETRANSPLANTATION: WORSE v/sRETRANSPLANTATION: WORSE v/s
SAME AS FIRST TxSAME AS FIRST Tx
– OUTCOME REDUCES AS NUMBER OFOUTCOME REDUCES AS NUMBER OF
REPEAT TRANSPLANTS INCREASEREPEAT TRANSPLANTS INCREASE
– III & IV GRAFT CANNOT USUALLY BEIII & IV GRAFT CANNOT USUALLY BE
JUSTIFIED.JUSTIFIED.

63. IMMUNOSUPPRESSIONIMMUNOSUPPRESSION
• TRIPLE THERAPY :TRIPLE THERAPY :
– PREDNISOLONEPREDNISOLONE
– AZATHIOPRINEAZATHIOPRINE
– CYCLOSPORINECYCLOSPORINE
• NEWER AGENTS :NEWER AGENTS :
– SUPPLANTED CYCLOSPORINE WITH TACROLIMUSSUPPLANTED CYCLOSPORINE WITH TACROLIMUS
– BETTER LONG TERM OUTCOME.BETTER LONG TERM OUTCOME.
• PREDNISOLONE –PREDNISOLONE –
– TO TREAT REJECTION EPISODESTO TREAT REJECTION EPISODES
– EARLY MAINTENANCE THERAPYEARLY MAINTENANCE THERAPY
– USUALLY CAN BE STOPPED WITHIN 3 MONTHUSUALLY CAN BE STOPPED WITHIN 3 MONTH

64. AZATHIOPRINE :AZATHIOPRINE :
• STILL USED IN MANY CENTRESTILL USED IN MANY CENTRE
• INCREASINGLY REPLACED BYINCREASINGLY REPLACED BY
MYCOPHENOLATE MOFETILMYCOPHENOLATE MOFETIL
(MMF)(MMF)
CALUNEURIN INHIBITORSCALUNEURIN INHIBITORS
(CYCLOSPORINE + TACROLIMUS) :(CYCLOSPORINE + TACROLIMUS) :
• NEPHROTOXICITYNEPHROTOXICITY
• LOW DOSE TACROLIMUS + MMFLOW DOSE TACROLIMUS + MMF
MAY PRESERVE RENAL RESERVE.MAY PRESERVE RENAL RESERVE.

65. RECENTRECENT
• SIROLIMUS : MACROLYTICSIROLIMUS : MACROLYTIC
LACTONELACTONE
• EFFECTIVE SUBSTITUTE FOREFFECTIVE SUBSTITUTE FOR
CALCINEURIN INHIBITORSCALCINEURIN INHIBITORS
• NO NEPHROTOXICITYNO NEPHROTOXICITY
• NEGATIVE IMPACT AN WOUNDNEGATIVE IMPACT AN WOUND
HEALINGHEALING
• MAY HAVE A ROLE IN LATERMAY HAVE A ROLE IN LATER
LONG TERMLONG TERM
IMMUNOSUPPRESSIONIMMUNOSUPPRESSION

66. POLYCLONAL ANTIBODY PREPARATIONSPOLYCLONAL ANTIBODY PREPARATIONS
DISAPPOINTING, HIGH INFECTIOUSDISAPPOINTING, HIGH INFECTIOUS
COMPLICATION RATECOMPLICATION RATE
• CD 25 ANTIBODIES : GREATER PROMISE AS CD 25CD 25 ANTIBODIES : GREATER PROMISE AS CD 25
RECEPTORS PRESENT ONLY IN ACTIVATEDRECEPTORS PRESENT ONLY IN ACTIVATED
CELLS.CELLS.
• MURINE HUMAN CHIMERIC PREPARATIONMURINE HUMAN CHIMERIC PREPARATION
BASILIXIMABBASILIXIMAB
• HUMANIZED MONOCLONAL ANTIBODYHUMANIZED MONOCLONAL ANTIBODY
DACLIZUMABDACLIZUMAB
BOTH ARE CD 25 RECEPTOR BLOCKINGBOTH ARE CD 25 RECEPTOR BLOCKING
ANTIBODIES – UNDERGOING CLINICALANTIBODIES – UNDERGOING CLINICAL
EVALUATION.EVALUATION.

67. MANAGEMENT OFMANAGEMENT OF
COMPLICATIONSCOMPLICATIONS
PRIMARY NON FUNCTIONPRIMARY NON FUNCTION
PR. DYSFUNCTION :NON UNCOMMONPR. DYSFUNCTION :NON UNCOMMON
PR. NON FUNCTION :RARE 2-3%PR. NON FUNCTION :RARE 2-3%
MAY BE DUE TOMAY BE DUE TO
• UNIDENTIFIED PREEXISTING DISEASEUNIDENTIFIED PREEXISTING DISEASE
IN DONOR LIVERIN DONOR LIVER
• LIVER INJURY DURING RETRIEVAL &LIVER INJURY DURING RETRIEVAL &
PRESERVATIONPRESERVATION
• SECONDARY TO REPERFUSION INJURYSECONDARY TO REPERFUSION INJURY

68. • EARLY Tx : ONLY SOLUTIONEARLY Tx : ONLY SOLUTION
• EARLY GRAFT FUNCTION :EARLY GRAFT FUNCTION :
LONG TERM GRAFTLONG TERM GRAFT
SURVIVALSURVIVAL

69. POST OPERATIVE HEMORRHAGEPOST OPERATIVE HEMORRHAGE
• LESS OF A PROBLEMLESS OF A PROBLEM
• SIGNIFICANT REDUCTION IN TRANSFUSIONSIGNIFICANT REDUCTION IN TRANSFUSION
REQUIREMENTREQUIREMENT
DUE TO :DUE TO :
– METICULOUS SURGICAL TECHNIQUE.METICULOUS SURGICAL TECHNIQUE.
– CONTINUOUS MONITORING OF COAGULATIONCONTINUOUS MONITORING OF COAGULATION
PARAMETERS DURING SURGERY.PARAMETERS DURING SURGERY.
– USE OF ANTIFIBRINOLYTIC AGENTSUSE OF ANTIFIBRINOLYTIC AGENTS
– DECOMPRESSION OF SPENCHNIC CIRCULATIONDECOMPRESSION OF SPENCHNIC CIRCULATION
BY VENO-VENOUS BYPASS OR TEMPORARYBY VENO-VENOUS BYPASS OR TEMPORARY
PORTO-CAVAL SHUNT.PORTO-CAVAL SHUNT.
– MAINTENANCE OF RECIPIENT'S COREMAINTENANCE OF RECIPIENT'S CORE
TEMPERATURETEMPERATURE

70. ACUTE RENAL FAILURE :ACUTE RENAL FAILURE :
COMMON PROBLEMCOMMON PROBLEM
DUE TODUE TO
• PREEXISTING RENAL IMPAIRMENTPREEXISTING RENAL IMPAIRMENT
• ISCHEMIA – REPERFUSION INJURYISCHEMIA – REPERFUSION INJURY
• EFFECTS OF POST OPERATIVE SEPSISEFFECTS OF POST OPERATIVE SEPSIS
• SIDE EFFECTS OF IMMUNOSUPPRESSIVESIDE EFFECTS OF IMMUNOSUPPRESSIVE
THERAPYTHERAPY
RENAL SUPPORT DURING 2 – 3 WEEKSRENAL SUPPORT DURING 2 – 3 WEEKS
BEFORE RENAL FUNCTION RECOVERS.BEFORE RENAL FUNCTION RECOVERS.
1.1. VENO-VENOUS HAEMOFILTERATIONVENO-VENOUS HAEMOFILTERATION
2.2. HAEMODIALYSISHAEMODIALYSIS

71. REJECTIONREJECTION
ACUTE CELLULAR :ACUTE CELLULAR :
– WITHIN FIRST TWO WEEKSWITHIN FIRST TWO WEEKS
– 75-80% H.P. EVIDENCE75-80% H.P. EVIDENCE
– 30-40% BIOCHEMICAL EVIDENCE30-40% BIOCHEMICAL EVIDENCE
– DIAGNOSED BY P.C. LIVER BIOPSYDIAGNOSED BY P.C. LIVER BIOPSY
• PORTAL VENOUS ENDOPHLEBITISPORTAL VENOUS ENDOPHLEBITIS
• PORTAL INFILTRATIONPORTAL INFILTRATION
• BILE DUCT INFLAMMATION &BILE DUCT INFLAMMATION &
INJURYINJURY

72. • SHORT COURSE OF HIGHSHORT COURSE OF HIGH
DOSE STEROIDDOSE STEROID
• OPTIMIZING LEVELS OFOPTIMIZING LEVELS OF
CALINEUIRIN INHIBITORSCALINEUIRIN INHIBITORS
• SINGLE EPISODE :SINGLE EPISODE :
• HAS NO IMPACT ONHAS NO IMPACT ON
INCIDENCE OF CHRONICINCIDENCE OF CHRONIC
REJECTIONREJECTION
• MAY HAVE FAVORABLEMAY HAVE FAVORABLE
LONG TERM OUTLOOKLONG TERM OUTLOOK

73. • RESPONSE TO THERAPY :RESPONSE TO THERAPY :
PROMPT IN MOSTPROMPT IN MOST
PATIENTSPATIENTS
• ONGOING ACUTEONGOING ACUTE
REJECTION :REJECTION :
–REPEATED TREATMENTREPEATED TREATMENT
–INCREASE IN BASELINEINCREASE IN BASELINE
IMMUNO SUPPRESSION.IMMUNO SUPPRESSION.

74. CHRONIC REJECTIONCHRONIC REJECTION
• DUCTOPENIC REJECTIONDUCTOPENIC REJECTION
• FEW WEEKS OR MONTHS/YEARS LATERFEW WEEKS OR MONTHS/YEARS LATER
• DUE TO IMMUNOLOGICAL INJURY TODUE TO IMMUNOLOGICAL INJURY TO
BILE DUCTBILE DUCT
• VARIABLE RESPONSE TO TREATMENTVARIABLE RESPONSE TO TREATMENT
• SEVERE :SEVERE :
– 10%10%
– RETRANSPLANTATIONRETRANSPLANTATION

75. SEPSIS : MAJOR PROBLEMSEPSIS : MAJOR PROBLEM
• NOSOCOMIALNOSOCOMIAL
• CYTO MEGALOVIRUSCYTO MEGALOVIRUS
1.1. 4-8 WEEKS AFTER Tx4-8 WEEKS AFTER Tx
2.2. FEVER & LEUCOPENIAFEVER & LEUCOPENIA
3.3. RAPID DIAGNOSIS WITH PCRRAPID DIAGNOSIS WITH PCR
4.4. PROPHYLACTIC GANCICLOVIR UNDER STUDYPROPHYLACTIC GANCICLOVIR UNDER STUDY
• FUNGALFUNGAL
GIVING PROPHYLAXIS TO THOSE ATGIVING PROPHYLAXIS TO THOSE AT
RISK CAN REDUCE INVASIVE FUNGALRISK CAN REDUCE INVASIVE FUNGAL
INFECTIONSINFECTIONS

76. BILIARY COMPLICATIONSBILIARY COMPLICATIONS
• STRICTURESSTRICTURES
– ANASTOMOTICANASTOMOTIC
– NON ANASTOMOTICNON ANASTOMOTIC
• BILE LEAKSBILE LEAKS
• USGUSG
– BILIARY DILATIONBILIARY DILATION
– HEPATIC ARTERIAL PATENCYHEPATIC ARTERIAL PATENCY
• MANAGEMENTMANAGEMENT
– ERCP & STENTINGERCP & STENTING
– PERCUTANEOUS DRAINAGEPERCUTANEOUS DRAINAGE
LATE BILIARY STRICTURES MORE LIKELY TO RECURLATE BILIARY STRICTURES MORE LIKELY TO RECUR
AFTER RADIO LOGICAL OR ENDOSCOPICAFTER RADIO LOGICAL OR ENDOSCOPIC
TREATMENT & USUALLY REQUIRES SURGICALTREATMENT & USUALLY REQUIRES SURGICAL
CORRECTION.CORRECTION.

77. HEPATIC ARTERYHEPATIC ARTERY
THROMBOSISTHROMBOSIS
• DEVASTATING COMPLICATIONDEVASTATING COMPLICATION
• PREDOMINANTLY IN FIRST MONTHPREDOMINANTLY IN FIRST MONTH
• 2-3% IN ADULTS2-3% IN ADULTS
• MASSIVE RISE IN SERUMMASSIVE RISE IN SERUM
AMINOTRANSFERASESAMINOTRANSFERASES
• CAN PRESENT AS ACUTE FULMINANTCAN PRESENT AS ACUTE FULMINANT
HEPATIC OR BILIARY SEPSIS &HEPATIC OR BILIARY SEPSIS &
STRICTURESTRICTURE

78. TREATMENTTREATMENT
• THROMBECTOMY – FEWTHROMBECTOMY – FEW
• URGENT RETRANPLANTATION –URGENT RETRANPLANTATION –
MOSTMOST
DELAYED :DELAYED :
– UNCOMMONUNCOMMON
– PRESENT WITH BILIARY SEPSIS ORPRESENT WITH BILIARY SEPSIS OR
– ASYMPTOMATICASYMPTOMATIC
1.1. REMAINS WELL 1/3REMAINS WELL 1/3rdrd
2.2. PROGRESSIVE GRAFT FAILURE 20%PROGRESSIVE GRAFT FAILURE 20%

79. HYBRIDHYBRID
BIOARTIFICIALBIOARTIFICIAL
DEVISESDEVISES
EX VIVOEX VIVO
PERFUSIONPERFUSION
TECHNIQUETECHNIQUE
SELECTIVESELECTIVE
IMMUNOSUPPRESSIONIMMUNOSUPPRESSION
DRUGSDRUGS
REFINEMENTREFINEMENT
OF PRE EMPTIVEOF PRE EMPTIVE
ANTIMICROBIALANTIMICROBIAL
THERAPYTHERAPY
NEW IMMUNONEW IMMUNO
SUPPRESSANTSSUPPRESSANTS
MONOCLONALMONOCLONAL
ANTIBODIESANTIBODIES
GENETICGENETIC
ENGINEERINGENGINEERING