This document provides an overview of liver transplantation, including:
1) A brief history of liver transplantation and developments in the field.
2) The types of liver disease that can require transplantation, including acute liver failure and chronic liver disease from cirrhosis.
3) The criteria for determining when a patient requires transplantation, including factors like MELD score and signs of liver decompensation.
4) The surgical procedure of liver transplantation, including donor selection, organ harvesting, implantation of the new liver, and post-operative monitoring.
Liver transplant In India by Dr. Abhideep Chaudhary, Sir Ganga Ram Hospitaldrabhideep
This presentation is related to Liver Transplant, Liver Failure, It's causes and remedy.
Here we also talk about liver transplant scenario in india and success rate of liver transplant both cadaver or living donor.
We also give a brief about the cost of liver transplant.
Dr. Abhideep Chaudhary, is liver transplant consultant/surgeon at Sir Ganga Ram Hospital, New Delhi, India.
Email : drabhideep@yahoo.com , care@drabhideep.com
History of liver transplant.
Why and When liver need to be transplant ?
What at basic requirements in LT.
Success and Failure %age
Global statistics of organ donation
Liver transplant In India by Dr. Abhideep Chaudhary, Sir Ganga Ram Hospitaldrabhideep
This presentation is related to Liver Transplant, Liver Failure, It's causes and remedy.
Here we also talk about liver transplant scenario in india and success rate of liver transplant both cadaver or living donor.
We also give a brief about the cost of liver transplant.
Dr. Abhideep Chaudhary, is liver transplant consultant/surgeon at Sir Ganga Ram Hospital, New Delhi, India.
Email : drabhideep@yahoo.com , care@drabhideep.com
History of liver transplant.
Why and When liver need to be transplant ?
What at basic requirements in LT.
Success and Failure %age
Global statistics of organ donation
Liver transplantation current status, controversies and mythsAbhishek Yadav
Details the present status, indications, techniques about liver transplantation. Also dispels some common myths surrounding liver transplantation. #liver transplantation # living donor liver transplantation #liver cirrhosis #liver failure#transplantation#live donor#drabhishekyadav.com#liversurgeon#myths#livedonorlivertransplantation#organtransplantation#alcohololiverdisease
Devascularization in portal hypertension.dr quiyumMD Quiyumm
role of surgery in portal hypertension is promising. Devascularization is one of the procedure of choice in unshuntable portal vein. Though LT is treatment of choice
In Depth review of the Surgical management of esophageal carcinoma including management overview, endoscopic management, Type of surgeries, Open, and minimally invasive, Extent of lymphadenectomy. Literature review of evidence for type of surgery and complications
Liver transplantation; notes of DM/DNB/SpecialistsPratap Tiwari
Liver transplantation; extensive notes of DM/DNB/Specialists. This was my notes for my exam compiled from several sources, credit goes to original authors. This is just for quick revision
Brief description of hepatectomy with indications, procedure, pre operative, intra operative and post operative management of the patient. Also describes the various techniques and instrument available for liver resection.
Liver transplantation current status, controversies and mythsAbhishek Yadav
Details the present status, indications, techniques about liver transplantation. Also dispels some common myths surrounding liver transplantation. #liver transplantation # living donor liver transplantation #liver cirrhosis #liver failure#transplantation#live donor#drabhishekyadav.com#liversurgeon#myths#livedonorlivertransplantation#organtransplantation#alcohololiverdisease
Devascularization in portal hypertension.dr quiyumMD Quiyumm
role of surgery in portal hypertension is promising. Devascularization is one of the procedure of choice in unshuntable portal vein. Though LT is treatment of choice
In Depth review of the Surgical management of esophageal carcinoma including management overview, endoscopic management, Type of surgeries, Open, and minimally invasive, Extent of lymphadenectomy. Literature review of evidence for type of surgery and complications
Liver transplantation; notes of DM/DNB/SpecialistsPratap Tiwari
Liver transplantation; extensive notes of DM/DNB/Specialists. This was my notes for my exam compiled from several sources, credit goes to original authors. This is just for quick revision
Brief description of hepatectomy with indications, procedure, pre operative, intra operative and post operative management of the patient. Also describes the various techniques and instrument available for liver resection.
Background of organ transplant infrastructure in the US. Some history. Definitions. Nursing Care of the transplant patient in hospital, and home settings. Intended for senior level nursing students in an ADN program
Liver transplantation or hepatic transplantation is the replacement of a diseased liver with some or all of a healthy liver from another person. Liver transplantation is a viable treatment option for end-stage liver disease and acute liver failure.
Liver transplant (LT) is becoming the need of the hour and often the last ray of hope for many of our cirrhotic patients. The dearth of deceased donors, acceptance of living-related donors, better operative skills, and post transplant outcomes have played an important role is making LT accessable to more and more needy people. However, for best outcome it is important to stick to the established criteria laid down for listing a patient for LT for both best outcomes and better distribution of donor livers.
Anaesthesia for liver transplantation.pptxKLahari7
Introduction
Liver transplantation (LT) is the treatment of choice for end-stage liver disease regardless of its aetiology. Ever since the first transplant interventions in the 1960s, mortality rates after LT have significantly improved and have led to an increase in the number of successful procedures and improved outcomes.
Significant challenges remain for the transplant team as the procedure is performed on high-risk patients with impaired cardiovascular, pulmonary, renal and coagulation systems. Recent publications have indicated that transplant candidates are older, sicker and with multiple associate co-morbidities and organ dysfunctions compared to those treated in the past. Adequate perioperative care is essential for a prompt graft function which will improve organ system recovery and recipient’s quality of life [1].
Though there is a potential worldwide liver graft shortage, the expansion of the donor pool using marginal donors and increasing donor age has resulted, never the less, in reduced waiting list mortality [2]. A successful LT requires teams with a particular set of skills and competences, including a complete and detailed understanding of the multi-organic pathophysiology of liver failure and its implications and management during the three stages of surgery.
There have been many innovations, updates and procedural changes in the anaesthetic management of patients during this time. This article gives an overview of the current literature regarding anaesthetic management during liver transplantation and its singularities during the three stages of surgery.
Go to:
Indications for liver transplantation
The indications for LT in patients with acute and chronic liver failure should be assessed independent of the aetiology and are listed in Table 1 [3].
Table 1
Indications for liver transplantation
Class Disease
Non-cholestatic liver disease HepatitisB
HepatitisC
HepatitisD
HepatitisA
Alcoholic liver disease
Autoimmune hepatitis
Cryptogenic cirrhosis
Non-alcoholic steatohepatitis
Other
Cholestatic liver disease Primary biliary cirrhosis
Secondary biliary cirrhosis (Caroli disease, choledochal cyst)
Primary sclerosing cholangitis
Other
Malignant disease Hepatocellular carcinoma
Cholangiocarcinoma
Hepatoblastoma
Other
Extrahepatic biliary atresia or hypoplasia Alagille syndrome
Other
Metabolic diseases Alpha-1 antitrypsin deficiency
Crigler-Najjar disease, Type I
Byler’s disease
Glycogen storage disease, Type I
Wilson’s disease
Hemochromatosis
Tyrosinemia
Wolman’s disease
Familial amyloidotic polyneuropathy
Primary hyperoxaluria type 1
Other
Hepatic vein thrombosis Budd-Chiari
Acute hepatic failure Hepatitis
Drugs
Unknown aetiology
Re-transplantation Primary non-function
Hepatic artery thrombosis
Acute/chronic rejection
Open in a separate window
The US and European countries have been using the Model for End-Stage Liver Disease (MELD) score for organ allocation since 2007. This is a grading system from 6 to 40 points, which depen
Acute Kidney Injury epidemiology, pathophysiology and management based on current evidence. The presentation is suitable for internal medicine trainees and nephrology fellows.
Adjuvant therapy protocols for liver cancer in patients undergoing liver tran...hr77
Many patients undergo liver transplantation for a liver cancer in a setting of liver cirrhosis. When is it possible to consider chemotherapy in such patients? Is it even possible? Is there a role?
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
4. Liver Transplantation History
• 1958 Research programs on liver
replacement at Northwestern and Harvard
• 1963 First liver transplant (Univ. of CO)
• 1967 First long survival
• 1979 Cyclosporine
• 1987 Univ. of WI solution for improved
organ preservation
• 1989 FK 506
• 1999 Living donor liver transplantation
5. Liver Transplantation
Liver transplantation is the OPTIMAL
treatment for end stage liver disease
(ESLD)
ESLD has 2 forms: Acute and Chronic
- Acute = Fulminant Hepatic Failure
- Chronic = Cirrhosis
6. Fulminant Hepatic Failure (FHF)
Synonymous with Acute Liver Failure
Definition: Development of encephalopathy
within about 8 weeks of the onset of
symptoms or within about 2 weeks of the
onset of jaundice
Pathology: Pan-lobular or Sub-massive
necrosis
Classically seen in Paracetamol poisoning.
In India – commonest cause is HEV, HAV
and drug induced.
7. Criteria for transplantation of acute
liver failure
KING’S COLLEGE CRITERIA
• Acetaminophen toxicity
ph < 7.30 (after hydration and regardless of degree of encephalopathy)
or
INR >6.5
creatinine >3mg/dl
Encephalopathy III-IV
• Non-acetaminophen etiology
•INR >6.5 irrespective of degree of encephalopathy
or 3 of the following five criteria
Age<10, >40
Etiology: nonA-E hepatitis, drugs
Duration of jaundice before encephalopathy >7 days
INR >3.5
Serum bilirubin >17.5 mg%.
CLICHY CRITERIA
• Factor V <20% (age <30 years) or 30% (age >30 years)
• Confusion and/or coma
8. Acute Liver failure (PGIMER criteria –
Clinical prognostic Indicators)
age ≥50 yr,
JEI >7 days,
grade 3 or 4 encephalopathy,
presence of cerebral edema,
prothrombin time ≥35 seconds, and
creatinine ≥1.5 mg/dL.
Presence of any 3 of 6 CPI was optimum in
identifying survivors and nonsurvivors
9. Chronic Liver disease : Cirrhosis
All patients with cirrhosis do not qualify for liver
transplantation.
Transplantation is generally considered when a
patient has suffered from either a complication of
portal hypertension.
The onset of decompensation is associated with
significantly impaired survival.
The development of hepatorenal syndrome is an
ominous marker that signals the need for
immediate transplant evaluation.
10. Chronic Liver Disease — Signs of
decompensation
Ascites
Encephalopathy
Portal Hypertensive Bleeding
Hepatocellular Carcinoma in the setting of
Cirrhosis
11. Chronic Liver Disease—Indications for
Transplantation
Ascites
Ascites has a two-year mortality of 50%
SBP has a two-year mortality of 80%
Hepato-Renal Syndrome :
- 2 types, type 1 has very poor prognosis,
>50% mortality at 2 weeks, and type 2 has 50%
mortality at 1 year.
Variceal bleed and hepatic encephalopathy:
difficult to quantify the effect on mortality as they
are a mechanical result of portal hypertension
12. When?
Quality of life issues
– Severe lethargy
– Intractable itching
– Recurrent bile duct infections
– Intractable ascites
– Severe bone thinning
– Pain
14. When….?
Patients who are too well should not be
transplanted.
Likewise, transplantation of patients who are
too sick is associated with poor outcomes.
The goal of transplantation is to prolong
survival.
Thus, liver transplantation should be
performed at the time point when the patient
is expected to have greater survival with a
liver transplant than without.
15. Prognostication
Survival of a patient with ‘‘Child’s C cirrhosis’’ is
about 20–30% at 1 year and less than 5% at 5
years.
In contrast, the survival rate after transplantation
is 85–90% at 1 year and over 70% at 5 years.
By the time the patient has evidence of advanced
clinical liver disease (Child’s C cirrhosis), the
patient may not survive long enough to get a
transplant.
16. MELD score
• MELD -- Model for End-Stage Liver Disease
Scoring System – MELD Score
= 0.957 x Loge(creatinine mg/dl)
+ 0.378 x Loge(bilirubin mg/dl)
+ 1.120 x Loge(INR)
+ 0.643
• MELD score depends upon kidney function,
bilirubin level and clotting factor levels
17. MELD score
Introduced in Feb 2002.
The MELD score originally was developed and
validated to assess the short-term prognosis of
patients with cirrhosis undergoing TIPS.
Developed by the Mayo Clinic.
Using the MELD model, patients are assigned
a score from 6 to 40.
Estimated 3-month survival for a score of 6 is
90%, and for a score of 40 is 7%.
18. Chronic Liver Disease—Indications for
Transplantation
Ultimately, the decision to transplant is based
upon the patient’s likelihood of survival
Survival with transplantation:
One-year ~85-90%
Two-year ~80-88%
Five-year ~65-75%
Usually a patient will be listed for liver tx at a
MELD of 10 or more, when the expected 3
month survival is less than 90%.
20. Guidelines for Organ Allocation
Organs should be allocated to transplant
candidates in the order of medical urgency
The role of waiting times in determining
allocation order should be minimized
Every attempt should be made to promote
efficient use of donor organs
21. Requirements for Transplantation
End stage liver disease
Physiologic ability to tolerate surgery: Cardiac,
pulmonary, renal, cerebral function
Anatomy – status of vessels (PV/HA/HV)
Social support/ psychological support
No extra-hepatic infection or malignancy
Alcohol abstinence for 6 months/ no substance
abuse
22. Contra-indications
Cardiopulmonary disease that cannot be corrected and is a
prohibitive risk for surgery.
Malignancy outside of the liver within five years of
evaluation (not including superficial skin cancers) or not
meeting oncologic criteria for cure.
Active alcohol and drug use. Minimum period of abstinence
of at least six months (+/- participation in a structured
rehabilitation program) may be needed.
Advanced age and AIDS are examples of relative
contraindications.
Liver transplantation can be performed in those older than
65 provided that there has been a comprehensive search
made for co-morbidities
23. Liver Transplantation
Evaluation
Determine cause of liver disease
Document severity of liver disease
Determine survival and functional ability
Concomitant medical problems
Psychiatric evaluation
Social Evaluation
24. LTx Evaluation
• Medical history
– Symptoms such as fatigue, itching, swelling,
changes in mental status and GI bleeding
– Other medical problems
– Medications
– Includes alcohol use and drug use history
• Physical examination
• Blood tests
– Determine underlying cause of liver disease
– Determine current functional status of the liver
25. LTx Evaluation
Liver Ultrasound/CT scan/MRI
Liver biopsy
ERCP/ MRCP – Cholangiogram – examines
bile ducts if cirrhosis is otherwise
unexplained
PET scan and other inv for cancer
26. Evaluation of psychosocial support for
LTx
Psychosocial evaluation
– Support systems
– Compliance with post transplant
immunosuppression medication protocol
after transplantation
Social and family support around the
transplant
27. Limitations of MELD
• Patients with liver cancer
• Bile duct infections
• Itching
• Disabling mental status changes (hepatic
encephalopathy)
• ? Criteria for living donors
Other conditions like : HPS, metabolic diseases,
congenital errors of metabolism, fulminant
liver failure, graft non-function, etc
28. Surgical perspective
Immediate function of a transplanted liver is essential.
Unlike in kidney, pancreas, or, to some extent, heart
transplantation, there is no effective artificial support
for a hepatic patient in the event of graft failure.
A complex surgical exercise in a severely physiologically
compromised patient –
- major surgery
- blood loss – portal hypertension
- immunosuppression
- risk of infection
- necessity of liver function
29. Donor selection
Cadaveric/ living donor.
Blood group match. (HLA not
required/ cross matching not
required).
Size match.
Marginal donors.
Split liver.
30. Organ harvesting/ procurement
HTK solution (custodiol)
UW (Viaspan)
Goal: Cool the organs and
perfuse with preservative
solution while
exsanguinating the
organs.
Aortic canulation
Portal canulation
34. Anesthesia
Physiological processes, biological function, and drug
disposition, renal function, RBF
Interpretation of liver function study results
Portal hypertension and complications: variceal hemorrhage,
SBP, sepsis, ascites, hepatorenal syndrome, encephalopathy
Cardiac and circulatory effects: hyperdynamic circulation,
vasodilatation.
Portopulmonary hypertension
Coagulopathy
Cholestasis, jaundice
Impact of anesthesia on liver function
Limited functional reserve
Hepatic blood flow
Drug clearance
Anesthesia-induced hepatitis
Postoperative jaundice
Risk factors for decompensation in patients with cirrhosis
35. Implantation of the new liver.
Orthotopic/ auxillary
begins with a controlled
recipient hepatectomy
formidable task in individuals
with severe portal
hypertension and extensive
collateral
Role of temporary porta-caval
shunt..
Engraftment with venous,
arterial and then biliary
anastomoses.
Classic v/s piggy back
implantation.
36.
37. Classical v/s piggy back technique
Classical or cava
replacement
Piggy-back technique
38. Graft function
Helpful signs of hepatic function in the
immediate postoperative period
1. Hemodynamic stability
2. Awakening from anesthesia
3. Clearance of lactate
4. Resolution of hypoglycemia
5. Normalization of coagulation profile
6. Resolution of elevated transaminases
7. Bile of sufficient quantity and golden brown in
color
41. Immediate outcome
What factors:
Organ harvesting.
Organ preservation.
Warm and cold ischemia times.
Graft selection/ graft quality.
Donor-recipient matching.
Surgical problems.
Medical issues.
42. Post-op monitoring
Monitor hemodynamics, vitals, and blood tests.
Blood tests: LFTs, lactate, ABG, CBC, and coagulation
parameters.
Monitor immunosuppression.
rising transaminases and bilirubin in the 48 h immediately
after transplantation may not be ominous signs as long as
the prothrombin time, serum lactate, bile production, or
other measures of hepatic function are stable or improving
Usually anesthesia is not reversed and patients are kept
intubated for upto 48 hours.
Doppler examination of the transplanted liver.
Medication: immunosuppression, antibiotics, antiplatelets,
analgesics, and PPIs.
44. Complications
Immediate, early and late.
Immediate – post-op.
- Bleeding (commonest – 12-15%)
- Graft non-function (PNF) [5%] or
delayed graft function [6-7%].
- Vascular complications: HAT, PVT and
venous thrombosis.
- Renal dysfunction.
- complications related to prolonged and
major surgery, blood transfusion.
- Infections – viral and bacterial.
46. Complications
Late complications:
- Usually late, after more than a year.
- Recurrent disease
- Medication adverse effects
- Chronic rejection
- Infections
- Metabolic problems
- Recidivism
48. Waiting for a liver
Management of Ascites.
Management of portal hypertension
Renal function
Hepatic encephalopathy
General health and activity
Treatment of viral disease
Vaccination
Prevention of infection.
49. If waiting is not possible….,
getting too late….
LDLT: living donor liver transplant.
India: only related/ approved by a ethical committee.
Advantages:
- elective surgery.
- healthy known donor
- short cold ischemia times
- reduced waiting time
Disadvantages:
- risk to donor
- cost and more resources
- higher risk of biliary ad vascular complications
- reduced size liver
52. Essential Concepts for Using
Living Donors
• No conflict of interest
• No coercion
• Minimize donor risks
• Donors must be given every opportunity to
change their minds
• Emphasize alternatives
53. How Much Liver Do You Need?
• Liver = 2% body weight
• Optimal: > 1% liver weight/body weight ratio
• 70 kg recipient needs at least 700 cc (gm)
• Cannot go below 0.7 - 0.8%
- GRWR.
- Graft/ SLV ratio
- Usually right lobe.
- Recently the use of dual grafts has been done
successfully.
54. LDLT problems
Risk to donor: 0.2 – 0.3% risk of death
- 2-4% risk of major complications
- About 15-25% risk of minor complications.
Higher incidence of biliary problems
Higher incidence of vascular problems
Small for size syndrome
Ethical issues
Initially had poorer graft survival, but recently
has been equal to DDLT.
55. Diagnoses indicating potential candidacy for LT include the following:
* 070 Viral hepatitis
* 1550-1552 Malignant neoplasm of liver and intrahepatic bile ducts
* 2115 Benign neoplasm of liver and biliary passages
* 2308 Carcinoma of liver and biliary system
* 2353 Neoplasm of uncertain behavior in liver and biliary passages
* 2390 Neoplasm of unspecified nature in digestive system
* 2710 Glycogenesis
* 2720 Pure hypercholesterolemia
* 2727 Lipidoses
* 2751 Disorders of copper metabolism
* 2770-2776 Cystic fibrosis, disorders of porphyrin metabolism, other disorders of purine and pyrimidine
metabolism, amyloidosis, disorders of bilirubin excretion (like EHBA as well as Criggler Najar syndrome),
mucopolysaccharidosis, other deficiencies of circulating enzymes including urea cycle disorders, an dother metabolic
disorders.
* 2860 Congenital factor VIII disorder
* 2861 Congenital factor IX disorder
* 4530 Budd-Chiari syndrome
* 570 Acute and subacute necrosis of liver
* 5710 Alcoholic fatty liver
* 5712 Alcoholic cirrhosis of liver
* 5714 Chronic hepatitis
* 5715 Cirrhosis of liver without mention of alcohol
* 5716 Biliary cirrhosis
* 5718 Other chronic nonalcoholic liver disease
* 5719 Unspecified liver disease without mention of alcohol
* 5728 Other sequelae of chronic liver disease
* 5758 Other specified disorders of gallbladder
* 5761,5762 Cholangitis, obstruction of bile duct
* 75161,75169 Biliary atresia, other anomalies of gallbladder, bile ducts, and liver
* 7744 Perinatal jaundice due to hepatocellular damage
* 7778 Other specified perinatal disorders of digestive system
* 864 Injury to liver
* 3483 Encephalopathy, unspecified
* 452 Portal vein thrombosis.