Gordon, RD

Iwatsuki, S

Lerut, JP

Starzl, TE

English

PubMed

D-Scholarship@Pitt

Human Orthotopic Liver Transplantation: Surgical Aspects in 393 Consecutive Grafts J.P. Lerut, R.D. Gordon, S. Iwatsuki, and T.E. Starzl RESUL TS of orthotopic liver transplanta-tion (OL T) have dramatically improved due to better immunosuppression and to stan-dardization of surgical techniq ues.l.l Techni-cal problems are, however, still responsible for significant postoperative morbidity and mor-tality.] MATERIALS AND METHODS Between March I. 1980, and December 3 J, 1984,313 patients including 177 adults and 136 children received a primary Ol T under the cyclosporine-steroid regimen. Sixty-eight patients underwent a second transplant dur-ing the same time period; 12 required a third tranplant. All patients were followed for at least 1 year ::Ifter OL T or until death. The intraoperative and perioperative mor-tality rate is 3.8% (12 of 313 patients). Two hundred eighty patients (89.4%) lived for more than 3 months postoperatively. The techniques of donor and recipient operations have been thoroughly described.'·l Technical adjustments were necessary in nine (2.9%) and 51 (16.3%) recipients presenting with preexisting inferior caval and portal vein (PV) abnormalities, respectively.' In case of caval vein abnormalities the recipient operation is actually simpler than usual. In case of PV thrombosis (PVT) or hypoplasia. OL T is made possible by thrombec-tomy or by retrograde dissection of the abnormal vessel to the splenomesenteric confluence. In five patients portal inflow was restored after interpo-sition of a free vein graft. Fourteen (66.6%) of 21 patients who underwent previous operations on the PY and the splanchnic circulation had a major abnormality of the PV. Four patients died. and three developed PVT after OL T as a direct consequence of these abnormalities. Ninety of the 393 (22.9%) allografts had a complex arterial reconstruction consisting of the use of an iliac graft (39 times). a fold-over technique' (26 times). and abdominal (14 times) and thoracic (eight times) aortic ~onduitsK· In three patients the use of an iliac graft was combined with the fold-over technique.' Biliary reconstruction consisted of primary choledo-chocholedochostomy over a T tube (CC-T) if both donor and recipient ducts were suitable. If preexisting biliary tract disease, or inadequate or mismatched size of the bile ducts does not permit a direct duct-to-duct anastomosis or the introduction of T tube. a chokdochoJeJunostomy over an internal stent (R YCJ-S) is performed: Other methods of biliary tract reconstruction are rarely used anymore because of high complication rates. RESULTS Technical complications occurred in 92 of the 393 (24A%) grafts and were responsible for the loss of 41 grafts (10,4%) and 26 patients (8.3%). Twenty-six retransplanta-tions (re-OL T) were performed for technical fail u res of a previous graft, 15 of which were successful (Table I). Biliary tract complications (aTC) occurred in 52 of 393 grafts (13.3%) and thus accounted for 56.5% of the 92 technical fail-ures. There were 17 failures in pediatric grafts (10.0%) and 35 failures in adult grafts (16.2%). The incidence of BTC has declined significantly from 24.4% during 1980 to 1982 to 8% in 1984.9 BTC are described in Table 2 according to the technique of reconstruction. Biliary leakage occurs most frequently and is mainly revealed by septicemia. Eleven leaks at the T tube exit site of CC-T were simply closed or drained. Anastomotic leakage resulted in four deaths and one regrafting_ Conversion of a leaking CC to an R YCJ-S was successful in five of seven patients. Seven obstructions of CC resolved after transcutaneous or surgical removal of the T tube or internal stent. Percutaneous balloon dilation (PBD) of an obstructed CC resulted twice in delayed stone formation of the bile duct; in a third patient conversion to R YCJ-S was necessary because of a recurrent stricture. The smallest and youngest children had the lowest complication rate. They nearly all had From the Department of Surgery. ()niversity Health Center of Pitlsburgh, and the Veterans Adminislration ,Hedical Center. Pillsburgh. K~ddreRs reprinl requests to Professor T.E. Star:l, MD, Fr11k Clinic, Room ~D1UK Depurlment vf Surgery. 3601 Ftjih Ave. Pillsburgh, PA 152/J. " 1988 by Grune & Stratton, Inc. 004 I -1345/88/ 200/-J .'! J5503.00/0 TransplBntatlOn Proceedings, Vol XX. No 1. Suppl 1 (February), 1988: pp 603-606 603 604 LEAUT ET AL Table 1. Technical Complications in 393 Ol Ts Re-Ol Ts Deaths Compl;cation Grafts (393) Patients (313) Successful Failed Unrelated Related Biliary tract 52" (13.2%) 52" (16.6%) 3 1 2 5 (9.6%) HAT 27t (6.8%) 25tt (7.9%) 11 B 16t (64.0%) Hepatic artery aneurysm 4(1.9%) 4t (1.2%) 3+ (75.0%) PVT 6 (1.5%) 6 (1.9%) 2 (40.0%) PV stenosis 2°t (0.5%) 2·t (0.6%) PV and inferior vena cava thrombosis 1 (0.3%) 1 (0.3%) Inferior vena thrombosis 2 (0.5%) 2 (0.6%) 1 1 1 (50.0%) Total 92 (24.4%) 89 (28.4%) 15 11§ 4§ 26§ (8.3%) Abbreviation: HAT. hepatic artery thrombosIs. o • t. tSame patients. §Graft loss. 41 of 393 (10.4%). an RYCJ-S, the method yielding the lowest morbidity (5.2%) and 0% mortality rates. BTC were directly responsible for five deaths (9.6%, 5/52 patients); four patients required re-OLT (4/52 patients, 7.7%). Hepatic artery thrombosis (HAT) after OLT occurred in 25 patients and 27 grafts (6.8%) (Table 3). Three adults and three children had a massive hepatic necrosis. They all died despite re-O L T in three (l00% mor-tality). Eight patients with nine grafts developed a delayed bile leak. Three of six had a successful regraft and both unsuccessful regraft patients died of septicemia (mortality, 62.5%. five of eight patients). Relapsing bacteremia after HAT occurred in nine children and three adults. Four of nine re-OL T and one of the three conservatively managed recipients died (mortality, 45%, 5/ 12 patients). A child presenting with a late stricture of R YCJ-S was successfully treated by PBD. HA T is much more frequent in the pediat-ric age group (19/177 grafts [J 0.7%] v 8/216 [3.7%] in adults) and in the group of patients having a complex vascular reconstruction (15/90 grafts [16.6%] v 12/295 grafts [4%) with simple arterialization). Nineteen (23.2%) of the 82 re-OL T were done in 18 patients because of HAT. Eight (44.4%) sur-vived, one died of a mycotic aneurysm, and Table 2. Primary STC According to Technique of Reconstruction Reconstruction External Parameter RYCJ-S CC-T CC-S' Waddell-Calne Cholecystoanterostomy Drainage n 175 159 32 6 7 5 Successes 166 (94.8%) 139 (87.4%) 18 (56.2%) 5 (83.4%) 1 (14.3%) Failures 9 (5.1%) 20 (12.6%) 14 (43.8%) 1 (16.6%) 6 (85.7%) 2 (40%) Obstruction 4 (2.2%1 5 (3.1%) 5 5 Leakage 15 (9.4%1 Anastomotic 3 (1.7%) 4 (2.5%) 7 EXIt Site T tube 1116.9%) Hemobilia 2 Bile Casting 1 (0.6%) T orSIOf) Roux limb 1 (0.6%) Intrahepatic Str,cture 1 (06%) Mortality 0% 2 (12%) 2 (1.2%i 1 (0.6%) .... NOTE: AYCJ-S and CC-T reconstructIon has a success rate of 92% The other four reconstruction technIques are rarely used. 'CC with Internal stent was only used In adolescents. COMPLICATIONS IN LIVER TRANSPLANTATIONS 605 Table 3. Hepatic Artery Thrombosis and OL T G<afts Fulminant hepatic failure 5 Biliary leak 9·' Relapsing bacteremia 12't Total 27 16.8%) • tSame patients. tDeath due to primary nonfunctlon of the second graft. §Death due to late rupture of mycotic aneurysm. two died because of a primary nonfunctioning of the second graft. Two (28%) of the seven non-re-OL T patients survived their complica-tion. Despite the high re-OLT rate (19/27 grafts, 70%) the mortality of HAT was con-siderable (64%,16/25 patients). Three (I %) of four patients with an aneu-rysm of the allograft arterial supply died of delayed rupture (75%); the fourth had a suc-cessful vascular repair. Seven (2.2%) patients developed a PVT after OL T (Table 4). Four patients had satisfactory early convalescence. The diagnosis was made when evidence of portal hypertension including variceal hemor-rhage, persistance of esophageal varices, splenomegaly, and hypersplenism developed. Revision of the portal anastomosis, sclerother-apy, and a splenorenal shunt were necessary to control esophageal varices. One patient had a preexisting thrombosis of portal, splenic, and mesenteric veins. At the Outcome Re-0..T Jeat!1 3 6 7 5t§ 9 5§ 19/27 grafts 16; 25 recipients (7)%) 154%) time of OL T thrombectomy was possible. Bleeding esophageal varices were initially controlled with sclerotherapy. He died 14 months later of acute liver failure; at necropsy the portal and superior mesenteric veins had clotted. The other three patients developed acute liver failure; two received re-OL T early. One child, presenting both PVT and caval vein thrombosis (CVT), survived. Four of the seven patients whose portal vein clotted are still alive 3 to 5 years later (mortality, 42.8% [three of seven recipients]). Three have their original grafts, and one was rescued with re-OL T (graft loss, 57% [four of seven grafts]). Three inferior CVT after OLT origi-nated at lower vena cava anastomoses that were performed under poor technical condi-tions. All three patients presented with a liver failure associated once to a renal failure and a lower caval vein syndrome. Two patients Table 4. Venous Thrombosis and Ol T PV Persistent Recurrent Portal hypertension Liver failure Inferior Caval Vein Liver failure Hepatorenal failure. lower caval syndrome Grahs Therapy 4 Sclerotherapy, 2 Splenorenal shunt, 1 Phlebothrombectomy, 1 3 7 (18%) 2 1 3 (09%) 'Same child successfully received r....at.. T retransplanted for both CVT and PVT; Outcome r&-DI..r Death ., 2' 2 2/7 3/7 recipients (28.5%1 (42.8%) l' 1 2/3 2/3 recipients (666%) 606 received re-Ol T: only the one child present-ing both PYT and CYT survived (mortality, 66% [two of three recipients]: graft loss, 100%) (Table 4). DISCUSSION Surgical technical complications remain in important cause of morbidity and mortality after OL T J Restriction of the biliary tract reconstruction to CC-T and RYCJ-S reduced the incidence of BTCY CC-T is the ideal method of reconstruction in the recipient with a normal native bile duct. The exit site of the T tube must be secured to avoid later leakage 9 In case of bile leakage simple drainage or suture of the exit site will suffice. Anastomotic leakage after CC is uncommon and must be treated by conversion to R YCJ-S. Obstruc-tion of CC must be treated by conversion to RYCJ-S. PBD indeed only has a temporary benefit. If the recipient duct is diseased or inadequate, RYCJ-S is the best alternative. This method is the most reliable method of biliary tract reconstruction in Ol T (success rate, 95%). Anastomotic leakage is very rare; functional obstruction by a retained internal stent may necessitate surgical removal. Primary BTC must be differentiated from secondary (to HA T) complications because of their completely different management and outcome. Primary BTC can usually be man-aged by primary repair or conversion of the anastomosis; treatment of secondary BTC, however, nearly always consists of re-Ol T. 3.9 HA T of the allograft is one of the most devastating complications of Ol T. 3.10 The considerable mortality of HAT. despite the high re-Ol T rate. is due to a major delay in diagnosis and regrafting. Awareness of the three different types of clinical presentation of liver graft dearterialization. ego fulminant liver necrosis. delayed bile leakage. and relapsing bacteremia. is of utmost impor-tance. If HAT is suspected. Doppler ultra-sound and/or angiography must be performed without hesitation. This is especial1y true in pediatric patients and patients having a com-i LERUT ET AL plex vascular reconstruction, because they have a higher risk of developing HA T.lO Treatment of HAT nearly invariably consists of an early re-OL T. A decision to delay re-Ol T may only be considered in patients hav-ing stabk liver function and well-controlled relapsing bacteremia. 10 Aneurysms of the hepatic arterial supply occur seldom; prompt vascular repair or regrafting is necessary to avoid late fatal rupture. 3 Postoperative inferior CYT and PYT are rare and occur nearly always in pediatric recipients. Patients su bmitted to previous Sur-gery of the PY or splanchnic circulation are at high risk. Allograft PYT is manifested by persistent or recurrent portal hypertension and/or liver failure. In case of liver failure urgent regrafting is mandatory; if liver func-tion remains normaL conventional treatment of portal hypertension can be sufficient. CYT is manifested by liver failure, which is eventu-ally associated with renal failure or lower caval vein syndrome. Prompt re-OL T repre-sents the only chance to rescue a patient presenting with this complication. REFERENCES 1. Starzl TE. ]watsuki S, Shaw B\V Jr. et al: Trans-plant Proc 17:107.1985 (suppI2) 2. Starz] TE. ]watsuki SI. Esquivel CO. et al: Semin Liver Dis] 985.5:349. 1985 3. Gordon RD. Makowka L. Bronsther MO. et aJ: In Toledo-Pereyra LH (ed): In Complications of Organ Transplantation. New York. Dekker. 1987. p 329 4. Starzl TE: In Starzl TE. Putnam CW (eds): Experi-ence in Hepatic Transplantation. Philadelphia_ Saunders. 1969. p 112 5. Starzl TE. Hakala TR. Sha .... B\V Jr. et al: Surg Gynecol Obstet 158:223. 1984 6. Lerut J. Tzakis A. Bren K. et al: Ann Surg 205:404. 1987 7. Sha .... BW Jr. Iwatsuki S. Starz] TE: Surg Gynecoi Obstet 159:490. i 984 8. Gordon RD. Shaw BW Jr. ]watsuki S. et al: Surg Gynecol Obslet 160:474. 198.' 9. Lerut J. Gordon RD. Iwatsuki S. el al: Transplanta-tion 43:47. 1987 10. Tzakis AG. Gordon RD. Sha .... BW Jr. et al Transplan,ation 40:667. 1985 

Human orthotopic liver transplantation: surgical aspects in 393 consecutive grafts.

Name not available

Human orthotopic liver transplantation: Surgical aspects in 393 consecutive grafts

http://d-scholarship.pitt.edu/4236/1/31735062130012.pdf

Human orthotopic liver transplantation: surgical aspects in 393 consecutive grafts.

Abstract

Similar works

Full text

Available Versions

D-Scholarship@Pitt

Name not available

Name not available