ABC of diseases of liver, pancreas, and biliary system: Transplantation of the liver and pancreas

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Abstract
Liver transplantation Indications and contraindications Hepatocellular carcinoma complicates many chronic liver diseases, and a small tumour is not a contraindication to transplantaton because tumour recurrence is uncommon in these patients. However, most patients with large (>5 cm) or multiple hepatomas or most other types of cancer are not considered for transplantation as tumours recur rapidly. Patients with certain rare tumours, such as liver metastases from neuroendocrine disease and sarcomas, can do well for several years. Contraindications to liver transplantation include extrahepatic malignancy, severe cardiopulmonary disease, systemic sepsis, and an inability to comply with regular drug treatment. Common indications for liver transplantation Primary biliary cirrhosis Primary sclerosing cholangitis Cryptogenic cirrhosis Chronic active hepatitis (usually secondary to hepatitis B and C) Alcoholic liver disease (after a period of abstinence) Timing and selection of patients for transplantation The preoperative status of the patient is one of the most important factors predicting the outcome after transplantation. Patients with chronic liver disease and signs of decompensation should be assessed for transplantation before they become critically ill. In certain diseases, such as primary biliary cirrhosis, quality of life issues may form the basis for indication for transplantation. For example, chronic lack of energy can be debilitating in patients with biliary cirrhosis. Signs of decompensation in chronic liver disease Tiredness Ascites Encephalopathy Peripheral oedema Jaundice (not always a feature) Spontaneous bacterial peritonitis—abdominal pain (a late sign) Bleeding oesophageal or gastric varices Low albumin concentration Raised prothrombin time Acute liver failure and timing of transplantation Liver transplantation greatly improves the prognosis of patients with fulminant liver failure. In the United Kingdom paracetamol overdose is now the commonest cause of acute liver failure, followed by seronegative (non-A, non-B, non-C) hepatitis. Paracetamol overdose Causes death by acute liver failure Renal failure develops as a hepatorenal syndrome and by acute tubular necrosis but is usually recoverable Early deaths usually result from raised intracranial pressure, and comatose patients require monitoring in an intensive care unit Death in later stages can occur from multiorgan failure and systemic sepsis If the patient survives without transplantation, the liver will recover without the development of cirrhosis The donor organ is usually procured as part of a multiorgan retrieval from a heart beating, brain dead patient The mortality from fulminant liver failure can be as high as 90%, whereas one year survival after urgent transplantation is often above 70%. In the United Kingdom, criteria developed at King's College Hospital are used for listing patients for “super urgent” transplantation. This scheme relies on cooperation between the liver transplantation centres to allow transplantation within 48 hours of listing whenever possible. Surgical procedure Before organs are removed an exploratory laparotomy is done on the donor to rule out any disease process (such as unexpected carcinoma) that may preclude organ donation. The major vessels are then dissected and blood flow controlled in preparation for hypothermic perfusion with a cold preservation solution. University of Wisconsin preservation solution is used most widely. It can preserve the liver adequately for about 13 hours, with acceptable results up to 24 hours. View larger version: In this window In a new window Implantation of liver transplant after hepatectomy Hepatectomy in the organ recipient is the most difficult part of the operation as the patient is at risk of developing a serious haemorrhage due to a combination of portal hypertension, defective clotting, and fibrinolysis. Improvements in surgical technique and anaesthesia have resulted in large reductions in blood loss, and the average requirement for transfusion is now four units of blood. At reimplantation, the suprahepatic and infrahepatic inferior vena cava and the portal vein are anastomosed and the organ is reperfused with blood. This is followed by reconstruction of the hepatic artery and bile duct. Postoperative management Patients are usually managed in an intensive care unit for the first 12–24 hours after surgery. Enteral feeding is restarted as early as possible, and liver function tests are done daily. Immunosuppressive protocols usually include a combination of cyclosporin or tacrolimus together with azathioprine or mycophenolate mofetil and prednisolone. The dose of steroids is rapidly tapered off, and they can often be stopped after two to three months. The doses of cyclosporin or tacrolimus are reduced gradually during the first year (during which pregnancy should be avoided) and continued at much lower levels for life. Side effects of immunosuppresive drugs View this table: In this window In a new window Side effects of immunosuppresive drugs Acute rejection occurs in about half of patients, but this is easily treated in most cases with extra steroids or by altering the drug regimen. Despite routine use of prophylactic treatment against bacterial, viral, and fungal pathogens, infections remain a major cause of morbidity. The side effects of the drugs are usually well controlled before the patient leaves hospital about two weeks after surgery. At discharge, patients need to be familiarised with the drug regimen and side effects and educated about the warning signs of rejection and infection. Patients are usually followed up weekly for the first three months and then at gradually increasing intervals thereafter. Results The five year survival is 60-90%, depending on the primary disease and the clinical state of the patient before transplantation. The newer antiviral drugs plus the preoperative and postoperative adjuvant...

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