thesis
Optimisation of graft function in liver transplantation: functional and metabolic aspects
- Publication date
- 3 April 2002
- Publisher
- Part one of this thesis contains the general introduction to partial and whole liver
transplantation. Chapter 2 addresses the concept of auxiliary partial liver transplantation.
Auxiliary partial heterotopic liver transplantation was first introduced as a less invasive
procedure for patients who could not tolerate a standard orthotopic liver transplantation.
Later on the technique was proposed for patients with acute liver failure in whom
regeneration of the native liver was expected, but due to its complications it never gained
wide acceptance. Since 1990 a new concept of auxiliary partial liver transplantation was
introduced where the graft is placed in the orthotopic position.
In chapter 3 the development and current surgical technique of orthotopic liver
transplantation are discussed. Initially the diseased liver was removed with the vena cava
and replaced by a whole liver graft. With increasing waiting lists for donor organs, surgical
techniques were developed to split the donor liver and transplant both partial liver grafts in
the orthotopic position.
In part two three studies regarding experimental auxiliary partial liver transplantation are
presented. In chapter 4 we report the long-term correction of an inborn error of metabolism
with an auxiliary partial liver graft placed in a heterotopic position. Since the distribution of
portal blood flow between liver graft and native liver remains controversial in auxiliary liver
transplantation, the success of metabolic correction was related to four different forms of
portal inflow. With the introduction of auxiliary partial orthotopic liver transplantation several
disadvantages of the placement of the graft in heterotopic liver transplantation were
overcome.
In chapter 5 we therefore assess the importance of portal flow diversion in an
experimental model of auxiliary partial liver transplantation in the orthotopic position. The
portal blood flow was measured with Doppler ultrasonography and changes in portal flow
distribution were recorded after surgical intervention in the portal blood flow.
In chapter 6 the metabolic correction following these interventions in portal flow were
reported.
Part three contains three studies performed in patients receiving an orthotopic whole liver
transplantation. In chapter 7 we present the problem of graft dysfunction in the first 7 days
after liver transplantation. We report our data on mitochondrial dysfunction in patients with primary graft dysfunction and the relation with toxic reaction products of the nitric oxide
radical.
In chapter 8 we report an increased incidence of fibrinolysis, the most prominent
coagulation disorder during orthotopic liver transplantation, after introduction of virus
inactivated plasma. Consequences of fibrinolysis and treatment options are discussed.
In chapter 9 we evaluate patient and graft survival between patients transplanted with
standard liver replacement or a vena cava preserving technique.
Chapter 10 provides an overview of the development of different techniques for
splitting of the donor liver in an attempt to alleviate the shortage of donor organs in
paediatric and adult liver transplantation.
Chapter 11 summarises the previous studies, bringing the data in perspective and
provides future perspectives.