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Liver Diseases pp 741–756Cite as

Surgical Complications Following Liver Transplant and Their Management

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Abstract

Surgical complications are common after orthotopic liver transplantation. They have a significant detrimental impact on graft and patient survival and they increase medical costs. Their treatment may require vascular and biliary interventions by the interventional radiologists, re-operations or when graft salvage is impossible, retransplantation. Postoperative bleeding is the commonest cause for reoperation after OLT. Vascular complications in the early postoperative period are life threatening, with hepatic artery thrombosis and portal vein thrombosis being the most common. Most patients with hepatic artery thrombosis ultimately require retransplantation. Early detection and treatment of bile leaks and anastomotic biliary strictures usually result in good graft and patient survival. However, nonanastomotic biliary strictures are difficult to treat and most patients require retransplantation. Intra-abdominal infections and wound complications often require readmissions and reoperations, and close follow up and clinical examination are important in their early detection and effective treatment. Complications are more common when transplant is performed in advanced cirrhosis and with marginal donor livers, such as those from DCD (donated after cardiac death) donors. Optimal management of intraoperative coagulopathy and optimization of anaesthesia (see chapter 70: Anaesthesia for Liver Transplantation) and surgical techniques are important in preventing postoperative surgical complications. Early diagnosis and treatment of complications improves graft and patient survival but when graft damage is severe, early retransplantation can save the patient’s life.

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Author information

Authors and Affiliations

  1. HPB and Liver Transplant Unit, Royal Free London NHS Foundation Trust, London, UK

    Rahul S. Koti, Helen Tzerbinis & Brian R. Davidson

  2. Centre for Surgical Innovation, Organ Repair and Transplantation, Division of Surgery, Hampstead Campus, University College London (UCL), London, UK

    Rahul S. Koti, Helen Tzerbinis & Brian R. Davidson

Authors
  1. Rahul S. Koti
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  2. Helen Tzerbinis
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  3. Brian R. Davidson
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Corresponding author

Correspondence to Brian R. Davidson .

Editor information

Editors and Affiliations

  1. Faculty of Medicine, “Titu Maiorescu” University, Central Military Emergency University Hospital “Dr. Carol Davila”, Bucharest, Romania

    Florentina Radu-Ionita

  2. New Jersey Medical School, Rutgers University New Jersey Medical School, Newark, NJ, USA

    Nikolaos T. Pyrsopoulos

  3. Carol Davila University of Medicine and Pharmacy, Central Military Emergency University Hospital “Dr. Carol Davila”, Bucharest, Romania

    Mariana Jinga

  4. Faculty of Medicine, “Titu Maiorescu” University, Central Military Emergency University Hospital “Dr. Carol Davila”, Bucharest, Romania

    Ion C. Tintoiu

  5. Medical Radiation Sciences, Curtin University, Perth, WA, Australia

    Zhonghua Sun

  6. “Prof. C.C. Iliescu” Emergency Institute for Cardiovascular Diseases, Bucharest, Romania

    Ecaterina Bontas

Self Study

Self Study

1.1 Questions

  1. 1.

    Which of the following statements is correct?

    1. (a)

      Hepatic artery thrombosis is the most common reason for reoperation following liver transplantation.

    2. (b)

      Hepatic artery thrombosis is the most common vascular complication in liver transplantation.

    3. (c)

      Hepatic artery thrombosis can have greater impact on graft and patient survival than portal vein thrombosis.

    4. (d)

      Laparotomy is indicated for all patients with early bleeding following liver transplantation.

  2. 2.

    Which of the following statements is correct?

    1. (a)

      Wound infections in transplant patients are more commonly caused by single organisms and gram negative bacteria are the most frequently isolated bacterial microorganisms

    2. (b)

      Incisional hernias are a frequent complication following liver transplantation and should be treated surgically with mesh placement.

    3. (c)

      ERCP and/or PTC are the gold standard for biliary leak diagnosis, but MRCP should be the initial investigation when a biliary complication is suspected.

    4. (d)

      Covered self-expanding stents are associated with fewer complications and higher success rates when compared to plastic stents in the management of biliary complication and should be the treatment of choice.

1.2 Answers

  1. 1.

    Which of the following statements is correct?

    1. (a)

      Postoperative haemorrhage is the most common reason for reoperation following liver transplantation. Reoperation is required in 8–27% of OLT recipients

    2. (b)

      CORRECT. Hepatic artery thrombosis is the most common vascular complication in liver transplantation occurring in 1–9% of OLT recipients and can leads to graft loss in 56% of the patients and is associated with a 33% mortality.

    3. (c)

      Portal vein thrombosis has overall a more detrimental effect on patient and graft survival than hepatic artery thrombosis, as it may involve extension into the mesenteric vessels and thus preclude retransplantation.

    4. (d)

      Patients with haemodynamic instability, persisting despite clotting correction, require emergency relaparotomy. However haemodynamically stable patients can have a diagnostic US or CT scan prior to deciding on whether a laparotomy is necessary.

  2. 2.

    Which of the following statements is correct?

    1. (a)

      Most common pathogens causing wound infections are gram positive cocci including Staphylococcus and Enterococcus species and multiple microorganisms can be isolated. Antimicrobial treatment should be tailored according to each transplant centre’s microbiology policy.

    2. (b)

      Only patients with symptomatic incisional hernias should be treated surgically. The preferred method of treatment is reconstruction of the abdominal wall with a mesh, as primary closure has high recurrence rates.

    3. (c)

      CORRECT. ERCP and/or PTC are the gold standard investigations for diagnosis of biliary complications but should be preceded by MRCP which is a non-invasive investigation and has a high sensitivity and specificity (96% and 94% respectively).

    4. (d)

      Currently covered self-expanding stents are reserved for patients with strictures refractory to plastic stent treatment, as there are associated with spontaneous stent migration and higher stricture recurrence rate.

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Koti, R.S., Tzerbinis, H., Davidson, B.R. (2020). Surgical Complications Following Liver Transplant and Their Management. In: Radu-Ionita, F., Pyrsopoulos, N., Jinga, M., Tintoiu, I., Sun, Z., Bontas, E. (eds) Liver Diseases. Springer, Cham. https://doi.org/10.1007/978-3-030-24432-3_69

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  • DOI: https://doi.org/10.1007/978-3-030-24432-3_69

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