Transcript Przeszczepienie wątroby

Department of General &
Transplant Surgery
Medical University of Warsaw
History:
1st Kidney Tx Joseph Murray
1st. Liver Tx
1st. Successful Liver Tx
-1953
March’1st 1963
July’23 1967
Polish transplantation program
Kidney Tx
January’26 1966
Comb. Pancreas&Kidney Tx –
April’29 1988
Liver Transplantation
1990
Local 1st Liver
July 2000
Transplant program activity
Transplant procedures :
Kidney
>900 / year
Comb. Pancreas
>20 / year
Liver
> 320 / year
Orthotopic Liver Transplantation
Indication: CHRONIC LIVER FAILURE
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Viral hepatitis
ALD
HCC
PBC
PSC
Cryptogenic
AIH
Wilson Disease
42%
23%
5-15-30%*
9%
11%
7%
4%
1%
*
evolution in last 15 years
Proportion of liver transplants for
specific etiologies,
1992–2007.
Indications for Liver Transplantation. GASTROENTEROLOGY 2008;134:1764–1776
Hepatology, Department of Medicine, Baylor University Medical Center, Dallas, Texas
Indications – local perspectives
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HCV/ HBV
ALD
WILSON DISEASE
CYPTOGENIC
PBC
AUTOIMMUNE
TOXIC
PSC
HCC
GRAFT FAILURE
HEPATIC ARTERY THROMBOSIS
42 %
21 %
9 %
7 %
9 %
11 %
1 %
6 %
17 %
<1%
<1%
Chronic liver failure
modyfied CHILD – PUGH scale
1
1-2
2
2-3
3
>3
ALBUMIN ( G% )
>3,5
2,8-3,5
<2,8
Prolong. PT ( S )
1-4
4-6
>6
ENCEFALOPATHY
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I-II
III-IV
ASCITES
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temporal
refractory
BILIRUBIN ( MG% )
GRUPA
A: 5-6 pkt
B: 7-9 pkt
C: 10-15 pkt
Elective OLTx criteria
CP class B & C are qualified
Class A if :
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Reccurent SBP
Reccurent cholangitis
GI / Varicous bleeding
Refractory Itching
Reccurent Encephalopathy
Renal Impaiment-hepatorenal syndrom
Advanced Osteoporosis
Malaise
MELD
3.8 x log(e) (bilirubin mg/dl)+11.2 x log (e)
(INR) + 9.6 log (e) (creatinin mg/dl)
MELD > 14
Urgent indications for OLTx
- Fulminant hepatitis
B
- intoxication/poisoning :
- PARACETAMOL
- AMANITA PHALLOIDES
- BUDD CHIARI’ syndrom
- WILSON’ disease
- PNF liver graft
- HAT 7-10 days following OLTx
Acute Liver failure
Criteria for OLTx
1. Viral hepatitis CLICHY
2.
other KING’S COLLEGE
Clichy criteria
age < 30 y
Factor V (%)
Encephalopaty
< 20
III/IV
age > 30 y
< 30
III/IV
King`s College criteria
Paracetamol
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ABG’s pH < 7,3
or :
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PT> 100 s.
creatynin > 3,4 mg%
Encephalopaty III/IV
Other causes
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PT > 100 s.
Or 3 out of 5 :
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jaundice > 7 days
age < 10 or > 40 lat
PT > 50 s.
Bilirubin > 17,5 mg%
Intoxic. halotan or
othermadication
Contraindications
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Extrahepatic malignancy
Systemic infections
(except SBP)
Irreversible Respiratory Failure pO2< 50
Irreversible Circulatory Failure
Multiorgan Failure
Portal Thrombosis incl. SMV & Splenic vein
Uncooperative patient i.e. active Alcohol (other
substances) Abuse
Dep. Of General & Transplant
Surgery
Medical University of Warsaw
First 100 OLTx – learning curve 2000-2004
100 LIVER TRANSPLANTATION
4 RETRANSPLANTATIONS
17 urgent indications
99 FULL SIZE 1 REDUCED GRAFT
58 FEMALE
42 MALE
RECIPIENT AGE 17 – 67
Technic
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TX PIGGY-BACK (147) ; ORTH (3)
CELL-SAVER ; BIOPOMP (1 CASE)
BLOOD REPERFUSSION 250-300 ML
BILIARY ANASTOMOSIS END TO END
BILIARY DRAINAGE INSTITUTED
FEEDING JEJUNOSTOMY
Results
100 O.LIVER TRANSPLANTATION
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URGENT (17) :
12 patients survived ( 70,1% )
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ELECTIVE (83) :
74 patient alive & well ( 89.1% )
Cause of death
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( 14 cases)
Septicemia
CVA (intracr. Aneurysm rupture)
Cl. Difficile Vanco-resistant
Cardiac failure
Irreversible brain damage+MOF
Fulminant HCV hepatitis
Graft necrosis – humoral rejections
Other
*All exept one over 50 years of age
4
2*
1
2
2
1
1
1
Complications
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Bleeding requireing re-operation - 4
1 2 1 -
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Bile leakage requireing operation - 2
11-
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G.I bleeding from jejunostomy site
oozing from diaphragma surface
spontaneous spleen rupture (day5 after Oltx)
graft reduction surface
from biliary drain site after rem.
Lymphocyte passenger syndrom - 2
Wound infection - 6
Jejunostomy/Bile drain removal syndrom - 6
Complications
cont.
CMV disease
 Acute fulminant reccurent HCV
 Rejection
 Psychosis
 Cholangitis
(pos. cultures)
 Pseudomembranaceus collitis
 HSV infection
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34
4
21
3
27
45
8
Thank you for attention