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INTRODUCTION

  • Intraabdominal fluid collections occur commonly after liver transplantation.1 Most of them are asymptomatic, sterile, and resolve spontaneously. However, up to 10% are infected and can affect graft and patient survival. Liver abscesses, if untreated, can be fatal.2

  • A thorough knowledge of the most common localizations and characteristics of fluid collections leads to early diagnosis and treatment.

  • Large collections can compress vascular or biliary structures.

  • Bilomas may alert of bile leak or arterial insufficiency.

  • Hematomas should warn about bleeding, and they can also become infected.

ETIOLOGY AND MOST COMMON LOCALIZATIONS

  • Hematomas, seromas, bilomas, localized ascites, and abscesses are most commonly found. Imaging surveillance is crucial for early detection of postoperative complications3,4 (Table 89-1) (Fig. 89-1).

  • Peritoneal reflections around the liver are divided during transplantation, which changes the distribution pattern of fluid in liver transplant recipients.

  • In the transplanted patient, fluid appears to accumulate more frequently in the teres ligamentum. Visualization of this ligament may help localize the collection more accurately (Fig. 89-2).

  • During liver transplant surgery, the right superior and right inferior coronary ligament is divided, communicating the right posterior subphrenic and subhepatic spaces (Morrison pouch). This allows for fluid collections to cover the whole posterior surface of the liver, including the bare area (which is normally retroperitoneal) (Figs. 89-3 to 89-8).

  • Collections occur most frequently in the right upper quadrant or subhepatic space, although they may be found anywhere within the abdomen.

  • Fluid collections and hematomas are often adjacent to vascular and biliary anastomoses.

  • It is important to distinguish between intrahepatic and extrahepatic collections. Intrahepatic collections are usually bilomas and, in rare cases, hematomas.

  • Small extrahepatic collections are more likely to resolve spontaneously.

FIGURE 89-1

Imaging surveillance for liver transplant recipients. CT, computed tomography; CTA, computed tomography angiography; MRA, magnetic resonance angiography; MRCP, magnetic resonance cholangiography; MRI, magnetic resonance imaging; US, ultrasonography.

FIGURE 89-2

A 66-year-old male 2 months after orthotopic liver transplant due to alcoholic cirrhosis who developed biliary fistula. CT scan shows fluid collection at the site of the teres ligament (arrows).

FIGURE 89-3

(A) Inferior aspect of the liver, showing the fissure for the teres ligamentum (TL), the fissure for the ligamentum venosum (LV), and the transverse fissure connecting both; GB, gallbladder; IVC, inferior vena cava. (B) Transverse section of the liver showing the teres ligamentum, the fissure for the gallbladder, the LV, and transverse fissure. (C) Anterior aspect of upper abdomen after liver removal. FL, falciform ligament; GHL, gastrohepatic ligament; HDL, hepatoduodenal ligament; LCL, left coronary ligament; RCL, right coronary ligament. (D) Posterior surface of liver after removal; the bare area is seen between the peritoneal reflections of the ...

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