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Liver Transplantation with severe steatotic graft and postoperative organ dysfunction

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Clinical case presented at 6eme HPB Congress in Montpellier France.

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Liver Transplantation with severe steatotic graft and postoperative organ dysfunction

  1. 1. Liver transplantation with severe steaotic graft and postoperative organ dysfonction EricVibert, MD, PhDHopitalPaul Brousse (AP/HP) Villejuif
  2. 2. The recipient •Male, 54 year-old, 72 kg, 1.70 m, Groupe A+ •Diabetemellitus •ChronicLymphoidLeukemiatreatedin 2007 withrecentrecurrencetreatedwithchemotherapy(Fludarabine/ Endoxan/ MABthera) •No historyof liverdisease •Hospitalizedfor gastroenteritis3 weeksafterthe last cycle of chemotherapy…
  3. 3. Hospitalized for Gastroenteritis… •Abdominal pain, diarrhea, nausea •No encephalopathy •Liver Echography : No bile duct dilatation Leuco Hb Plat. PT Uree Creat Lact 2550 16 73000 46% 12 91 1.57 Bili(μmol/L) ASAT ALAT GGT 90 1450 1528 151
  4. 4. Then for HVB Acute Hepatitis… •Viral serologywerenegativeexceptHVB –High positive viral load+++ (9 UI/ML) •HVB Reactivationdue to Chemotherapyfor LeukemiaadministratedwithoutHVB serology •Treatmentby Vireadand NAC during2 weeks •No clinicaland/or biologicalimprovement Transfert in ourtertiarycare center
  5. 5. From Acute Hepatits to Fulminant •Day 0 : Jaundice/ No encephalopathy/ No Drugs •Day 1 : Transjugularliverbiopsy: 30% of livernecrosis–Signof HVB replication–No cirrhosis •Day 5 : Encephalopathyand HeartRythme Trb… 1300 1128 1110 854 320 149 1200 1174 1200 911 800 291 D0 D1 D2 D3 D4 D5 Cytolysison five days ASAT ALAT 307 347 211 312 350 378 35 30 28 30 20 17 D0 D1 D2 D3 D4 D5 Bilirubin rate and PT on five days Bil TP
  6. 6. No liver morphological abnormalities Pancreas oedema…
  7. 7. Listing for LT in «Super Urgence» •First proposal was refused (at H1 after listing) –Male, 86 year-old with GGT 800 UI/ml •Second proposal (at H12… after listing) –Male, 45 yea-old, 82 kg for 1.80 m, Gr 0- –48 hours of ICU for Cerebral Stroke and Anoxia Bili ASAT ALAT GGT At Admiss. 30μmol/L 1280 450 1330 AtProposal 6μmol/L 316 151 492
  8. 8. The graft… from France South West.. Evaluation by the surgeon who make the retrieval : Big graft, probably steaotic but transplantable… Frozen section not feasible in situ, we need to come back to Paris We increased Cold Ischemia of 8 hours….. We accepted these graft because the recipient is more and more severe….
  9. 9. Liver Transplantation under veno-venous bypass with VC replacement VC Replacement and CEC : Big graft (Risk of VC compression) + Acute Pancreatitis Cold Ischemia : 10h00 25 Red Pack Cell… Diffuse hemorrhage… Levesque et al, Vibert. Clin Tranpl 2012
  10. 10. At the end of liver transplantation Volume of the graft, Acute pancreatis, Hemorrhage… and probable re LT
  11. 11. Evolution at Day 1 from LT Biopsyofthegraft:Morethan50%ofmacrosteatosisand10%ofmicrosteatosis… / LT Bili ASAT ALAT PT/ Fact V AtH4 117 6607 1482 34/ 23 AtH12 130 5900 1200 23/ 15 Under Noradrenaline, no bleeding
  12. 12. Re Listing for LT in «Super Urgence» •First proposalwasaccepted… (at H1 afterlisting) –Male, 45 year-old, 69 kg for 1.60 m, Gr 0- –24 hoursof ICU for CerebralStroke and Anoxia Bili ASAT ALAT GGT At Admiss. 30μmol/L 203 470 91 Re LT / Cold Ischemia 4h / 7 RPC
  13. 13. 8 reinterventions with abdominal exploration and pancreatic necrosectomy
  14. 14. Very long post operative course… 12 weeks of ICU and 8 weeks in Hospitalization
  15. 15. Actual status at 3 years of FU •Asymptomatic, heworksin a bank •ASAT 29, ALAT 100, GGT 83, TP 87% •Under viread… Thanksfor yourattention eric.vibert.pbr@gmail.com These slides will be on slideshare

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