LIVER TRANSPLANTATION

1. LIVER TRANSPLANTATION Presented by SC 胡婉妍 SC 陳建嘉 Directed by VS 詹光政 R3 陳建宇

2. CONTENTS • Case presentation • Indications of liver transplantation • Contraindications • Pathophysiology of end-stage liver diseases • Pre-op evaluations • Intra-op considerations and management

3. CASE PRESENTATION

4. Brief History of Recipient • Name: 林XX • Chart no: 3280455 • Age: 34y/o • Sex: Female • Indication of liver transplantation  Hepatocellular carcinoma • Living donar: Her husband

5. Present illness • HBV carrier for 10+yrs • 1995/12 AFP ↑ (4460) abd. ultrasound: tumor of left lobe 1996/01/22 lateral segmentectomy • Tumor recurrence  TAE were performed at 2002/03/02 2002/05/31 2002/07/25

6. Past History • DM (-) ; HTN(-) • HBV infection with cirrhosis for 10+yrs • History of allergy: nil • Drinking or smoking: nil • Family history: non-contributory

7. Lab Data • CBC; electrolytes: normal • Plt count: 209K • Albumin: 4.3 • Total bilirubin: 0.5 • GOT/GPT: 20/17 • PT: 12.5/10.4 • pTT: 35.7/36.4

8. Course of Operation • OP procedures: Under ETGA ↓ Bilateral subcostal incision with extension to xyphysis ↓ Identify the liver hilum, portal v., hepatic a. and v. ↓ Cholecystectomy & CBD ligation ↓ Hepatic a. ligation ↓ Clamp portal v. & hepatic v. when donar liver was well prepared ↓

9. Remove liver ↓ Connect portal v.  hepatic v.  hepatic a. by plastic surgeon ↓ Connect CBD to hepatic duct ↓ Irrigation with warm N/S and wound closure

12. DISCUSSION

13. Fulminant hepatic failure Viral hepatitis Drug-induced Metabolic (eg. Reye’s syndrome) End-stage chronic liver disease Chronic viral Primary biliary cirrhosis Primary sclerosing cholangitis Biliary atresia Vascular disease ( Budd-Chiari syndrome) Veno-occlusive disease Idiopathic autoimmune Alcoholic Metabolic liver diseases Wilson’s disease Hematochromatosis Glycogen storage disease Α1-antitrypsin deficiency Nonresectable hepatic malignancies Cholangiocarcinoma HCC Indications of Liver Transplantation • 1. Solitary tumor< 5cm • ≤ 3 lesions with the • diameter of the largest • tumor ≤ 3cm

14. Contraindications • AIDS • Extrahepatic malignancy • Uncontrolled sepsis • Active alcoholism or substance abuse • Fulminant hepatic failure with sustained ICP > 50 mm Hg or CPP < 40 mm Hg • Advanced cardiac or pulmonary disease • Child-Turcotte-Pugh score < 7 • HLA incompatibility?

15. Preanesthetic Considerations for End-Stage Liver Diseases • Encephalopathy • ICP monitor; TCD • hyperventilation

16. Circulation Intravascular volume depletion SVR↓; CO↑; normal~low BP Epinephrine & norepinephrine (starting dose 0.1μg/kg/min) Prostacyclin

17. Pulmonary functions Atelectasis from abdominal distention and ascites Pleural effusions hepatopulmonary syndrome clinical triad:1. advanced chronic liver disease; 2. severe arterial hypoxemia; 3. intrapulmonary vascular dilatations ~Rodriguez-Roisin R, Agusti AGN, Roca J; Thorax 47:897-902, 1992.

18. Renal dysfunction intravascular volume depletion hepatorenal syndrome Plasma volume expansion (colloid) Renal dose dopamine (3μg/kg/min) Lasix infusion at 10~50mg/h

19. Metabolic manifestations Diminished albumin synthesis narcotics & barbituates chronic hypoglycemia coagulopathy thrombocytopenia reduced hepatic clearance of fibrinolysins and tPA

20. Monitor & Induction • Invasive monitoring with systemic and PA catheters • Radial and femoral artery catheters • End-tidal CO2 • Urine output • Temperature • Aspiration precautions

21. IV anesthetics Thiopental, etomidate, propofol, ketamine, succinylcholine Plasma pseudocholinesterase levels Thiopental Inhalational anesthetics contraindicated in patients with IICP Nitrous oxide isoflurane Muscle relaxants Highly water soluble Atracurium; cisatracurium Ref: Mosby: Principle & Practice of Anesthesiology 2nd ed. Miller:Anesthesia; 5th ed.

22. Operation Preanhepatic phase Anhepatic phase Neohepatic phase

23. Preanhepatic Phase

24. Physiological alterations in preanhepatic phase • Hemorrhage • Acute decompression of ascites • Coagulation and metabolic derangements • Citrate-induced hypocalcemia • Oliguria

25. Management • Close monitoring • Fluid, blood and FFP transfusion • Calcium infusion • Correction of metabolic acidosis • Diuretics and renal-dose dopamine

26. In our patient… • Hemodynamic status • Metabolic change • Coagulation function • Electrolyte level • Urine output • Management

27. Anhepatic Phase

28. Physiological alterations in anhepatic phase • Obstruction of venous return (lower body, bowel and kidneys) • Increased metabolic alterations (absence of the liver’s metabolic functions) -> acidosis, hypocalcemia… • Atelectasis (retraction on diaphragm) • Decreased endogenous glucose production

29. Management • Fluid loading and small dose of vasoconstrictors • Correction of metabolic acidosis • Calcium infusion • PEEP and inspiratory pressure↑ • Glucose infusion

30. In our patient… • Hemodynamic status • Metabolic change • Coagulation function • Electrolyte and glucose level • Urine output • Management

31. Neohepatic Phase

32. Physiological alterations in neohepatic phase • Hypotension: cardiac output↑, systemic vascular resistance↓ • Large load of potassium, metabolic acid and endotoxin • Oxygen consumption and CO2 elimination↑ • Post-reperfusion foagulopathy

33. Management • Vasoconstrictors and inotropic support • Preflushing of the portal vein and liver • Correct metabolic acidosis and electrolyte imbalance • Potamine sulfate

34. In our patient… • Hemodynamic status • Metabolic change • Coagulation function • Electrolyte level • Urine output • Management

35. Conclusion Anhepatic phase Neohepatic phase Preanhepatic phase

36. Thanks for your attention!