intensivists- basics of post operative biliary and vascular complications of LT

1. VASCULAR AND BILIARY
COMPLICATIONS
FOLLOWING LIVER
TRANSPLANTATION
DR.MALAKA MUNSINGHE
SENIOR REGISTRAR-ANAESTHESIOLOGY
2018.11.01

2. VASCULAR COMPLICATIONS
• INFREQUENT
• HIGH INCIDENCE OF GRAFT LOSS AND MORTALITY
• ROUGH INCIDENCE- 7-13% ( DECEASED VS LIVING DONOR)
• ARTERIAL AND VENOUS COMPLICATIONS

3. ARTERIAL COMPLICATIONS
HEPATIC ARTERIAL COMPLICATIONS
- THROMBOSIS
- STENOSIS
- PSEUDOANEURYSM FORMATION
- RUPTURE

4. HEPATIC ARTERY THROMBOSIS( HAT)
• COMMONEST VASCULAR COMPLICATION ( 50% OF VAS. COMPLICATIONS)
• GRAFT FAILURE AND MORTALITY OF MORE THAN 50% IF NOT MANAGED
• EARLY AND LATE HAT

6. EARLY HAT
• ONSET WITHIN 30 DAYS
• CAUSES/RISKS - TECHNICAL PROBLEMS, LDLT, CIGARETTE SMOKING,
HYPERCOAGULABILITY
- PRESENTATION- MILD ELEVATION OF SERUM TRANSAMINASE AND BILIRUBIN
LEVELS (75%)
BILIARY COMPLICATIONS (15%)
FEVER AND SEPSIS (6%)
GRAFT DYSFUNCTION OR FAILURE (4%)

7. LATE HAT( AFTER 30 DAYS)
- RELATED TO ISCHEMIC OR IMMUNOLOGIC INJURY
- INCREASED RISK IN,
 CMV POSITIVE DONORS
 FEMALE DONOR AND MALE RECIPIENT
 HEPATITIS C SEROPOSITIVE RECIPIENTS
• 50%- ASYMTOMATIC WITH ELEVATED TRANSAMINASES
• BILIARY COMPLICATIONS( BILIARY STRICTURES/ LEAKS/CHOLANGITIS) MORE
FREQUENT THAN IN EARLY HAT

8. DIAGNOSIS
• INCREASED SERUM TRANSAMINASE LEVELS
• DOPPLER ULTRASOUND MONITORING IN THE POSTOPERATIVE PERIOD- REDUCED
BLOOD FLOW/ REDUCED RESISTIVE INDEX
• CONFIRMED BY CONTRAST-ENHANCED ABDOMINAL CT SCAN AND/OR VISCERAL
ANGIOGRAPHY

9. TREATEMENT OF HAT
• ENDOVASCULAR RADIOLOGICAL INTERVENTIONS (INTRAARTERIAL
THROBOLYSIS, PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY AND STENT
PLACEMENT)
• OPEN SURGICAL REVASCULARIZATION
• RETRANSPLANTATION (ASSOCIATED WITH THE BEST SURVIVAL RATES
COMPARED WITH REVISION OR THROMBOLYSIS)

10. HEPATIC ARTERY SRTICTURE
• NARROWING OF THE TRANSVERSE DIAMETER > 50% ON THE ANGIOGRAM
ASSOCIATED WITH CLINICAL SUSPICION, WITH A RESISTIVE INDEX < 0.5 AND A
PEAK SYSTOLIC VELOCITY > 400 CM/S DETECTED BY DUS
• 2% -13% OF TRANSPLANTS- AT THE LEVEL OF THE ANASTOMOSIS /GRAFT HA
OR RECIPIENT HA
• IF UNTREATED-65% CAN PROGRESS TO HAT AT 6/12

11. • MOST PATIENTS ARE ASYMPTOMATIC
• ABNORMAL LIVER FUNCTION TESTS
• RARELY- LIVER FAILURE
• CAUSES- TECHNICAL AND SURGICAL FACTORS/ ACUTE REJECTION
• CONTRAST-ENHANCED CT SCAN AND ANGIOGRAPHY -TO CONFIRM THE
DIAGNOSIS

13. • TREATEMENT
- RADIOLOGICAL ENDOVASCULAR INTERVENTION BY PTA WITH OR WITHOUT
STENT PLACEMENT
- SURGICAL REVISION AND RETRANSPLANT - HIGHER RATE OF SUCCESS, BUT THE
OVERALL MORTALITY RATE HIGH (20%)

14. HEPATIC ARTERY PSEUDOANEURYSMS
• 0.27% TO 3% OF CASES
• EXTRA-HEPATIC
• EARLY POSTOPERATIVE PERIOD (1 MONTH POST-OLT)
• PATIENTS CAN BE ASYMPTOMATIC
• ABDOMINAL PAIN WITH FEVER AND GASTROINTESTINAL BLEEDING
• MAJOR BLEEDING WITH INCREASED ABDOMINAL DRAINS/ SHOCK
• RISK FACTORS - PERITONEAL INFECTION, BILIARY LEAK, BILBO-DIGESTIVE
ANASTOMOSIS AND DIGESTIVE LEAK

16. TREATEMENT
• REOPERATION (URGENT LAPAROTOMY FOR HA LIGATION: MORTALITY RATE 60%
• HAP EXCISION AND IMMEDIATE REVASCULARIZATION WITH A CRYOPRESERVED
ARTERIAL ALLOGRAFT: MORTALITY RATE 28%
• INTERVENTIONAL RADIOLOGY (HA EMBOLIZATION WITH A COIL OR HAP
EXCLUSION WITH A COVERED STENT

17. VENOUS COMPLICATIONS
• LESS COMMON THAN ARTERIAL COMPLICATIONS( 3%)
• PORTAL VENOUS/HEPATIC VENOUS OR CAVAL

18. PORTAL VENOUS THROMBOSIS
EARLY AND LATE
- INCIDENCE HIGHER IN PEDIATRIC TRANSPLANTATION, LDLT AND SPLIT LIVER
TRANSPLANTATION
PRESENTATION
- PORTAL HYPERTENSION MANIFESTATIONS (ABDOMINAL PAIN, ASCITES,
GASTROINTESTINAL BLEEDING, SPLENOMEGALY)
- SEVERE ALLOGRAFT DYSFUNCTION AND MULTIORGAN FAILURE
- CAUSES- TECHNICAL ERRORS AND ANATOMIC COMPLICATIONS SUCH AS VENOUS
REDUNDANCY, KINKING AND/OR STENOSIS OF THE ANASTOMOSIS

19. • DIAGNOSIS
- DUS, CEUS, CONTRAST-ENHANCED CT, MRI AND PORTOGRAPHY

20. TREATEMENT
- SYSTEMIC ANTICOAGULATION THERAPY
- CATHETER-BASED THROMBOLYTIC THERAPY BY PERCUTANEOUS RADIOLOGICAL
INTERVENTION WITH OR WITHOUT STENT PLACEMENT
- PORTOSYSTEMIC SHUNTING (TIPS)
- RETRANSPLANTATION

21. CAVAL ANASTAMOTIC COMPLICATIONS
- THROMBOSIS/ KINKING/ STENOSIS
- RELATIVELY UNCOMMON
PRESENTATION
- LOWER LIMB EDEMA, HEPATOMEGALY, ASCITES, PLEURAL EFFUSIONS, BUDD-
CHIARI SYNDROME, LIVER AND RENAL FAILURE, HYPOTENSION, LEADING TO
ALLOGRAFT LOSS AND EVEN DEATH

22. • PERCUTANEOUS RADIOLOGICAL INTERVENTION AS CHOICE OF TREATEMENT
( ANGIOPLASTY+STENTING)

23. BILIARY COMPLICATIONS
• INCIDENCE OF BILIARY COMPLICATIONS-5-32%
• RISK FACTORS-
 HEPATIC ARTERY THROMBOSIS
 ACUTE CELLULAR REJECTION
 COLD ISCHEMIA TIME/ DURATION OF ANHEPATIC PHASE
 DONOR AND RECEPTOR OLD AGE

24. TYPES
• BILIARY FISTULA
• BILIARY STENOSIS/STRICTURES
• STONES
• CHOLANGITIS
• RECURRENCE OF PRIMARY BILIARY DISEASES
• SPHINCTER OF ODDI DYSFUNCTION

25. BILE LEAKS
• EARLY OR LATE
• OCCUR AT THE ANASTOMOTIC SITE OR AT THE T-TUBE INSERTION SITE
• PRESENTATION- ABDOMINAL PAIN, FEVER OR ANY SIGN OF PERITONITIS AFTER
LIVER TRANSPLANT, ESPECIALLY AFTER T-TUBE REMOVAL
• FEVER MAY BE ABSENT IN PATIENTS ON CORTICOSTEROIDS
• UNEXPLAINED ELEVATIONS IN SERUM BILIRUBIN, BILIOUS ASCITES

26. MANAGEMENT
• PAIN CONTROL WITH ANALGESICS
• INTRAVENOUS FLUIDS
• SUPPORTIVE CARE
• LEAKS DUE TO ISCHAEMIA- DIFFICULT TO TREAT
• REST OF LEAKS- ENDOSCOPIC BILIARY DIVERSION+ STENTING/
SPHINTEROTOMY/PTC/ SURGICAL INTERVENTIONS IF NOT RESPONDING

27. BILIARY SRTICTURES
• ANASTOMOTIC AND NON-ANASTOMOTIC
• LATE OCCURRENCE- AT 5-8 MONTHS
ANASTOMOTIC
• INADEQUATE MUCOSA-TO-MUCOSA ANASTOMOSIS, SURGICAL TECHNIQUE,
LOCAL TISSUE ISCHEMIA, AND THE FIBROTIC NATURE OF THE HEALING PROCESS

28. NON-ANASTOMOTIC STRICTURES
• RISK FACTORS
- HAT
- PROLONGED COLD ISCHEMIA TIME
- IMMUNOLOGICAL

29. PRESENTATION
- JAUNDICE, FEVER, ABDOMINAL PAIN
- ASYMPTOMATIC BIOCHEMICAL CHOLESTASIS
- IMAGING- DUCT DILATATION
- HISTOLOGY- DUCT PROLIFERATION/PERICHOLANGITIS

30. MANAGEMENT
• ENDOSCOPIC DILATATION+STENTING- PERFORMED 3 MONTHLY UP TO AN YEAR
• SURGICAL INTERVENTION IF FAILED
• SECONDARY BILIARY CIRRHOSIS, RECURRENT CHOLANGITIS, OR PROGRESSIVE
CHOLESTASIS- RETRANSPLANTATION

31. SPHINCTER OF ODDI DYSFUNCTION
• INCIDENCE- 7%
• DENERVATION OF THE SPHINCTER DURING OLT
• STENOSIS OR DYSKINESIA
• INCREASE IN THE SIZE OF DONOR AND RECIPIENT COMMON BILE DUCTS
• TREATED BY ENDOSCOPIC SPHINTEROTOMY WITH STENTING

32. • BILOMAS- BILE RUPTURE AND SPILLING OF BILE WITHIN THE LIVER AND
ABDOMINAL
CAVITY
TREATMENT - ANTIBIOTICS AND PERCUTANEOUS
DRAINAGE/PLACEMENT OF A BILIARY STENT/
SURGICAL DRAINAGE LASTLY
• HEMOBILIA- AFTER PERCUTANEOUS LIVER BIOPSY OR PTC/ CORRECTION OF
CLOTTING/ EMBOLIZATION
• DUCTOPENIA

33. THANK YOU!