Liver Yao

Question 1

What are the potential graft options for liver transplantation?

Answer 1

○ Liver grafts are harvested from deceased or living donors.
○ Cadaveric livers are procured after brain or cardiac death.
○ Because of the increasing number of patients who die waiting for a transplant, efforts to expand the donor pool have focused on donation after cardiac death (DCD), extending donor criteria, and partial grafts from live donors.
○ DCD is the fastest growing
source of transplant organs in the United States. Upon cardiac
death (defined as the irreversible cessation of circulatory and
respiratory function), the liver is harvested after a mandatory
waiting period of 1 to 5 minutes.
○ Warm ischemic time begins when the waiting period starts and ends when the liver is flushed with cold preservative solution.
○ Transplantation of a DCD-donor
liver that has been exposed to a longer warm ischemic time than
a graft from a brain-dead donor may be associated with ischemia-reperfusion injury leading to early graft dysfunction
and potential graft loss.
○ Ideal organs have shorter warm and cold ischemic times and are harvested from hemodynamically stable donors younger than 50 years of age who are free ofhepatobiliary or renal disease, infection, and cancer.
○ Extending donor criteria (age older than 65 years; positive viral serology; hypernatremia; prior carcinoma, steatosis, or high-risk behaviors; split livers) to harvest organs with initial
poor function or primary nonfunction also expands the donorpool.
○ Split liver transplantation creates two transplants from one allograft. ○ This is especially important in pediatric patients, where size-matched whole liver allografts are scarce, resulting in increased waiting list mortality.
○ A related or unrelated healthy individual may donate a portion of the liver for transplantation. Usually, the right hepatic lobe is removed and transplanted into an adult recipient.
○ Transplantation of the smaller left hepatic lobe into pediatric or
very small adults may decrease the incidence of complications
in the donor.
○ This chapter focuses on cadaveric liver transplantation into adult recipients.

Question 2

What are the indications and contraindications for liver transplantation?

Question 3

What is acute liver failure (ALF)?

Question 4

What is the MELD score, and how is it used in liver
transplantation evaluation?

Question 5

What is portal hypertension? What are the sequelaeof portal hypertension?

Question 6

Describe the cardiovascular system of patients with end-stage liver disease (ESLD).

Question 7

What causes acute kidney injury (AKI) in patients
with cirrhosis?

Question 8

What causes hyponatremia in patients with
cirrhosis?

Question 9

Discuss the neurologic manifestations of acute and
chronic liver disease.

Question 10

Why do patients with ESLD have abnormalities of
hemostasis?

Question 11

What is the differential diagnosis for hypoxemia in
patients with cirrhosis?

Question 12

What are the risk factors and treatment guidelines
for spontaneous bacterial peritonitis (SBP)?

Question 13

What preoperative workup is desirable?

Question 14

How is ascites managed preoperatively?

Question 15

How is hyponatremia managed preoperatively?

Question 16

What is a transjugular intrahepatic portosystemic
shunt (TIPS) procedure? What is the role of TIPS in
the management of patients with ESLD?

Question 17

How are hepatic encephalopathy and elevated
intracranial pressure (ICP) treated?

Question 18

Should this patient be transfused with fresh frozen
plasma prior to surgery?

Question 19

What monitors would you use? Why?

Question 20

What are the considerations for the induction of
anesthesia?

Question 21

How does liver disease affect intraoperative medication management?

Question 22

What happens during the first stage (preanhepatic phase) of the liver transplant operation?

Question 23

What happens during the second stage (anhepatic
phase) of the liver transplant operation?

Question 24

What physiologic disturbances should be anticipated during the second stage (anhepatic phase) of the liver
transplant operation?

Question 25

What is venovenous bypass? What are the potential
advantages and disadvantages of this procedure?

Question 26

What surgical techniques anastomose the donor and
recipient inferior vena cava (IVC)?

Question 27

What are the potential advantages of the
“piggyback” (vena cava preservation) technique?

Question 28

What hemodynamic changes are expected after
removal of vascular clamps? What is postreperfusion
syndrome (PRS)?

Question 29

C.11. How would you treat hyperkalemia?

Question 30

Why should you anticipate hypocalcemia?

Question 31

What happens during the third stage of the liver
transplant operation?

Question 32

What causes intraoperative bleeding during each
phase of liver transplantation? How is coagulopathy
monitored and treated? What are
thromboelastography (TEG) and rotational
thromboelastography (ROTEM)?

Question 33

What are the complications of massive transfusion?

Question 34

How are the complications of massive transfusion
prevented?

Question 35

How is hyperfibrinolysis managed?

Question 36

When is intraoperative renal replacement therapy
indicated?

Question 37

What intraoperative signs suggest that the hepatic
graft is working?

Question 38

What are the goals of immediate postoperative care
of the liver transplant patient?

Question 39

What postoperative findings suggest that the hepatic
graft is functioning?

Question 40

What coagulation disturbances should be anticipated
in the postoperative period?

Question 41

Can renal function change after liver
transplantation?

Question 42

What vascular and biliary complications occur after liver transplantation?

Question 43

What immunosuppressive agents will be given after
liver transplantation? What are the major side
effects?