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14-September-2008 10:43:23 - Liver transplantation Intervention: Liver transplantation Human liver ICD-10 code: ICD-9 code: 50.5 MeSH D016031 Other codes: Liver transplantation or hepatic transplantation is the replacement of a diseased liver with a healthy liver allograft. The most commonly used technique is orthotopic transplantation, in which the native liver is removed and the donor organ is placed in the same anatomic location as the original liver. Liver transplantation nowadays is a well accepted treatment option for end-stage liver disease and acute liver failure. Francis Chan born November 3, 1991 is believed to be the youngest liver transplant patient in Australia. He was 2 months old when he underwent two transplant operations 3 days apart at The Children's Hospital at Westmead. Contents 1 History 2 Indications 3 Techniques 4 Immunosuppressive management 5 Results 6 Living donor transplantation 7 References 8 Further reading 9 External links History The first human liver transplant was performed in 1963 by a surgical team led by Dr. Thomas Starzl1 of Denver, Colorado, United States. Dr. Starzl performed several additional transplants over the next few years before the first short-term success was achieved in 1967 with the first one-year survival posttransplantation. Despite the development of viable surgical techniques, liver transplantation remained experimental through the 1970s, with one year patient survival in the vicinity of 25%.2 The introduction of cyclosporine by Sir Roy Calne markedly improved patient outcomes, and the 1980s saw recognition of liver transplantation as a standard clinical treatment for both adult and pediatric patients with appropriate indications. Liver transplantation is now performed at over one hundred centres in the USA, as well as numerous centres in Europe and elsewhere. One year patient survival is 85-90%, and outcomes continue to improve, although liver transplantation remains a formidable procedure with frequent complications. Unfortunately, the supply of liver allografts from non-living donors is far short of the number of potential recipients, a reality that has spurred the development of living donor liver transplantation. Indications Liver transplantation is potentially applicable to any acute or chronic condition resulting in irreversible liver dysfunction, provided that the recipient does not have other conditions that will preclude a successful transplant. Metastatic cancer outside liver, active drug or alcohol abuse and active septic infections are absolute contraindications. While infection with HIV was once considered an absolute contraindication, this has been changing recently. Advanced age and serious heart, pulmonary or other disease may also prevent transplantation relative contraindications. Most liver transplants are performed for chronic liver diseases that lead to irreversible scarring of the liver, or cirrhosis of the liver. Techniques Before transplantation liver support therapy might be indicated bridging-to-transplantation. Artificial liver support like liver dialysis or bioartificial liver support concepts are currently under preclinical and clinical evaluation. Virtually all liver transplants are done in an orthotopic fashion, that is the native liver is removed and the new liver is placed in the same anatomic location. The transplant operation can be conceptualized as consisting of the hepatectomy liver removal phase, the anhepatic no liver phase, and the postimplantation phase. The operation is done through a large incision in the upper abdomen. The hepatectomy involves division of all ligamentous attachments to the liver, as well as the common bile duct, hepatic artery, and portal vein. Usually, the retrohepatic portion of the inferior vena cava is removed along with the liver, although an alternative technique preserves the recipient's vena cava piggyback technique. The donor's blood in the liver will be replaced by an ice-cold organ storage solution, such as UW Viaspan or HTK until the allograft liver is implanted. Implantation involves anastomoses connections of the inferior vena cava, portal vein, and hepatic artery. After blood flow is restored to the new liver, the biliary bile duct anastomosis is constructed, either to the recipient's own bile duct or to the small intestine. The surgery usually takes between five and six hours, but may be longer or shorter due to the difficulty of the operation and the experience of the surgeon. The large majority of liver transplants use the entire liver from a non-living donor for the transplant, particularly for adult recipients. A major advance in pediatric liver transplantation was the development of reduced size liver transplantation, in which a portion of an adult liver is used for an infant or small child. Further developments in this area included split liver transplantation, in which one liver is used for transplants for two recipients, and living donor liver transplantation, in which a portion of healthy person's liver is removed and used as the allograft. Living donor liver transplantation for pediatric recipients involves removal of approximately 20% of the liver Couinaud segments 2 and 3. Immunosuppressive management Like all other allografts, a liver transplant will be rejected by the recipient unless immunosuppressive drugs are used. The immunosuppressive regimens for all solid organ transplants are fairly similar, and a variety of agents are now available. Most liver transplant recipients receive corticosteroids plus either tacrolimus or Cyclosporin or Mycophenolate Mofetil. Liver transplantation is unique in that the risk of chronic rejection also decreases over time, although recipients need to take immunosuppresive medication for the rest of their lives. It is theorized that the liver may play a yet-unknown role in the maturation of certain cells pertaining to the immune system. There is at least one study by Dr. Starzl's team at the University of Pittsburgh which consisted of bone marrow biopsies taken from such patients which demonstrate genotypic chimerism in the bone marrow of liver transplant recipients. Results Prognosis is quite good. However those with certain illnesses may differ. 3 There is no exact model to predict survival rates however those with transplant have a 58% chance of surviving 15 years. 4 Living donor transplantation Living donor liver transplantation LDLT has emerged in recent decades as a critical surgical option for patients with end stage liver disease, such as cirrhosis and/or hepatocellular carcinoma often attributable to one or more of the following: long-term alcohol abuse, long-term untreated Hepatitis C infection, long-term untreated Hepatitis B infection. The concept of LDLT is based on 1 the remarkable regenerative capacities of the human liver and 2 the widespread shortage of cadaveric livers for patients awaiting transplant. In LDLT, a piece of healthy liver is surgically removed from a living person and transplanted into a recipient, immediately after the recipient's diseased liver has been entirely removed. Historically, LDLT began as a means for parents of children with severe liver disease to donate a portion of their healthy liver to replace their child's entire damaged liver. The first report of successful LDLT was by Dr. Silvano Raia at the Universidade de São Paulo USP Medical School in 1986. Surgeons eventually realized that adult-to-adult LDLT was also possible, and now the practice is common in a few reputable medical institutes. It is considered more technically demanding than even standard, cadaveric donor liver transplantation, and also poses the ethical problems underlying the indication of a major surgical operation hepatectomy on a healthy human being. In various case series the risk of complications in the donor is around 10%, and very occasionally a second operation is needed. Common problems are biliary fistula, gastric stasis and infections; they are more common after removal of the right lobe of the liver. Death after LDLT has been reported at 0% Japan, 0.3% USA and 1% Europe, with risks likely to improve further as surgeons gain more experience in this procedure.5 In a typical adult recipient LDLT, 55% of the liver the right lobe is removed from a healthy living donor. The donor's liver will regenerate to 100% function within 4-6 weeks and will reach full volumetric size with recapitulation of the normal structure soon thereafter. It may be possible to remove 70% to 75% of the liver from a healthy living donor without harm in most cases. The transplanted portion will reach full function and the appropriate size in the recipient as well, although it will take longer than for the donor. 1 References ^ STARZL T, MARCHIORO T, VONKAULLA K, HERMANN G, BRITTAIN R, WADDELL W. Homotransplantation Of The Liver In Humans. Surg Gynecol Obstet 117: 659-76. PMID 14100514. ^ Starzl TE, Klintmalm GB, Porter KA, Iwatsuki S, Schroter GP. 1981. Liver transplantation with use of cyclosporin A and prednisone. New England Journal of Medicine 305: 266-269. PMID 7017414. ^ http://www.innovations-report.com/html/reports/medicine_health/report-22829.html ^ https://www.uktransplant.org.uk/ukt/statistics/presentations/pdfs/april_05/liver_life_expectancy.pdf ^ Umeshita K, Fujiwara K, Kiyosawa K, et al August 2003. Operative morbidity of living liver donors in Japan. Lancet 362 9385: 687-90. doi:10.1016/S0140-67360314230-4. PMID 12957090. Further reading Eghtesad B, Kadry Z, Fung J 2005. Technical considerations in liver transplantation: what a hepatologist needs to know and every surgeon should practice. Liver Transpl 11 8: 861-71. doi:10.1002/lt.20529. PMID 16035067. Adam R, McMaster P, O'Grady JG, Castaing D, Klempnauer JL, Jamieson N, Neuhaus P, Lerut J, Salizzoni M, Pollard S, Muhlbacher F, Rogiers X, Garcia Valdecasas JC, Berenguer J, Jaeck D, Moreno Gonzalez E 2003. Evolution of liver transplantation in Europe: report of the European Liver Transplant Registry. Liver Transpl 9 12: 1231-43. doi:10.1016/j.lts.2003.09.018. PMID 14625822. Reddy S, Zilvetti M, Brockmann J, McLaren A, Friend P 2004. Liver transplantation from non-heart-beating donors: current status and future prospects. Liver Transpl 10 10: 1223-32. doi:10.1002/lt.20268. PMID 15376341. Tuttle-Newhall JE, Collins BH, Desai DM, Kuo PC, Heneghan MA 2005. The current status of living donor liver transplantation. Curr Probl Surg 42 3: 144-83. doi:10.1067/j.cpsurg.2004.12.003. PMID 15859440. Martinez OM, Rosen HR 2005. Basic concepts in transplant immunology. Liver Transpl 11 4: 370-81. doi:10.1002/lt.20406. PMID 15776458. Krahn LE, DiMartini A 2005. Psychiatric and psychosocial aspects of liver transplantation. Liver Transpl 11 10: 1157-68. doi:10.1002/lt.20578. PMID 16184540. Nadalin S, Malagò M, et al. Current trends in live liver donation. Transpl. Int. 2007;20:312-30. Vohra V. Liver transplantation in India. Int Anesthesiol Clin. 2006;44:137-49. Strong RW. Living-donor liver transplantation: an overview. J Hepatobiliary Pancreat Surg. 2006;13:370-7. Fan ST. Live donor liver transplantation in adults. Transplantation. 2006;82:723-32. External links Official organ sharing network of U.S. Official organ procurement center of the U.S. American Liver Foundation: Comprehensive information about Hepatitis C, Liver Transplant and other liver diseases, including links to chapters for finding local resources Management of HBV Infection in Liver Transplantation Patients Management of HCV Infection and Liver Transplantation Antiviral therapy of HCV in the cirrhotic and transplant candidate Living Donors Online Liver Donor Liver Transplantation Guide and Liver Transplant Surgery in India History of pediatric liver transplantation ABC Salutaris: Living Donor Liver Transplant Organ Donation Awareness and former potential donor blog All You Need to Know about Adult Living Donor Liver Transplantation Children's Liver Disease Foundation v d e Organ transplantation Types Allograft · Alloplant · Allotransplantation · Autotransplantation · Xenotransplantation Organs and tissues Bone · Bone marrow · Corneal · Face · Hand · Heart · Heart-lung · Kidney · Liver · Lung · Pancreas · Penis · Skin · Spleen · Uterus Related topics Biomedical tissue · Cellular memory · Edmonton protocol · Eye bank · Graft-versus-host disease · Immunosuppressive drugs · Islet cell transplantation · Implants · Living donor liver transplantation · Lung allocation score · Machine perfusion · Medical grafting · Non-heart beating donation · Organ donation · Post-transplant lymphoproliferative disorder · Repugnant market · Total body irradiation · Transplant rejection Organizations Halachic Organ Donor Society · Human Tissue Authority · National Marrow Donor Program · United Network for Organ Sharing People Christiaan Barnard · Michael Woodruff · Alexis Carrel · Norman Shumway · Jean-Michel Dubernard · List of notable organ transplant donors and recipients v d e Digestive system surgical and other procedures ICD-9-CM V3 42-54 Digestive tract esophagus: Esophagectomy stomach: Gastrostomy Percutaneous endoscopic gastrostomy - Gastrectomy Billroth I, Billroth II, Roux-en-Y - Gastric bypass surgery - Gastroenterostomy - Nissen fundoplication - Gastropexy small bowel: Duodenal switch - Jejunoileal bypass - Ileostomy - Partial ileal bypass surgery large bowel: Colectomy - Colostomy - Appendicectomy - Hartmann's procedure rectum: Lower anterior resection - Abdominoperineal resection anus: Anal sphincterotomy - Lateral internal sphincterotomy endoscopy: Esophagogastroduodenoscopy - Colonoscopy - Proctoscopy - Sigmoidoscopy Accessory liver: Hepatectomy - Liver transplantation - Artificial extracorporeal liver support Liver dialysis, Bioartificial liver devices gallbladder/bile duct: Endoscopic retrograde cholangiopancreatography - Percutaneous transhepatic cholangiography - Cholecystectomy pancreas: Pancreatectomy - Pancreaticoduodenectomy - Pancreas transplantation - Puestow procedure - Frey's procedure Other Herniorrhaphy - Laparotomy - Paracentesis Retrieved from http://en..org/wiki/Liver_transplantation Categories: Surgery | Gastroenterology | Transplantation medicine | Hepatology Views Article Discussion this page History Personal tools Log in / create account Navigation Main page Contents Featured content Current events Random article Search Go Search Interaction Community portal Recent changes Contact Donate to Help Toolbox What links here Related changes Upload file Special pages Printable version Permanent link Cite this page Languages БългарÑ?ки Deutsch Français Italiano עברית Nederlands Polski Português Suomi This page was last modified on 27 August 2008, at 22:03
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