ročník 11,2003 č.4
Kongres

Treatment of early surgical complications after liver transplantation

Ryska, M.

Transplant surgery department
Institute for clinical and experimental medicine (IKEM),
Prague

The results of liver transplantation have improved dramatically over the past 20 years. This has produced a huge increase in demand for this procedure. The improvements in outcome are multifactorial and include identification of the patients who are likely to benefit from liver transplantation, earlier referral of such patients, improved surgical technique and perioperative care, better immunosuppressive regiments. In the last decade 1-year survival of patients after liver transplantation has reached more than 90 % in many transplant centres and the survival curve for other years is relatively flat (Maddrey WC et al, 2001). On the other hand liver transplantation is a procedures with high morbidity. Nearly 100 % patients have at least one complication of any kind (Clavien PA et al, 1994). Complications of liver transplantation occur in patients who often have had serious medical problems before transplantation. Complications affecting liver transplant recipients prior to discharge or death can be classified as immediate in intensive care phase or early:
Immediate - postoperative bleeding, PNF (primary non-function of the graft) and acute renal failure.
Early - primary poor or delayed function of the graft, HAT (hepatic artery thrombosis), portal vein thrombosis, bile leakage or biliary obstruction (cholangitis), bacterial infection, AR (acute rejection), opportunistic infection (viral, fungal).

Complications immediate after surgery

Complications following liver transplantation in the immediate period influenced by the transplant operation itself and the quality of the newly inserted liver graft. Excessive intraoperative bleeding poses a major risk for the development of postoperative complications. In liver transplantation the surgeon is most often confronted with patients with portal hypertension with fragile venous collaterals and coagulopathy. Pharmacological therapy like administration of aprotinin can reduce the fibrinolysis inherent in liver transplantation. Surgical skill and experience are probably still the most important predictors of blood loss during surgery and immediate postoperative bleeding (Bechstein WO et al, 2000). The incidence of postoperative haemorrhage with the need of operative revision is about 10 - 15 %.
PNF is the failure of the new liver graft. This may be due to pre-existing factors in the donor (i.e. fat liver), poor preservation or reperfusion injury (Bzeizi K et al, 1997). After surgery the patient develops a progressive acidosis, renal failure and all of the other features characterising fulminant hepatic failure. Hemodynamic instability and death ensues unless retransplantation is urgently undertaken. Fortunately PNF is rare although poor or delayed function of the liver graft occurs in about 5 - 10 % of cases. Renal impairment is observed in many liver transplant recipients. It is characterised by a period of oliguria and a rise in creatinine for several days after surgery. It is usually responded to correction of any fluid deficit and an infusion of dopamine. Acute renal failure requiring haemofiltration or dialysis is uncommon in stable patients transplanted for chronic liver disease. Patients with acute liver failure are often dialysis-dependent before and after liver transplantation. This is best performed as continous arterio-venous haemodialysis. Most patients will produce a diuresis within 2 weeks. Nephrotoxicity of CyA and FK506 is well known and in some cases in early postoperative period a drug regimen should be tailored according to creatinine.

Early complications after surgery

Causes of PNF in this period are displayed on table 1 (Busuttil RW, 1996).

  Incidence Time Coagulopathy Graft survival
PNF 6 % … 48 hours Yes … 10 %
HR Rarely 6 - 24 hours Yes not mentioned
AR 50 - 70 % 5 - 7 days No 90 %
Tab. No.1 - Causes of PNF early after liver transplantation

The incidence of HAT early after transplantation reaches about 3 - 5 %, more in paediatric recipients. Early detection and urgent surgical treatment can be crucial for graft and patient survival. Fortunately portal thrombosis is rare complication. Early biliary leakage or obstruction as a cause of cholangoitis can be detected by ERCP and mostly treated by minimally invasive approaches (endoscopically or percutaneously). All patients receive prophylactic broad-spectrum antibiotics for 3 days following surgery and this period is extended in the patients requiring prolonged ventilation. Bacterial infections are common and most frequently involve the respiratory and biliary tract, especially in the case of biliodigestive anastomoses (hepaticojejunostomy - HJA). High incidence of pleural effusions contributes to impaired respiratory function, larger ones should be tapped. All immunosuppressed patients are at risk of developing opportunistic infections and after liver grafting CMV and fungal infection are common. Risk factors include fulminant hepatic failure as an indication for liver transplantation, prolonged ventilation, PNF or delayed graft function and high dosage immunosuppression (Villacian JS et al, 1999).
The introduction of CyA in the early 1980s and other immunosupressants in 1990s and induction triple therapy leaded to minimise the problems with acute rejection. Nevertheless episode of acute rejection especially in HCV patients can start infection complication and following deterioration of patient status including liver function. Therefore it is the place of the tapering of immunosuppression regiment in each patient as a results of experience of transplant team. Nevertheless acute rejection after liver transplantation as a cause of graft failure is extremely rare. Complications leading to the indications for early retransplantation are very similar to the causes of PNF.

IKEM experience

Within the period of 4/1995 till 5/2002 in Institute for clinical and experimental medicine (IKEM) 246 liver transplantation were provided. The incidence of HAT was 3,3 % (9 cases) with the incidence in 4,1 day (1-15 days). After selective angiography urgent thrombectomy in 3 patients and reanastomosis in 5 patients were done with mortality reached 22,2 %. Incidence of biliary complications was in the first 280 liver transplantation 27,8 % (78 pts.). In 2002 was only 12 %. Transduodenal endoscopy in 36 and percutaneous approach in 9 patients successful. In the failure of the miniinvasive approach HJA was done in 21 patients (3 anastomosis reconstruction). 4 patients were indicated to re-transplantation. Deaths related to biliary complication we mentioned in 2 patients after re-LTx (0.7 %).

Conclusion

There are a few areas in surgery it can match the major advances in outcome after liver transplantation for the patients. Nevertheless complications developing after liver transplantation are common and varied producing a lengthy learning curve for the liver transplant team. Many problems can often be preemted by experience transplant team by the early recognition of clinical patterns. Potential disasters can be averted.

References

  1. Maddrey, W.C., Schiff, E.R., Sorrell, M.F.: Transplantation of the liver. Lippincott, Williams and Wilkins, 3rd ed., 2001: 275 - 295
  2. Clavien P.A., Camargo, C.A., Croxford, R. et al.: Definition and classification of negative outcomes in solid organ transplantation. Application in liver transplantation. Ann.Surg., 220, 1994: 109 - 120
  3. Bechstein, W.O., Neuhaus, P.: Blutungsproblematik in der Leberchirurgie und lebertransplantation. Chirurg, 71, 2000: 363 - 368
  4. Bzeizi, K., Jalan, R., Plevris, J.N. et al.: Primary graft dysfunction after liver transplantation: from pathogenesis to prevention. Liver Transpl. Surg., 3, 1997: 137 - 148
  5. Busuttil, R.W.: Liver transplantation. Sauders, 1996
  6. Villacian, J.S., Paya, C.V.: Prevention of infections in solid organ transplant recipients. Transpl. Inf. Dis., 1, 1999: 50 - 64.

Address for correspondence:

Miroslav Ryska, MD, PhD.
Transplant surgery department
Institute for clinical and experimental medicine (IKEM)
Videnska 1958/9
140 00 Prague 4