What Are the Most Common Liver Transplant Complications?

According to the site of donor liver implantation, it can be divided into orthotopic liver transplantation and ectopic liver transplantation. Orthotopic liver transplantation can be divided into classic liver transplantation and piggyback liver transplantation according to the anastomosis of the donor vein and the recipient's inferior vena cava. In order to solve the problems of donor liver shortage and children's liver transplantation, living partial liver transplantation, reduced volume liver transplantation, split (split) liver transplantation, domino liver transplantation, etc. have appeared successively. In addition, there are auxiliary liver transplantation, liver and heart, kidney and other organs combined transplantation. Currently the world's most popular allogeneic orthotopic liver transplantation, that is, liver transplantation in the usual sense. In short, after the patient's diseased liver is removed, the donor liver is implanted into the recipient's (patient's) original liver in accordance with the normal anatomy of the human body.

Zhou Jian

(Chief physician)

Shanghai Zhongshan Hospital Hepatic Tumor Surgery

The so-called liver transplantation surgery refers to a surgical treatment method in which a healthy liver is implanted into a patient's body through surgery, so that the liver function of patients with end-stage liver disease can be well restored.

Chinese name

Liver transplant surgery

Applicable diseases

Malignant liver disease, liver failure, etc.

Affiliated Department

Surgery-Hepatobiliary Surgery

Liver Transplant Surgery Introduction

It can be divided into orthotopic liver transplantation and heterotopic liver transplantation according to the site of donor liver implantation. Orthotopic liver transplantation can be divided into classic liver transplantation and piggyback liver transplantation according to the anastomosis of the donor vein and the recipient's inferior vena cava. In order to solve the problems of donor liver shortage and children's liver transplantation, living partial liver transplantation, reduced volume liver transplantation, split (split) liver transplantation, domino liver transplantation, etc. have appeared successively. In addition, there are auxiliary liver transplantation, liver and heart, kidney and other organs combined transplantation. Currently the world's most popular allogeneic orthotopic liver transplantation, that is, liver transplantation in the usual sense. In short, after the patient's diseased liver is removed, the donor liver is implanted into the recipient's (patient's) original liver in accordance with the normal anatomy of the human body.

Since 1963, the father of modern liver transplantation, American doctor Starzl, has performed the world's first human orthotopic liver transplantation. After more than 40 years of vigorous development, liver transplantation has entered a mature period in the world. So far, more than 100,000 liver transplantation operations have been performed worldwide, and the rate of 8000-10,000 cases is advancing each year. At present, the one-year survival rate after liver transplantation is> 90%, and the 5-year survival rate is between 70 and 85%, which means that most patients can survive long-term health. The longest patient has survived 36 years after transplantation. He has 1 son.

Compared with foreign countries, liver transplantation in China started late. In 1977, human liver transplantation was attempted in China, and the prelude to clinical liver transplantation in China was unveiled. With the accumulation of experience, especially the rapid development in the past 10 years, liver transplantation in China has ranked among the internationally advanced. As of October 2011, a total of about 20,900 liver transplants have been performed nationwide, and the curative effect after surgery has approached the international advanced level. There are 80 hospitals nationwide for liver transplantation, of which more than 20 are larger.

Indications for liver transplant surgery

Above we know the current status of liver transplantation at home and abroad. So, what kind of patients need liver transplantation? In principle, when various acute or chronic liver diseases cannot be cured by other medical and surgical methods, it is expected that deaths cannot be avoided in the short term (6-12 months) as an indication for liver transplantation. At first, liver transplantation was only a life-saving process. Now, with the continuous development of surgical technology, the application of new immunosuppressants and the accumulation of clinical experience, the perioperative complications and mortality of liver transplantation have decreased significantly. Survival rates and survival times continue to increase. Therefore, when the symptoms of liver lesions cause a serious decline in the quality of life of patients, it has also become one of the main indications for liver transplantation.

In recent years, the types of diseases treated by orthotopic liver transplantation have been expanding. So far, according to incomplete statistics, liver transplantation has been successfully used for the treatment of more than 60 liver diseases. According to the nature of the disease, it can be broadly divided into: end-stage liver Sclerosis, malignant liver disease, congenital metabolic disease, and acute or subacute liver failure. As the experience of liver transplantation increases, the contraindications for transplantation continue to decrease. Many previously considered absolute contraindications have now become relative contraindications, and many relatively contraindications have now become indications. ^[1]

Contraindications to liver transplant surgery

Absolute contraindications for liver transplantation

Generally speaking, patients with the following conditions are not suitable for liver transplantation: there are malignant tumors outside the liver that are difficult to cure; infections that are difficult to control; alcoholics or drug users who are difficult to quit; severe heart, lung, brain, kidney and other important organs Organic lesions; mental disorders or mental illnesses that are difficult to control.

Relative contraindications for liver transplantation

In addition, patients with the following conditions currently generally need to be carefully considered for liver transplantation: those over 65 years of age; those with portal or superior mesenteric venous thrombosis; sepsis from the biliary system; previous history of mental illness or drug abuse.

Preparing for liver transplant surgery

Therefore, before a patient visits a transplant center for the first time and has not been included in the list of liver transplant recipients, he must undergo a comprehensive medical evaluation. The evaluation of liver transplant candidate recipients involves the patient's social psychology, economic status, general conditions, the impact of other diseases on liver transplant recipients, the degree of liver disease in patients, and the impact on the body. Candidate recipients of liver transplantation must not only have indications for liver transplantation, but also have good social and psychological quality and economic security. In addition, some diseases and complications that may affect the prognosis of patients during perioperative period and after liver transplantation are also needed. Focus on evaluation of dysfunction of the esophagus, such as esophageal gastric varices, hepatocellular carcinoma, portal vein thrombosis, cardiopulmonary and renal diseases, etc.

Preoperative examination of liver transplantation

The systemic system check before liver transplantation is mainly to evaluate the functions of heart, lungs, kidneys and other important organs, the mental and mental state, the nutritional status, and the evaluation of infectious diseases. Specifically, it can be divided into three types: routine inspection, special inspection and individual inspection.

Routine tests include blood, urine, stool, and sputum tests, as well as chest radiographs, electrocardiograms, and abdominal B-ultrasounds.

Special examinations include liver color ultrasound and abdominal magnetic resonance or CT angiography (understand the anatomy and blood flow of the portal vein, hepatic artery, hepatic vein, and inferior vena cava), and magnetic resonance imaging of the biliary system (understand the anatomy of the bile duct inside and outside the liver) structure).

The individualized examination is mainly based on the results of the preliminary examination to determine whether to carry out more in-depth examinations, such as the addition of HBV-DNA and virus-resistant variants in patients with hepatitis B; the original cardiopulmonary disease and echocardiography in patients with cardiopulmonary disease Map, coronary angiography, 24-hour dynamic electrocardiogram, etc.

Examinations required for liver transplantation in patients with liver cancer:

In addition, for liver cancer patients, liver transplantation is the best treatment method, because liver transplantation can maximize the removal of tumors and sclerotic livers, and fundamentally eliminate the soil generated by liver cancer; meanwhile, it can avoid serious liver failure after liver resection. Complications. But the biggest problem is still tumor recurrence after transplantation. It is generally believed that the reason for tumor recurrence after transplantation is that metastases that cannot be detected by conventional methods outside the liver during surgery or tumor cells caused by surgical operations have entered the blood circulation. Therefore, patients with liver tumors must undergo a comprehensive and systematic examination before liver transplantation to exclude the presence of extrahepatic metastases and the possibility of multiple primary tumors.

The first is a comprehensive physical examination and examination of serum tumor markers including AFP, CA19-9, etc .; the second is a comprehensive imaging examination, such as chest radiographs and CT scans to exclude lung metastases and primary lung tumors, skull CT or MRI. The scan excludes brain metastases and primary brain tumors, the isotope bone scan excludes tumor bone metastases, and abdominal CT and MRI scans observe the presence of celiac lymph node metastases and vascular invasion. Finally, further examination is selected based on the medical history and examination results. In addition, PET-CT can complete a whole-body scan at one time, enabling patients to perform detailed screening of various tissues and organs throughout the body during an examination, which is helpful for finding metastases in other parts of the body except the primary tumor. Compared with CT and MRI, It has higher sensitivity and accuracy, and also overcomes the deficiency of whole body nuclide bone scan images that can not provide lesion information to other tissues except bone tissue. It plays an increasingly important role in preoperative evaluation of liver transplantation. As a result, some patients changed their diagnosis stages and corresponding treatment plans. ^[2-3]

Liver transplant operation time

Liver transplantation takes much longer than conventional surgery. With the rapid advancement of surgical technology, in many liver transplant centers, a classic orthotopic liver transplant operation can now be successfully completed in 4-6 hours. Of course, the length of the operation depends on many factors, including whether the patient has a history of upper abdominal surgery, the skill of the physician, the method of operation, whether to perform external venous-venous bypass, etc. The higher the complexity of the operation, the longer the time. Longer. The shorter the operation time, the better the patient's postoperative recovery. The length of hospital stay after surgery often varies from person to person. Most patients can recover within 3 weeks to a month or so after surgery and can be discharged smoothly. However, there are also a small number of patients who may be hospitalized for an extended period of time due to early postoperative complications or the need to adjust immunosuppressive drugs. Once the situation is stable, they can be discharged.

Review after liver transplantation

During the perioperative period after liver transplantation, a complete examination is essential to enable doctors to make a comprehensive and in-depth understanding of the patient's recovery at various stages after surgery and to correctly guide treatment. Laboratory tests and examinations usually include the following:

Vital signs: including the regular measurement of body temperature, blood pressure, pulse, and breathing, and if necessary, central venous pressure and pulmonary arterial pressure, etc., are gradually simplified as the patient recovers.

Urine and fecal routine and culture: 1-2 times a week.

Blood routine, electrolyte and liver and kidney function: check at least once a day, and check twice a week after returning to normal.

Blood coagulation test: check once a day in the early stage of treatment, and check once or twice a week after returning to normal.

Immunosuppressant blood concentration monitoring: measured once every morning. After the blood drug concentration is basically stable and reaches the desired level, it can be checked once a week.

Hepatitis virus detection: routine determination of hepatitis B virus, hepatitis C virus antibodies, and hepatitis B and C virus DNA replication. The first examination will be performed within 1 week after the operation, and will be periodically reviewed afterwards according to the situation.

Cytomegalovirus and Epstein-Barr virus detection: Measured every 2 to 4 weeks during immunosuppressive therapy.

Blood ammonia test: When the patient has changes in consciousness and spirit, it is measured in time and continuously observed, usually once a week. Blood culture: When a systemic infection is suspected, an antibiotic drug sensitivity test is performed to guide the use of antibiotics.

Drainage, secretion, bacterial culture, and fungal testing: Once a week, when infection is suspected, it should be reviewed at any time.

Chest X-ray: Early bedside chest radiograph 1 to 2 times a week, once every 2 weeks after stable respiratory function, check at any time when lung disease is suspected.

Ultrasound examination: One bedside color Doppler ultrasound per day for one week after operation. After multiple consecutive results, the examination can be changed to every 2 to 4 weeks. Ultrasound can help the transplant doctor know whether the patient has pleural fluid, ascites, new liver size and texture, and whether the blood vessel and biliary anastomosis are unobstructed without any pain. One week after surgery is often a period of high incidence of complications such as bleeding, thrombosis and rejection. The use of color Doppler ultrasound can often detect abnormalities in time and treat them in time before patients have discomfort.

Liver biopsy: If liver rejection is suspected, liver biopsy should be performed. It is the gold standard for diagnosing liver transplant rejection for timely detection and treatment. Under normal circumstances, various biochemical indicators of patients' liver function decreased in parallel, and returned to normal in about 3 to 4 weeks after operation, which is a manifestation of successful transplantation. In the event of infection, rejection, vascular and biliary complications, recovery of liver function often takes longer.

Nursing after liver transplantation

Patients need to rely on self-care after recovery and discharge from hospital. They should take medicine strictly according to the doctor's advice. They must not trust other people's advice to change or stop taking medicine. In addition, the patient should maintain the regular life and avoid fatigue, but this does not mean that the patient only rests in bed all day. Proper activities are beneficial. As the body recovers, the patient can resume normal study and work.

Follow-up after liver transplantation

Follow-up frequency of liver transplant surgery

Patients were followed up once a month during the first half of the transplant. Three to six months after surgery, patients need to take large doses of immunosuppressants and hormones. At this time, they often have low resistance and are prone to infections. On the other hand, during this period, the patient's body is resistant to liver transplantation into the body. The immune response is strongest and prone to acute rejection. 3 to 6 months after surgery is a critical moment that affects the long-term survival of liver transplantation and the quality of life of patients. After the six months after transplantation, follow-up was performed every 2 months. In the second year after transplantation, follow-up visits every 3 months; in the third year after transplantation, follow-up visits 1-2 times per year.

Follow-up examination items for liver transplant surgery

The main items for follow-up examination were: blood routine, liver function, FK506, rapamycin or cyclosporine blood concentration.

Of course, once you feel abnormal, don't be lucky, you should go to the hospital immediately to see the doctor, if necessary, review the chest X-ray, liver B-ultrasound, electrolytes, blood lipids, coagulation function, etc. Patients with liver cancer liver transplantation also need to closely monitor the tumor recurrence and follow up various tumor indicators to detect tumor recurrence and metastasis in time, such as regular chest and abdominal CT, B-ultrasound, and serum alpha-fetoprotein (AFP). In addition, some patients with liver cancer need regular systemic chemotherapy and other adjuvant treatments after transplantation to prevent tumor recurrence and further kill cancer cells that may remain in the body.

Frontiers of liver transplant surgery

Unfortunately, due to the relative shortage of donor livers, some patients still lose their chance of being saved. In order to resolve this contradiction, a living liver transplantation technology has been developed, in which a part of the liver of a healthy donor is transplanted into a patient. Since its first successful application in 1989, this technology has been promoted worldwide and achieved better results. Compared with cadaver donor liver and liver transplantation, donors have normal liver function before surgery, hemodynamic stability, and organ preservation time. Shorter, the graft has better viability. A high-quality liver guarantees a high success rate and normal function after the operation. The donors of living liver transplantation are mostly from fathers, mothers, siblings, adult children and spouses. They are greatly satisfied by saving a family member they care about, and they are also respected by the society. The safety of donors is a matter of concern to many people. In fact, out of more than 2,000 live liver transplants to date, only two donor deaths have occurred, so the risk of donors is still very low.

It is not difficult to see that the successful development of liver transplantation in China has brought a lot of hope to many patients with end-stage liver disease.