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ischemia secondary to atrial brillation–related embolic events after discontinuation of anticoagulation for other reasons [49]. In this setting it is important to communicate with the surgical team the timing for restarting therapeutic anticoagulation
as continuing to hold it can put them at further embolic risk [50].
R. N. Kulkarni and M. H. Eslami
Second-Look Operations
In the past, second-look procedures were common, and in certain circumstances
even an open-abdomen option was adopted, despite catastrophic complications
[51–56]. Intestinal perfusion was typically documented when it was already too
late, and gangrenous bowel carried an ominous mortality. Today, efcient hemodynamic and oxygenation markers provide a useful picture of the post-operative
course, even though regional perfusion decits or imbalances are harder to detect
and, in most circumstances, anticipate potential or imminent troubles. Metabolic
acidosis, hypoxia, intramural pneumatosis, and signs of sepsis continue to carry
prognostic relevance. If a high level of suspicion for ongoing bowel ischemia
remains, imaging methods should be repeated, and further interventions planned.
Nutritional Support
Tolerance of the oral diet may be markedly delayed or insufcient even after successful revascularization; notably, if enteral resection was required, thus enteral nutrition
could be delivered via a nasogastric or nasoenteric tube. Exceptionally a percutaneous
gastrostomy or jejunostomy tube may be placed to facilitate enteral feeding. Short
bowel syndrome is a possibility after total small bowel ischemia, and intestinal transplantation should be considered depending on the circumstances [57–62].
Treatment Options: Arterial
The choice of treatment option depends on various factors such as patient age, comorbidities, and the severity of the disease and inuences post-operative care algorithms.
Endovascular interventions have been increasingly utilized over the last decade, and
they have been shown to be a safe and effective alternative to open surgery [3, 63].
Endovascular Interventions
Percutaneous transluminal angioplasty (PTA): PTA involves the use of a balloon
catheter to dilate the stenotic or occluded segment of the mesenteric artery to
improve blood ow and relieve ischemia. Angioplasty is typically utilized in conjunction with stenting in patients with chronic mesenteric ischemia.
13 Current Management ofPost-operative Mesenteric Ischemia
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Stenting: Stenting involves the placement of a bare metal (uncovered) or covered
stent graft within the mesenteric artery, usually the SMA, to maintain patency and
improve blood ow. Stenting may be used in conjunction with PTA or performed
primarily. Often times after stenting, a patient will need to be placed on antiplatelet
medications to prevent stent thrombosis. The most commonly used antiplatelet
agents after vascular stenting are aspirin and P2Y12 receptor inhibitors (such as
clopidogrel, ticagrelor, or prasugrel) [64]. P2Y12 receptor inhibitors are often prescribed in addition to aspirin and are usually continued for a period of 1–12 months,
depending on the type of stent [65]. When patients are newly placed on a P2Y12
inhibitor, they should be monitored closely for signs or symptoms of bleeding.
Common access sites include the brachial or common femoral arteries. They
should be closely monitored in the immediate post-operative period for any bleeding, hematoma formation, or pseudoaneurysm development. It is extremely important to have a full pulse/signal exam performed and documented at the end of any
endovascular case.
Retrograde open mesenteric stenting (ROMS): When percutaneous stenting has
no indication or has failed, an alternative is to access the affected artery through an
exploratory laparotomy incision via direct percutaneous access into the distal SMA
[46]. Aspirin and/or P2Y12 inhibitors will need to be administered in the postoperative setting.
215
Open Surgical Interventions
Thrombectomy and bowel resection, with eventual bypass grafting of the mesenteric artery, were used during decades. In the era of endovascular rst approach,
open arterial proposals deserve much less interest. By the same token, mesenteric
venous thrombosis is most often handled with systemic anticoagulation without
surgical revascularization. Catheter-directed thrombectomy and thrombolysis could
be attempted depending on angiographic ndings [66–68]. Non-occlusive mesenteric ischemia, as alluded to, is primarily a non-surgical condition, except in circumstances of late diagnosis, when bowel gangrene already occurred and demands
resection.
Post-operative Management: Mesenteric Venous
Thrombosis (MVT)
Unlike arterial mesenteric ischemia which is typically considered a surgical emergency, symptoms of mesenteric venous thrombosis are often less severe and may
develop gradually over time. Treatment is often via anticoagulation alone, although
surgical intervention may be necessary in extreme cases. Diagnosis is made by CT
scan in 90% of patients, and management depends on the presence or absence of
bowel necrosis [67, 68]. Long-term management should be directed toward
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R. N. Kulkarni and M. H. Eslami
treatment of the underlying cause, and regular follow-up after MVT is essential in
evaluating the response to treatment. Up to 25% of patients will experience recurrent thromboses of the mesenteric circulation within the rst 30days. This rate is
lowered to 3% if maintained on therapeutic oral anticoagulation [32, 68].
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R. N. Kulkarni and M. H. Eslami
Chapter 14
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Safety andSuccess inModern Liver
Transplantation
MadelynnZhang, NavdeepSingh, WilliamK.Washburn,
andAustinD.Schenk
Abbreviations
ARDS Acute respiratory distress syndrome
BD Brain dead
CIT Cold ischemic time
CMV Cytomegalovirus
CRRT Continuous renal replacement therapy
DAA Direct-acting antiretroviral
DCD Deceased from cardiac death
DILI Drug-induced liver injury
EAD Early allograft dysfunction
EBV Epstein-Barr virus
ESLD End-stage liver disease
HAT Hepatic arterial thrombosis
HCC Hepatocellular carcinoma
HCV Hepatitis C virus
HIV Human immunodeciency virus
HPS Hepatopulmonary syndrome
HSV Herpes simplex virus
IC Ischemic cholangiopathy
LDLT Living donor liver transplant
MARS Molecular adsorbent recirculation system
MELD Model for end-stage liver disease
M. Zhang
The Ohio State University College of Medicine, Columbus, OH, USA
e-mail: madelynn.zhang@osumc.edu
N. Singh · W. K. Washburn · A. D. Schenk (
Department of Surgery, Division of Transplantation, The Ohio State University Wexner
Medical Center, Columbus, OH, USA
e-mail: navdeep.singh@osumc.edu; ken.washburn@osumc.edu; austin.schenk@osumc.edu
Switzerland AG 2024
J. Faintuch, S. Faintuch (eds.), Recent Strategies in High Risk Surgery,
https://doi.org/10.1007/978-3-031-56270-9_14
*)
219© The Author(s), under exclusive license to Springer Nature
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M. Zhang et al.
NASH Non-alcoholic steatohepatitis
PBC Primary biliary cirrhosis
PNF Primary non-function
POPH Portopulmonary hypertension
PSC Primary sclerosing cholangitis
SIRS Systemic inammatory response syndrome
SMV Superior mesenteric vein
SRTR Scientic Registry of Transplant Recipients
TPA Tissue plasminogen activator
Introduction
In the six decades since Dr. Thomas Starzl performed the world’s rst successful
liver transplant [1], signicant improvements in surgical technique, anesthetic practice, and critical care have allowed liver transplantation to become standard-of-care
treatment for patients with end-stage liver disease (ESLD). Without doubt, liver
transplantation remains one of the most complex and high-risk abdominal surgical
procedures performed. This chapter is intended to provide a practical overview of
adult liver transplantation with emphasis on modern strategies employed to mitigate
risk and achieve ideal recipient outcomes.
Indications forLiver Transplantation
The Scientic Registry of Transplant Recipients (SRTR) groups the indications for
liver transplantation into the 10 categories shown in Table14.1 [2]. As of 2021,
33.9% of patients awaiting liver transplantation carried the diagnosis of alcoholic
liver disease [3]. Non-alcoholic steatohepatitis (NASH) is the second most common
indication for liver transplantation comprising 19.2% of the waiting list, and notably
Table 14.1 Potential indications
for liver transplantation
Non-alcoholic steatohepatitis (NASH)
Alcoholic liver disease
Hepatitis B or C
Cholestatic liver disease
Autoimmune liver disease
Metabolic liver disease
Malignant liver disease
Liver graft failure
Acute liver failure
Other modalities of acute or chronic liver failure
14 Safety andSuccess inModern Liver Transplantation
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this number has increased by 250% over the last 10years. Hepatitis C (HCV) was
historically a leading indication for liver transplantation, and a common cause of
early graft failure sometimes necessitating re-transplantation [4]. The advent of
direct-acting antiretroviral (DAA) medications has greatly reduced the prevalence
of HCV, need for HCV-related liver transplantation, and has even allowed for expansion of the donor pool wherein HCV-positive donor livers can be transplanted followed by recipient treatment with DAAs, allowing for excellent long-term
outcomes [5, 6].
The category of cholestatic liver diseases includes primary biliary cirrhosis
(PBC), primary sclerosing cholangitis (PSC), IgG4-related sclerosing cholangitis,
and genetic diseases such as Caroli’s disease that lead to progressive cholestasis.
Not infrequently there are mixed disorders in which autoimmune and cholestatic
etiologies intersect. Liver transplantation for metabolic diseases is far more common in the pediatric population; however, patients with alpha-1-antitrypsin deciency, hemochromatosis, and Wilson’s disease are often transplanted in adulthood.
Hepatocellular carcinoma (HCC) is by far the most common malignancy treated
with liver transplantation; however, the eld of transplant oncology is rapidly evolving [7] to include intrahepatic and hilar cholangiocarcinoma, colon cancer with
unresectable liver metastases, and neuroendocrine tumors [8]. Common causes of
acute liver failure include acetaminophen overdose and other forms of drug-induced
liver injury (DILI), acute alcoholic hepatitis, viral etiologies, and acute Budd-Chiari
syndrome.
221
Preoperative Evaluation forLiver Transplantation
Liver transplantation provides full cure for appropriately chosen recipients, but also
it has potential to shorten overall length of life when offered to unsuitable candidates [9, 10].
Evaluation typically begins with an electrocardiogram, echocardiogram, stress
test, and assessment of cardiac risk factors. Risk factors for coronary artery disease including tobacco use, peripheral vascular disease, diabetes, hypertension,
hyperlipidemia, and obesity are considered, and left heart catheterization is generally pursued in patients with multiple risk factors. Right heart catheterization is
warranted in any candidate with elevated right ventricular systolic pressures or
other suggestions of possible right heart dysfunction, and the combination of
echocardiography and right heart catheterization are generally used to identify and
distinguish between hepatopulmonary syndrome (HPS) and portopulmonary
hypertension (POPH). Arterial blood gases should be obtained in all candidates,
and formal pulmonary function testing should be pursued in patients with abnormal blood gases, a baseline oxygen requirement, signicant exercise-induced
desaturation, and smoking history or radiographic evidence of obstructive pulmonary disease.
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Two-dimensional liver imaging (CT or MRI) is recommended for all potential candidates and serves dual purposes. Because cirrhosis increases risk for
hepatocellular carcinoma, preoperative imaging is used to identify, stage, and
plan bridging therapies for candidates with HCC.From a surgical perspective,
preoperative imaging allows the transplant surgeon to verify portal vein
patency or select alternative inflow, decipher hepatic arterial anatomy, and
measure the dimensions of the right upper quadrant in order to select an appropriately sized donor. In cases of acute or decompensated cirrhosis where candidates are unstable for transport to radiology, a bedside Doppler ultrasound
can substitute.
M. Zhang et al.
Oncology Screening
Upper endoscopy is generally performed to treat esophageal varices prior to waitlisting. Searching for occult malignancies is warranted as these lesions will blossom
with the initiation of immunosuppression, and thus colonoscopy should also be performed for all candidates over the age of 50 or with increased risk factors for colon
cancer. Likewise guidelines for other age-related cancer screenings are followed
including mammograms in all female candidates over the age of 40, Papanicolaou
(PAP) smear testing in women without hysterectomy, and prostate specic antigen
(PSA) testing in men. Alfa fetoprotein levels are also checked in all candidates as an
additional screen for HCC.
Several additional components round out the pretransplant work-up. Dental
screening is recommended, and critical dental issues should be addressed pretransplant. Formal or informal clinical frailty assessment is absolutely essential to identify candidates who can complete the rigorous recovery that follows liver
transplantation [11]. Psychiatric and neurocognitive testing can be useful to assess
readiness for transplant in cases of addictive disease (e.g. alcohol or drug-related
HCV) and to ensure medication adherence and baseline stability in cases of comorbid psychiatric disease (e.g. schizophrenia, bipolar disease).
Transplant centers generally verify the willingness of at-home support resources
for transplant candidates, particularly in cases where physical or mental barriers
decrease recipient independence and necessitate intensive care-giving. Financial
and insurance assessments help verify transplant center reimbursement and also
ensure that transplant-related costs will not be bankrupting for the recipient.
Lastly, preoperative bloodwork is used to calculate model for end-stage liver disease (MELD) score, assess renal function, measure cytomegalovirus (CMV),
Epstein- Barr virus (EBV), and herpes simplex virus (HSV) serostatus, and exclude
syphilis, active hepatitis, human immunodeciency virus (HIV) and tuberculosis.
Most programs also include drug and alcohol screening in candidate bloodwork
(Table14.2).
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223
Table 14.2
for liver transplantation
Essential evaluation
Cardiovascular screening
Electrocardiogram
Echocardiogram
Stress test
Right and left heart catheterization (if indicated)
Pulmonary testing
Chest X-ray
Arterial blood gas
Pulmonary function tests
Liver imaging (CT, MRI, or Doppler US)
Frailty assessment
Upper gastrointestinal endoscopy
Age and gender appropriate cancer screening
Dental screening
Psychiatric and neurocognitive assessment
Verication of at-home support
Financial and insurance assessment
Bloodwork
CT Computed tomography, MRI Magnetic resonance
imaging, US Ultrasonography
Absolute Contraindications toLiver Transplantation
Flow-limiting coronary artery disease not amenable to percutaneous or open surgical intervention is a rare but absolute contraindication to liver transplantation.
Likewise, non-correctable severe valvular disease and conditions causing signicant non-reversible depression of the ejection fraction prohibit transplantation. Due
to the proximity and “in-series” relationship of the liver and right ventricle, dynamic
right heart function is essential for safe liver transplantation. Regardless of etiology,
non-correctable conditions causing a mean pulmonary artery pressure >40mmHg
are generally considered an absolute contraindication [12]. Extra-hepatic malignancy is almost always a contraindication to liver transplantation, as are uncontrolled psychiatric illness, lack of adequate social support, and inability to pay for
post-transplant medications.
Relative Contraindications toLiver Transplantation
There is no recommended maximum age for liver transplant recipients, and certainly transplant recipients in their seventies and even eighties can experience excellent outcomes [13, 14]. Rather, age must be considered in the context of functional
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