الفهرس 
LIIVER TRANSPLANTATIIONOnly 14 pages are availabe for public view
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Abstract
Liver transplantation is perceived as the only curative treatment for patients with end-stage liver disease. Approximately 20–25% of patients with liver failure die while waiting for a liver transplant, and another 20–30% of patients with hepatocellular carcinoma DROP off the waiting list because of tumour progression.
LDLT has emerged as the alternative life-saving treatment to DDLT. Over the past 2 decades, the number of LDLTs has steadily increased in many transplant centres, especially in Asia.
LDLT has the following advantages over DDLT: a shorter wait time, a shorter cold ischemic time, and a better organization of the surgery time. However, donor risks are inevitable and are an undeniable problem that troubles transplant surgeons. Moreover, LDLT has a smaller biliary and vascular caliber and an additional transection step, which may potentially increase the surgical risk and the incidence of postoperative complications. Previous investigations have suggested that patients undergoing LDLT may have a higher incidence of biliary and vascular complications and a lower long-term survival rate than patients undergoing DDLT.
As surgical techniques and postoperative managements continue to advance, the outcomes of LDLT have continued to improve. Patients considering LDLT should know whether the risk, severity of complications and long-term survival.
Postoperative biliary complication is commonly referred to as the “Achilles heel” of liver transplantation. Despite progress in surgical techniques, organ preservation and immunosuppressive management, biliary complications still frequently occur after liver transplantation (7–29%) and have retained a high risk of significant mortality and morbidity. Anastomotic problems have been the major reason for biliary complications, despite various innovations for biliary reconstruction that have been achieved for whole organ liver transplantation.
Vascular complications are another common cause of morbidity of liver transplantation, especially hepatic artery problems. The literature reports the hepatic artery complication rate to be approximately 5%–16%. Due to the smaller vessel diameter, the insufficient length for reconstruction and the greater risk of a twist of the vascular pedicle, LDLT patients may suffer from a higher incidence of vascular complications.
The hepatic artery complication rate is much lower as Reconstruction of the hepatic artery using microsurgical techniques with the help of a trained vascular surgeon. During the hepatic artery reconstruction, selecting an appropriate anastomotic artery for hepatic artery reconstruction is very important. This approach greatly reduced the hepatic artery complication rate in the recepient. Furthermore, intraoperative Doppler ultrasound was used in LDLT. The use of intraoperative Doppler ultrasound can reduce vascular complications following the liver transplantation.
Triphasic computerized tomography is performed to assess arterial and venous anatomy; to assess whether the middle hepatic vein should stay in the donor or the recipient; and to estimate the volume of the whole liver. The liver resection plane is assessed to ensure that the residual liver weight to total liver weight ratio would be 30% or greater. The estimated graft-to-recipient weight ratio is calculated by dividing the volume of the right lobe by the recipient’s weight; a ratio of at least 0.8% is considered acceptable. Magnetic resonance cholangiography has been used to assess biliary anatomy since 2001.
Other complications occurred in the recipient include: intra abdominal bleeding, intra abdominal abscesses, ileus, bowel obstruction, pulmonary complications, deep venous thrombosis, wound dehiscence, incisional hernia, infections: bacterial, viral and fungal, ascitis, acute or chronic rejection, recurrence of previous infection with HBV, HCV OR malignancy as HCC.
The challenge of LDLT is to perform the donor operation safely without compromising the recipient outcomes. The risk of donor death is estimated to be 0.2% for left lateral segment donation and 0.5% for right lobe donation, so the emphasis on donor safety is of paramount importance in this procedure.
To proceed with Liver donation, there must be an agreement among the donor, recipient and the medical team that this surgery is appropriate. We will not perform LDLT if the medical and surgical team believe that the potential for harm outweighs the benefits.
Donor and recipient safety is the main priority guiding the timing of surgery. It is important to have a well-rested and experienced surgical team for LT to maximize safety.
Advance in surgical technique and the experience of transplant team lead to improvement of the recipient outcomes after LDLT in the recent years.