post liver tx complication surgeon role
TRANSCRIPT
SURGICAL COMPLCATIONS IN LIVER TRANSPLANTATON
S.VIVEKANANDANHEAD, LIVER TRANSPLANT SURGERY
KMCH, COIMBATORE
POST OP COMPLICATIONS
IMMEDIATE vs LATE
PEDIATRIC vs ADULT
LDLT vs CADAVERIC
Immediate post op
Bleeding
Arterial complications
Portal Venous Complications
Hepatic Venous Complications
Biliary Complications
Bleeding
Arterial Complications
Hepatic artery thrombosis 4-11%
Hepatic artery stenosis 5-13%
HA Aneuryms 0.3-1.2%
Hepatic artery rupture
Median arcuate ligament syndrome 1.5-10%
Early Vs Late HAT
EARLY <2%< 30 days
LATE 2-20%>30 days
Transminitis Fever
Bile Leaks Transminitis
Liver Abscess Cholangitis
PNF Liver Abscess
Hepatic Necrosis Biliary Stricture
Factors affecting HAT
Arterial complications
Resuscitation
Antibiotics, antifungals
Early HAT – exploration , thrombectomy, revision
IR-Catheter related thrombolysis – bleeding
Re Transplantation
Late HAT – IR – Plasty / Stenting
Retransplantation
Portal venous complications
Risk factors
Preexisting PVT
Small portal vein
Steal phenomenon
Prior shunt surgery
PVT – Presentation
Portal hypertension Variceal bleeding Ascitis Thrombocytopenia
Acute graft failure
PVT - Treatment
Surgical revision
Pharmacological – Portal Flow
Anticoagulation
Shunt surgery
Regular endoscopic surveillance
Outflow obstruction
Rare but serious problem
1% - 6%
Acute – technique / graft torsion
Chronic – peri anastamotic fibrosis
Outflow obstruction
Ascitis , congested Liver
Lower limb edema
Hepatic & Renal dysfunction
Investigations – CT, Cavogram- Pressure Studies
Trt – Stenting / plasty
5-7%
1%-17%
5%-10%
Treatment
Investigations – CT, MRCP, ERCP
Antibiotics
Antifungals
Controlled Fistula
Bile Recirculation
Bile Leaks
Bile leaks Depends on volume ERCP- sphincterotomy, stenting Controlled fistula Consequences – infection, HAT/PA, late
strictures
Anastamotic strictures
Within the first year
Technical issues , mismatch, fibrosis, HAT
Consequences – cholangitis, sepsis
ERCP / Surgery
Non anastamotic stictures
+ / - HAT
Ischemic and necrotic biliary tree
NHBD/> CIT
High mortality
Needs a Re transplant
Summary
A high degree of suspicion is required
Prevention is better – avoid technical errors
Interventional Radiology plays a major role these days
Multi Disciplinary team approach is required
Bile Duct Reconstruction
Duct to duct – preferred , no reflux, anatomical,
Roux – en-Y Hep J Insufficient length Ischemic duct PSC Pediatric Multiple ducts ( LDLT)