IVC control- Pringle maneuver- Temporary portocaval shunt1/30/2023 Liver transplantation 34Liver transplantation: Approach• Graft implantation- Portal vein anastomosis- Hepatic artery anastomosis- Biliary reconstruction: duct to duct, Roux-en-Y- IVC anastomosis- Biliary stenting- Hemostasis- Abdominal closure1/30/2023 Liver transplantation 35Liver transplantation: Approach• Post-operative care- ICU care- Monitoring: LFT, clotting profile, Doppler USS- Immunosuppression:- Tacrolimus, My

LIVER
TRANSPLANTATION
Olayinka L. Adewunmi
Division of General Surgery
UMTH
30th January, 2023

Outline
• Introduction
Definition
Historical perspective
Epidemiology- Nigeria, Africa and Global
• Immunology of liver transplantation
• Indications
• Contraindications
• Source of organ
• Perioperative approach
pre-op, Intra-op and post-op
• Complications
• Training opportunities and liver transplant societies/membership
• Summary
• References
1/30/2023 2
Liver transplantation

Introduction- Definition
• Liver transplantation is defined as the replacement of a non-
functioning liver with a functioning one.
• Liver transplantation is a form of orthotopic transplant, i.e. the
diseased organ is removed and replaced with a functioning one at the
same site.
• OLTx- Orthotopic Liver transplantation
1/30/2023 3

Introduction- Historical perspective
• 1952- Vittorio Staudacher described what looks like liver transplant
today
• 1955- C. Stuart Welch liver transplant in Dog
• 1956- Jack Cannon liver transplant in Dog
• 1963- Thomas Starzl started the first human liver transplant, but a
series of deaths led to a voluntary moratorium for 3.5 years
1/30/2023 4

Introduction- Epidemiology
• No Liver transplant services in Nigeria.
• In Africa, only 2 country has Liver transplant services: South Africa
(SA) and Egypt.
• Sudan just commenced Liver transplant services about 5month ago
• In SA, the first programme was established in 1988 at Groóte Schuur
Hospital in Cape Town and the second programme in 2004 at Wits
Donald Gordon Medical Centre (WDGMC) in Johannesburg.
1/30/2023 Liver transplantation 5

• Living donor liver transplant (LDLT) was first performed in Egypt in
1991 by the surgical team at the National Liver Institute (NLI),
Menoufeya University, with the help of Prof. Habib. The longest
recipient survival was 11 months
• There are thirteen LDLT centers in Egypt, including six university
centers, two military centers, three private centers and two centers in
the ministry of health hospitals.
• By the end of June 2014, the total number of cases reached 2,406.

• In 2021, there were just over 9,200 liver transplant carried out in the
USA. Most liver transplants in the U.S. are among adults aged 50 to
64 years, with this age group accounting for around 45 percent of all
liver transplants in 2021.
• California had the highest number of liver transplants performed
among all U.S. states. That year, there were just over 1,000 liver
transplants performed in California. The state with the second highest
number of liver transplants was Texas.
• Liver transplants are the second most common transplant in the
United States behind kidney transplants.

Immunology of liver transplantation
• Histocompatibility complex/protein
• Human leucocyte antigen (HLA)- 6q
2 types
Major- MHC- important in organ rejection
minor- miH
• HLA
• 2 types
Class I- HLA A, B and C- present in all antigen
Class II- HLA DP, DQ, DR- present in APCs

Immunology of liver
transplantation
A two-signal model,
• T-cell activation begins with the
engagement of the T-cell
receptor (TCR)/CD3 complex with
the foreign molecule- signal 1.
• An additional costimulatory
signal is required. Two well-
characterized costimulatory
interactions are the CD40/CD154
and B7/CD28 pathways- signal 2

Indications for OLTx
• End stage liver disease (ESLD)- decompensated liver failure
• Chronic non-Cholestatic liver disorders
Chronic hepatitis B(HBV)
Chronic hepatitis C (HCV)
Autoimmune hepatitis
Alcoholic liver disease
1/30/2023 10

• Cholestatic Liver disease
Primary biliary cirrhosis
Primary sclerosing cholangitis
• Congenital/Paediatric patients
Biliary atresia
Cystic fibrosis
Alagille syndrome
1/30/2023 11

• Metabolic disorders causing cirrhosis
Alpha-1-antitrypsin deficiency
Wilson’s disease
Hereditary hemochromatosis
Non-alcoholic fatty liver disease (NAFLD)
Glycogen storage disease type IV
• Acute fulminant hepatic failure- King’s college criteria
1/30/2023 12

• Primary liver malignancy
Hepatocellular carcinoma (HCC)- Milan criteria
Hepatoblastoma
Hemangioendothelioma
• Miscellaneous
Budd-Chiari syndrome
Polycystic disease
Metastatic NETs
1/30/2023 13

• Complications of End stage Liver Disease (ESLD)
Recurrent variceal hemorrhage
Intractable ascites
Spontaneous bacterial peritonitis
Refractory encephalopathy
Severe jaundice
Fulminant hepatic failure
Hepatorenal syndrome
1/30/2023 14

Contraindication
• Absolute
• Advanced Cardiopulmonary
disease
• Active sepsis/SBP
• Extensive portal/visceral venous
thromboses
• metastatic malignancy
• active drug/alcohol abuse
• untreated psychiatric illness
• Relative
• AIDS
• Advanced age (global variation)
• absent social support
• inadequate insurance for post-op
medications
1/30/2023 15

Liver transplantation: Overview
• First- establish a diagnosis End stage Liver disease (ESLD)
• Second- to exclude any absolute or relative contraindication for Liver
transplant
• Mandatory consultations/clearances
• Organ Procurement Transplant Network (OPTN)
• Listing of candidates
1/30/2023 16

Liver transplantation: Approach
• First- establish a diagnosis End stage Liver disease (ESLD)
History
Examination: Ascites, Jaundice,
Investigations
Laboratory- LFT, Total protein/albumin, Clotting profile, a-
fetoprotein, viral screening
Imaging: USS, CT, MRI, Angiography, PET scan
Biopsy: cirrhosis/chronic liver disease
1/30/2023 17

• Imaging
USS

• Imaging:
CT

• Second- to exclude any absolute or relative contraindication for Liver
transplant
Test for cardiopulmonary reserve:
CXR, FEV1, spirometry
ECG, ECHO, PAC
Tissue typing: HLA typing
other test as required
1/30/2023 20

• Mandatory consultations/clearances
cardiopulmonary clearance- chest physician
psychiatry and social worker consultation clearance
Financial/insurance clearance
Nephrologist, infectious dx clearance
1/30/2023 21

• Liver allocation list by Organ Procurement Transplant Network (OPTN)
Model for End stage Liver Disease (MELD) score >12ys
Paediatric End stage Liver Disease (PELD) score <12yrs
1/30/2023 22

• MELD score: 3 biochemical parameter
MELD Score = 10 * ((0.957 * ln(Creatinine)) + (0.378 *
ln(Bilirubin)) + (1.12 * ln(INR))) + 6.43
Cr=4mg/dl in a patient who underwent HD in the last 7 days
any value less than 1, is given a value of 1
1/30/2023 23

MELD Score No of patients Mortality rate (%) Death or removal from
list because of illness
<9 124 1.9 2.9
10-19 1800 6 7.7
20-29 1098 19.6 23.5
30-39 295 52.6 60.2
≥40 120 71.3 79.3
1/30/2023 24

• PELD score: 3 clinical and 3 biochemical variables
PELD Score = 10 * ((0.480 * ln(Bilirubin)) + (1.857 * ln(INR)) -
(0.687 * ln(Albumin)) + 0.436(if the child is <1yr old) + 0.667(if the child
has growth failure[<2 SD])
1/30/2023 25

Source of organ donation
• Deceased donors
Brain death- consent from relatives
cardiac death- consent before death
• Living donors OLTx
Split liver donors- left lobe, left lateral segment/section
1/30/2023 26

• Living donor evaluation
laboratory:
FBC, EUC, LFT, clotting profile, a-fetoprotein, work up for
metabolic dx.
HLA typing
Imaging:
Duplex USS
CECT/MRI
Angiography
1/30/2023 27

• Donor surgery
Deceased donor
follow the conventional
organ procurement method
Living donor:
left lobe or left lateral
segment
piggyback donor method
After harvest, organ is perfused
with preservation solution within the
acceptable Ischaemic time for liver
tissue.

Organ procurement for deceased donor

Organ Package and Transportation in Liver
Graft
• The liver is inspected in the basin.
• The first sterile bag is filled with the liver
graft and 700–1,000 mL of HTK solution
(4°C), and the bag is secured with a tie.
• It is then placed into the second sterile
bag filled with 1 L of cold normal saline
or slush ice and tied.
• The second bag is placed into the third
bag and tied. The liver in the three-
layered bag is then placed in the heat
preservation container box filled with ice
blocks for transportation.

Preservatives
• University of Wisconsin solution
• Histidine-Tryptophan-Ketoglutarate
• Celsior solution
• Collins solution
• Eurocollins solution

Organ procurement for LDLT
• Three different types of donor hepatectomies are used for living
donor liver transplantation (LDLT), as follows:
• Left lateral hepatectomy, in which the graft consists of segments II
and III, with or without segment I
• Left hepatectomy, in which the graft consists of the whole left lobe,
segments I, II, III, and IV
• Right hepatectomy, in which the graft consists of the right lobe,
segments V, VI, VII, and VIII

• Recipient hepatectomy
Bilateral subcoastal + midline extension (Mercedes-Benz incision)
all ligaments are mobilized
supra and infra hepatic vena cava is transected
hilar dissection: portal vein, HA and hepatic veins (with supra-
hepatic vena cava) and bile duct
veno-venous cannula passed from the femoral/portal to the
subclavian for those who are hemodynamically unstable
hepatectomy completed
1/30/2023 34

• Recipient graft transplantation
IVC: suprahepatic IVC, then Infrahepatic IVC
portal vein anastomosis: end-to-end
Hepatic artery: end-to-end
Bile ducts: end-to-side or roux-en-Y anastomosis
1/30/2023 35

1/30/2023 36

Liver transplantation:
Approach-Piggyback
technique
• IVC is not removed
• hepatic veins are divided at their
confluence before entering the
IVC.
• bypass may not be required or
partial bypass
• Adv: ↓hemodynamic instability,
good renal perfusion
• Disadv: ↑ hepatectomy time, ↑
blood loss

Liver
transplantation:
Approach- LDLT
• Donor and recipient
procedure for living
donor liver transplant
into a pediatric
recipient

Liver
transplantation:
Approach- LDLT
A. Hepatic transection
completed for removal of left
lateral segments (S2 and S3).
Bile ducts to segments 2 and
3 divided; vascular structures
still intact.
B. Implantation of the donor
left lobe.

Liver
transplantation:
Approach- LDLT
A.Hepatic transection
completed for right
lobe removal
B. Implantation of the
donor right lobe with
the MHV

Post-op care
• ICU monitoring until hemodynamic stability
• Serial liver function test: transaminases
• Duplex scan to check HA, portal vein, bile flow, bleeding
• Platelet sequestration by the graft but later normalizes
1/30/2023 41

Immunosuppressive medications
• Induction
steroid +
polyclonal/monoclonal antibody
• Maintenance
steroid,
cyclosporine/tacrolimus and
MMF/azathiopine

Immunosuppressive medications

Complications
• Peri-operative (first 30 days) complications
• Early (first 6 month) complications
• Late complications (>6month)
1/30/2023 44

Complications- first 30 days
• Primary non function or Primary poor function (1-7%)
• Hepatic artery thrombosis (2.9%)
• Portal vein thrombosis (<2%)
• Preservation/reperfusion injury
• Haemorrhage
• Biliary complications (10-35%)
bile leak
benign strictures
1/30/2023 45

Complications- first 6months
• Biliary strictures
• Acute graft rejection
• Infections
1/30/2023 46

Complications- >6month
• Malignancy: PTLD, Kaposi sarcoma, lymphoma, etc
• Incisional hernia
• Biliary strictures
• Vascular complications- aneurysm of HA, late thrombosis
• Chronic rejection
1/30/2023 47

• Founder of Dr Rela Institute and Medical
centre in Chennei, India
• President, International Liver transplant
Society (ILTS)
• Former President, Liver Transplant society
of India (LTSI)
• www.ilts.com and become a member
• Guinness book of records
• Done over

Liver Transplant fellowship (with HPB surgery)
• https://www.ihpba.org/fellowship/?group=Asia+%2F+Pacific
• https://www.ihpba.org/27_HPB-Fellowship-Registry.html
• https://www.ihpba.org/fellowship/?group=Europe%2C+Africa+%26+
Middle+East

Liver transplant society
• International Liver transplantation Society
President- Prof Mohamed Rela- Owner of Rela institute &
medical centre in Chennei, India.

Summary
• Liver transplantation has seen rapid development and growth from
the pioneering days of Starzl and Calne
• Today, liver transplant recipients enjoy excellent patient and graft
survival and the procedure has become routine in many centres
• Living donor LT has emerged as a viable option for patients with ESLD
• Advances in surgical technique, immunosuppression, perioperative
care have not only reduced operative morbidity/mortality, but have
also significantly improved the quality of life for the recipients
1/30/2023 51

References
• Charles F. Brunicardi: Schwartz’s principles of Surgery, 10th edition Chapters
33
• https://www.statista.com/statistics/954207/us-liver-transplants-by-state/
• O. James Garden and Simon Peterson-Brown: Hepatobiliary and pancreatic
surgery, a companion to specialist surgical practice, 5th edition, chapter 15
• Norman, S. W., Christopher J.K.B., and P.Ronan O’ Connell (2008). Bailey
and Love principles and practice of Surgery, 25th edition, chapter 61, 63 and
64
• Michael J Zinner and Stanley W Ashley: Maingot’s abdominal operations,
12th edition. Chapter 59
1/30/2023 52

• John L. R. Forsythe: Transplantation, a companion to specialist
surgical practice, 5th edition, chapter 8
1/30/2023 53

THANK YOU FOR
YOUR ATTENTION
1/30/2023 54

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