Chapter 67: Liver Transplantation

INDICATIONS FOR LIVER TRANSPLANT

• Biliary atresia often following the Kasai procedure

• Metabolic diseases

  • Alpha-1-antitrypsin deficiency

  • Tyrosinemia

  • Wilson's disease

  • Urea cycle defects

  • Hemochromatosis

  • Glycogen storage disease

• Fulminant hepatic failure (see Chapter 66)

  • Infection

  • Toxin

  • Drug ingestion

• Hepatic malignancy

• Chronic liver disease

• End-stage liver disease

CONTRAINDICATIONS FOR LIVER TRANSPLANT

• Absolute contraindications

  • Unresectable hepatic malignant tumor

  • Uncontrollable extrahepatic sepsis

  • Neurologic devastation (arrived by consensus, as stage IV hepatic encephalopathy can mask brain death)

• Relative contraindications

  • Acceptable alternative medical therapy

  • Expected suboptimal outcome

  • Impairment of other organ systems that would compromise function of the graft

  • Major systemic infection

  • Cancer with a high postsurgical recurrence rate

OPERATIVE TECHNIQUE

• Recipient hepatectomy phase

• Anhepatic phase

• Reperfusion phase

  • Arterial anastomoses

  • Biliary reconstruction

  • Hemostasis

TYPES OF TRANSPLANTS

• Reduced size graft

• Split liver graft

• Living related donor transplantation

POSTOPERATIVE MANAGEMENT

RESPIRATORY MANAGEMENT

• Most pediatric patients will return from the operating room intubated and mechanically ventilated.

• The goal should be to extubate as quickly as medically possible, generally within 48 hours.

• Factors that determine extubation readiness for all patients include ventilatory parameters, sedation and analgesia requirements, and hemodynamics.

• Extubation is often delayed until the 12-hour assessment of graft function.

• Prolonged ventilation increases the risk of nosocomial infection and ventilator-associated pneumonia.

• Age and nutritional status play a role in extubation readiness, as does the transplant type.

• Pleural effusion is common, and the right side is more frequently affected. These effusions can generally be managed with diuretics and fluid restriction and rarely require pleurocentesis and drainage.

• Atelectasis is a common problem, especially in young children, and contributes to respiratory distress and difficulty weaning from mechanical ventilation.

• Diaphragmatic dysfunction is associated with prolonged ventilatory requirement and prolonged PICU stay and may require diaphragmatic plication.

• Monitoring includes oxygen saturation, capnography, and arterial blood gas analysis (Table 67-1).

CARDIOVASCULAR MANAGEMENT

• Patients should be monitored with invasive and noninvasive blood pressure monitoring and central venous pressure monitoring, as well as heart rate monitoring (Table 67-1).

• Hemodynamic instability in the early postoperative period is contributed to by acid–base status, fluid status, and bleeding issues.

• A small percentage of patients will have evidence of bacterial translocation intraoperatively (taking down an old Roux-en-Y, manipulating bowel) and present with a ...