Postoperative Management and Complications in Living-related Liver Transplantation

Abstract

Living-related liver transplantation is widely accepted as a treatment for patients with end-stage liver disease, with survival rates of up to 80%. Liver transplant recipients are at risk for the same postoperative complications as any patient undergoing a major intraabdominal operation, in addition to several complications specific to this procedure. Maintenance immunosuppression relies principally on administration of tacrolimus and methylprednisolone. Nevertheless, approximately 36% of liver transplant recipients suffer acute rejection in the early posttransplant period and require bolus steroid therapy as a rescue agent. Vascular complications, including hepatic arterial thrombosis and portal vein thrombosis, are additional major problems. When they occur in the immediate postoperative period, they can produce fulminant hepatic necrosis requiring retransplantation, so intensive anticoagulation therapy is needed as prophylaxis against these vascular complications. If thrombosis of the hepatic artery or portal vein is diagnosed early in the postoperative course, emergency thrombectomy with reanastomosis should be attempted. Outflow obstruction by hepatic vein stenosis sometimes causes liver dysfunction, pleural effusion, and hepatosplenomegaly. Percutaneous transhepatic or transjugular approached hepatic vein dilatation is very useful in case of hepatic vein stenosis. Recipients are generally immunocompromised secondary to immunosuppressive therapy and their poor clinical condition and are at high risk for postoperative infection. Infection is a major cause of morbidity and the most common cause of death in liver transplant recipients. Antibiotic, antifungal, and antiviral agents are used empirically, and serologic examinations and bacterial investigations of blood, sputum, stool, urine, and discharge from drains should be performed as well as antibiotic sensitivity tests when necessary. Other complications related to the operation are intraabdominal bleeding, bile leakage, biliary anastomotic stenosis, and intestinal perforation. The postoperative course of liver transplant recipients with these complications depends on making an accurate diagnosis promptly and initiating appropriate management. Postoperative complications of living-related liver transplantation are protean, so it is very important to communicate with professionals in each specialized field to ensure optimal treatment.