Isg chennai march 2015 rajasekar

1. Cadaveric Liver
Transplantation - Where do
‘we’ stand Today
Dr. Rajasekhar Perumalla
MS, FRCS
Senior Consultant Transplant Surgeon
SIMS (SRM Institute of Medical Sciences)
Vadapalani
Chennai

2. Important milestones in transplantation
Dr.Thomas Starzl
1963- Denver, Colarado,US
• INTRODUCTION OF CYCLOSPORINE
A –
JEAN BOREL
• SIR ROY CALNE – CAMBRIDGE
UNIVERSITY
Initial results
130 LTX by 1970, 12 alive in 1976
Scope for improvement

3. Transplant scenario in India
 Brain Death and deceased donor organ donation is
legal - Human Organ transplantation Act 1994
 Liver transplant - First DDLT - 1998
First LDLT - 1999 (Paediatric)
First LDLT - 2000 (Adult)

4. Transplants Oct 2008 to Jan
2015
 Donors From TN 587
 Heart 116
 Lung 50
 Liver 542
 Kidney 1052
 Pancreas 4
 Small Bowel 1
 Total Major organs 1765
 Heart Valve 566
 Cornea 886
 Skin 13

Total Organs 3231

5. Liver transplant - survival
 1 year survival - 88- 90%
 2 year survival - 80- 85%
 5 Year survival - 70- 75%
Complication rate – 10- 15%
Artery, Bile duct, Infection, rejection

6. Improved outcomes
 Patient selection
 Organ preservation
 Refined surgery & anaesthesia
 Immunosuppression
 Early recognition of complications &
management

7. Prognostic Models
 CTP Score
 MELD score

10. Importance of HCC screening in Cirrhotics
6 monthly AFP and Ultrasound

13. Deceased Donor Vs Living Donor
– Which to offer and when?
 Time available for the Recipient -
Stable – Can wait
Stable – not ideal to wait
Unstable

14. Donor
 Deceased donor
1. Brain Dead Donor
2. DCD (Donation after cardiac death)
 Organ preservation time
Liver – 12 -24 hrs
 Whole organ / Reduced graft / Split

15. Organ harvesting /Procurement
 Laparotomy/Asessment
 Aortic cannulation
 Portal cannulation
 Goal: Cool the organs and perfuse with
preservative solution (HTK (Custodial)
UW (Belzer) while exsanguinating the
organs

16. Cold Ischemia Time
 Retrieval of liver following clamping the Aorta
 Packaging and Transport
 Recipient Hepatectomy
 Implantation of New Liver –
 Vena Caval anastomosis,
 Portal Vein Anastomosis,
 Reperfusion
TOTAL TIME 6 – 12 hrs.
Always a race against Time!

17. Selection
 Selection of transplant type depends on
 Organ availability
 ABO match
 Physical size (HT, WT, Abdominal girth)
 Medical condition - MELD, CTP score)
 Age match – Donor / Recipient
 DDLT preferred in a recipient
 High BMI
 Portal vein thrombosis
 Re-transplantation
 Sick recipients
 In India: organ shortage

18. DDLT- Is there a need for
Speed?
 Keys to a safe and quick transplant
 Prepare well - Know your patient, review the case
history, diagnosis & Lab values.
 Review the CT scan & Know the anatomy
 Start slowly, progress gradually with careful
mobilisation of liver & no traction
 Ensure haemostasis at every step
 DDLT is usually faster
 Implantation is less complex & quicker
 DDLT  Emergency - Race against time to CIT

19. Recipient hepatectomy
Level of dissection
High ligation of the hilar
structures: Arteries and bile
ducts
Beware of vascular intimal
dissection
LDLT- High ligation of
structures

20. Cava preserving hepatectomy
 Preferred
technique
 Avoids caval
clamping
 Could be avoided
in select DDLT
cases.

21. Veno venous bypass

22. Difficult hepatectomy
Caudate lobe hypertrophy
Severe portal hypertension
Volume overload- Tissue oedema
Retransplantation
Previous upper abdominal surgery
Abdominal cocoon

23. Temporary porto caval shunt
Belghiti et al
Difficult recipient
hepatectomy
Training period
No portal hypertension
 Acute liver failure
 Non cirrhotic

24. Implantation - Classic technique

25. Hepatic vein implantation
DDLT
 Piggyback technique
 Preferred
 Single cava anastamosis
 Cavacavoplasty
 Side to side cavo-caval
 Caval replacement
 Budd chiari syndrome
 Massive caudate lobe
 Retransplantation
LDLT
 Multiple veins to be
drained
 RHV in right lobe grafts
 Seg 5/8/ IRHV
reconstruction

26. Caval anastomosis –
“pyggy-back” technique

27. Caval anastomosis –
Belghiti technique

28. Final aspect of anastomoses

29. 1. Hepatectomy – can sometimes be the toughest
2. Anhepatic Phase – Major role for Anesthesiologist
3. Reperfusion – “ Anesthesia- watch for Toxin release to
the heart , Surgeons - Watch for golden bile”

30. Good graft function
 Haemodynamic stability
 Awakening from anesthesia
 Clearence of lactate
 Resolution of hypoglycemia
 Normalisation of coagulation profile
 Resolution of elevated transaminases
 Bile (Golden) production on the table

31. Uncomplicated post op period
 Stable Haemodynamics- Minimum to no
inotropes
 Patient wakes up - 1- 2 hrs.
 Acid base balance
 Extubation – 4-6 hrs.
 Doppler – day 1
 Out of ICU to wards
 Diet – NE feeds 6 hrs. to 12 hrs.
 OUT OF HOSPITAL – 10 -14 days

32. Factors? : Immediate outcome
 Graft selection / Graft quality
 Organ preservation
 Warm & cold ischaemia times
 Donor – Recipient matching
 Surgical & Medical problems

33. Post Op Care –
MULTI-FACETED APPROACH
 FLUID AND
ELECTROLYTE BALANCE
 RESPIRATORY STATUS
 RENAL FUNCTION – RRT
 INFECTION CONTROL
 IMMUNO-SUPPRESSION
 IMAGING ALL THE
‘PLUMBING’

34. Early complications
 Primary Non Function of Graft (2%)
 Delayed Graft Function
 Technical (Arterial, bile duct) 10- 12%
 Acute Rejection
 Infection

35. Post Transplant Phase - PNF
 Age
 Electrolyte imbalance
 Inotropes
 Prolonged ICU stay
 CIT
 PNF Prevention
 Careful management of donor

36. Long Term Complications
 Recurrence of primary disease
 Metabolic complications –
 Hypertension
 Renal failure
 Dyslipidemia
 PTDM (Immunosuppression related)
 Malignancy- PTLD, Skin tumors

37. Care of Transplant Patient
Primary Care physician
Hepatologist
Transplant Team

38. Expansion of the Organ Donor
Pool
 Improving results
 Increasing demand
 Scanty resource
 Decrease the waiting list mortality
 Efforts are on to expand the pool

39. Future?
 ORGAN SUPPLY – “Political”
 Opting out system (Spanish model)
 Infrastructure? ITU beds

40.  ORGAN SUPPLY – Surgical
 Using marginal grafts
 Resuscitation of grafts

Ischaemic preconditioning

Avoidance of cold ischaemia
 Fewer technical complications
 Split liver for 2 adults
Future?

41. The First Split & Auxiliary Liver Transplant in India was performed by Prof Mohamed Rela and
his team to save the lives of two different individuals.
Ms. Himani Koshala and Ms. Kamala Bulledulla
1919thth
September 2009September 2009

42. Split the liver graft for 2 adult recipients

47. Ex-situ Split Liver Transplantation
King’s College Hospital – Survival data
n 1 yr 3 yr 5 yr
 Overall patient survival 256 87% 84% 84%
 Patient survival – LLS 140 90% 88% 88%
 Patient survival – RL 116 85% 81% 80%

48. Results of Ex-situ
Split Liver Transplantation
Author Year Number Age group Technique Patient Graft
Survival % Survival %
Broelsch et al 1990 30 Adults Ex situ 67 55
Otte et al 1995 29 Mixed Ex situ 79 69
De Ville et al 1995 96 Mixed Ex situ 71 64
Azoulay et al 1995 27 Mixed Ex situ 79 79
Rela et al 1998 41 Mixed Ex situ 90 88
Mirza et al 1998 24 Mixed Ex situ 78 68
Reyes et al 2000 12 Paediatric Ex situ 64 45
13 Adult Ex situ 83 -
Azoulay et al 2001 34 Adult Ex situ 88 (LLS) 74 (RL)
Kings 2001 156 Mixed Ex Situ 88.6 88

50. Biliary anatomy of Caudate Lobe

53. Marginal Donor
 Definition
 Organs considered unsuitable for
transplantation are currently being used.
 New Terminology
 “Marginal” donor,
 “Expanded” donor
 “Extended criteria” donor

54. Marginal Donor
 Older donors
 Diabetes mellitus
 Hypertension
 Renal insufficiency
 Selected cases

Hepatitis B & C

HIV

55. Marginal Donor-
Disadvantages
 risk of delayed graft function
 Primary non function (PNF)

56. Assessment Extended Criteria Donor
 Donor age and history
 Donor haemodynamics
 Donor Anatomy
 Donor liver Biopsy
 Pump parameters
 Recipient selection important

59. Steatotic graft
 Western population: steatosis is prevalent in
30 to 70% of people
 Most common type of ‘‘extended criteria’’
organs
 Problems – depending on severity of steatosis
  Primary/delayed function
 Post transplant complications
 Poor long-term outcomes ??
Nocito A, et al. J Hepatol 2006;45:494–499

60. Steatotic Graft - Assessment
 Assessment
 Visual inspection and palpation
 Biopsy – Two cores from the right and left liver were
regarded to best predict overall liver histological
characteristics
 Frozen section may overestimate

61. Hepatic Steatosis
 Quantitative evaluation - based on the
percentage of hepatocytes containing cytoplasmic
fat inclusions
 Mild - ≥ 30%
 Moderate - 30 -60%,
 Severe - > 60%
 Fatty infiltration - Two categories
 Macrosteatosis
 Microsteatosis
1
.

62. Donor Risk Index
 May be acceptable to transplant with up to 60% steatosis
in the graft
McCormack L, et al. Journal of Hepatology 2011; 54: 1055–1062
 Cold ischemic time  5hrs. for grafts with steatosis
 Consider donor < 40 year
 Recipient MELD:
Those with low MELD seem to tolerate steatotic grafts better
Best scenario would be use this for low MELD score recipients
with urgency such as those with HCC

63. Long term outcome
 Steatotic Graft show a dramatic decrease in fatty
infiltration after LT
 Mechanism – not fully understood
 Factors that negatively affect this reversal of steatosis - donor age
(>50 years) and prolonged cold ischemia time (>12 h)
 Severe macrosteatosis :  Biliary complications
 Steatosis in the liver graft – negative prognostic factor
for HCV recurrence
 Literature is divided on the effect of donor graft steatosis as a
facilitator or stimulator of fibrosis on patients with post-LT HCV
recurrence
Baccarani U, et al. Clin Transplant 2009.
Li J, et al. Transplant Proc 2009;41: 3560–3563.

65. Future Challenges Ongoing work by the Pioneers
Long Term Complications IMMUNE Tolerance
Ever Increasing Demand Xenotransplantation

66. LIVER TX– TEAM EFFORT
TX SURGEONS
ANESTHESIOLOGIST
HEPATOLOGIST
INTENSIVIST
SCRUB NURSE
PERFUSIONIST
DIALYSIS TECHNICIANS
BLOOD BANK
PATHOLOGIST
LAB PERSONNEL
TX COORDINATORS

67. Don’t take your Organs to heaven,
heaven knows we need them here.
Thank you