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  • 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).

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Absolute

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  • 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.

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Relative

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  • 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.

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  • 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.

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Expected Benefits

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  • Restoration of hepatic function.

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Potential Risks

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  • 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%).

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  • 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).

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  • 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).

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  • 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.

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  • 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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