Hepatic transplantation: postoperative complications

Abstract

Advances in surgical techniques and immunosuppression have made orthotopic liver transplantation a first-line treatment for many patients with end-stage liver disease. The early detection and treatment of postoperative complications has contributed significantly to improved graft and patient survival with imaging playing a critical role in detection. Complications that can lead to graft failure or patient mortality include vascular abnormalities, biliary abnormalities, allograft rejection, and recurrent or post-transplant malignancy. Vascular abnormalities include stenosis and thrombosis of the hepatic artery, portal vein, and inferior vena cava, as well as hepatic artery pseudoaneurysm, arteriovenous fistula, and celiac stenosis. Biliary abnormalities include strictures, bile leak, obstruction, recurrent disease, and infection. While imaging is not used to diagnose allograft rejection, it plays an important role in identifying complications that can mimic rejection. Ultrasound is routinely performed as the initial imaging modality for the detection and follow-up of both early and delayed complications. Cholangiography and magnetic resonance cholangiopancreatography are used to characterize biliary complications and computed tomography is used to confirm abnormal findings on ultrasound or for the evaluation of postoperative collections. The purpose of this article is to describe and illustrate the imaging appearances and management of complications associated with liver transplantation.

Extravascular complications following abdominal organ transplantation

“…41 Post-transplant lymphoproliferative disorder (PTLD) is a generic term that refers to a variety of disorders ranging from abnormal lymphoid hyperplasia to frankly malignant lymphomas (predominantly B-cell). 9,42 Most cases are related to EBV infection. PTLD is the second most common post-transplant malignancy after skin cancer and affects approximately 10% of adults after solid-organ transplantation.…”

“…8 Typical leak sites include the biliary anastomosis, T-tube insertion site, cystic duct stump, and the cut surface of the liver. 9,13 Bile leaks can be due to direct mechanical injury, such as excessive periductal dissection, tension on the biliary anastomosis, or electrocautery trauma. 6 As, unlike the remainder of the liver, vascular supply to biliary structures is entirely arterial and can be fragile, anastomotic leaks are frequently due to hepatic artery thrombosis (HAT).…”

“…Non-anastomotic strictures may also be due to recurrence of PSC; this occurs in 20%, with a mean interval of 350 days following transplantation (Fig 7). 9,25 Endoluminal balloon dilatation and stenting is the first-line treatment for anastomotic strictures. 13 Non-anastomotic ischaemic-type strictures generally require surgery (e.g., conversion to a biliaryeenteric anastomosis or retransplantation).…”

“…7,9 Predisposing factors for the development of biliary sludge and calculi include biliary stasis (e.g., strictures or gallbladder conduits), supersaturation of bile (e.g., altered biliary composition due to use of cyclosporine, depletion of bile salts due to T-tube drainage), biliary epithelial damage (e.g., ischaemia), and foreign bodies (e.g., T-tubes, stents). Sludge, stones, and haemobilia appear as intraductal filling defects on imaging (Fig 4).…”

Perioperative White Blood Cell Count as a Marker for Patient and Graft Survival after Orthotopic Liver Transplantation

“…The highest mortality rate is observed within the first year after OLT due to early graft failure due to preexisting disease of the donated organ or technical complications during surgery such as revascularization [5]. Another major clinical problem after OLT is infection: infections are one of the leading causes of morbidity and mortality in liver transplant recipients [6].…”