Chapter 32. Liver Transplantation

• 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).

Absolute

• 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.

Relative

• 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.

Expected Benefits

• Restoration of hepatic function.

Potential Risks

• 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 ...