- End-stage liver disease in patients who meet the minimal criteria for placement on the liver transplantation list as defined by the American Association for the Study of Liver Diseases.
- Fulminant acute liver failure.
- Hepatocellular carcinoma fulfilling Milan criteria (tumor > 2 cm but < 5 cm or up to three tumors each < 3 cm).
- Some pediatric metabolic liver diseases as defined by the United Network for Organ Sharing (UNOS).
- Recidivism to alcohol and drug abuse (6-month abstinence- free period essential).
- Significant portal venous thrombosis that precludes venous reconstruction.
- Extrahepatic malignancies.
- Systemic sepsis and certain untreated chronic infections (eg, tuberculosis, Mycobacterium avium-intracellulare).
- In the case of hepatocellular carcinoma:
- Vascular or biliary tree invasion.
- Tumors outside Milan criteria.
- Significant cardiopulmonary disease or other medical illnesses, with the exception of liver or biliary tree specific disease and renal disease.
- Certain chronic infections (eg, HIV infection).
- Profound physical deconditioning.
- Advanced age (older than 70 years).
- Poor psychosocial support (eg, homeless).
- Inability to obtain immunosuppressive medications.
- The 1-year survival following liver transplantation is 86–90% in the United States, with a death rate of approximately 5% per year death thereafter.
- Approximately 20% of patients will require retransplantation.
- Restoration of hepatic function.
- Potential complications in the perioperative period are numerous given the magnitude of the procedure.
- Specific complications include:
- Infection: 66% total (bacterial, 35–70%; fungal, 20–42%; viral, 5–26%).
- Rejection (40–70%).
- Biliary complications (7–29%).
- Bleeding (10–25%).
- Primary nonfunction (7%).
- Hepatic artery thrombosis (2–10%).
- Portal vein thrombosis (1–2%).
- Rigorous fixed retractor (mandatory to facilitate exposure of the operative field).
- Argon beam coagulator (useful in patients with severe coagulopathy or in retransplantation).
- Cell saver (reduces allogenic packed red blood cell transfusion but should not be used in patients with hepatic malignancy).
- Patients are typically evaluated and deemed appropriate candidates for transplantation based on their preoperative transplant clinic evaluation.
- On the day of transplantation, laboratory values, ECG, and chest radiograph should be obtained and reviewed for potential contraindications soon after the patient is called to the hospital.
- Radiographic verification of portal vein patency should be up to date (within 6 months).
- Patients with known hepatoma should have up-to-date imaging of the chest, abdomen, and pelvis. The admission chest radiograph should be closely examined for evidence of metastatic disease.
- History and physical examination should specifically assess for potential contraindications to liver transplantation (eg, active infections, evidence of active alcohol or drug use).
- The patient should be supine.
- The left arm is extended and the axilla prepped in the sterile field (to provide access to the left axillary vein should venovenous bypass be required).
- The right arm can be tucked or extended.
- Figure 32–1: Incision and retractor placement.
- The chest and abdomen are prepped from the nipples to the pubis.
- A bilateral subcostal incision is made 2 fingerbreadths below the costal margin, ...
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