Liver Transplantation for Patients with 2ndary Biliary CirrhosisCirrhosis (BC)
Deok-Bog Moon, Sung-Gyu Lee, Shin Hwang, Ki-Hun Kim, Chul-Soo Ahn, Tae-Yong Ha, Gi-Won Song, Dong-Hwan Jung, Kwan-Woo Kim, Nam-Kyu Choi, Joo-Dong Kim, Young-Dong
Yu, Gil-Chun Park, Pyong-Jae Park, Young-Il Choi
Hepato-Biliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of
Medicine
Biliary strictures after biliary surgery.
• Sequences Repeated episode of cholangitis
Treated by re-operation or intervention
Ineffective treatment
Typical Case of 2ndary BC Previous Operation
Male/53
•13years ago Hepatico-Jejunostomy •5 & 2 years ago Liver abscess Tx
Diagnosis: •Stricture of H-J site •Intrahepatic duct stones •Biliary cirrhosis
Left Lobectomy 2007.3.18
• PTBD & repeated dilatation & retrieval biliary stents
• Additional PTBD
• Laboratory findings Hb 8.2 g/dL Platelet 79X1000 /mm3
PT 55.1% (INR 1.41) T.Bil 20.7 mg/dL Albumin 2.8 g/dL Cr 0.5 mg/dL Ca19-9 186 U/ml (1 yr ago, 16.5 U/ml)
• MELD : 22 points CTP : 10 points
Typical Case of 2ndary BC Clinical Courses
Typical Case of 2ndary BC Liver Transplantation
2009.1.19
Intra-OP RBC transfusion 43 units with Cell-saver 12000 ml reinfusion
Another Case
Backgrounds
• Liver transplantation might be a optimal choice for decompensated 2ndary BC.
• However, the results have rarely been reported.
Strong (4 cases), Hirohashi(1 cases), Yan (7 cases)
• Difficult operation due to severe perihepatic adhesion & fibrosis, and coagulopathy related to underlying DIC. – Massive bleeding – Long operation time – Higher post-op complication rate
• Particular preparation and management is essential during peri-LT periods.
Use of Rapid Infusion System & Cell-Saver
Cell-Saver
Cell-Saver
RIS
• To introduce our experiences in liver transplantation, especially LDLT, for 2ndary Biliary Cirrhosis at Asan Medical Center.
• To propose ideal approaches for successful operation in 2ndary Biliary Cirrhosis.
Patients
• Liver Transplantation : 2158 patients
Largest series in the worlds.
LDLT : 15 patients, OLT : 5 patients
• More common in Female
Methods • Diagnosis of Decompensated 2ndary BC
– 3-Dimensional CT scan – Cirrhosis related Cx (bleeding, ascitis, HEP etc) – Clinical history of hepatolithiasis, or biliary OP &
strictures
• Study variables – Previous operation, Duration from initial treatment to LT
– Pre-OP MELD scores
– ICU stay, In-hospital day, Complications
– Explant biopsy
• Comparison with 20 randomly selected Acute-on- Chronic liver failure patients (MELD >30 points)
Pre-LT Characteristics Age 47.1 ± 10.8 years (range, 18 – 57)
Sex Female 12 patients (60.0%)
Cause of 2ndary BC
Open cholecystectomy
Kasai operation
Intra-Operative Variables Type of LT
Living donor LT †
Deceased donor LT
† Re-LT (Deceased donor)
15 patients (75%)
5 patients (25%)
Cell-saver use
Cell-saver re-infusion
1300 - 12000 ml
Operation time 1018 ± 201 min (range,720-1350)
Post-Operative Data ICU stay (days) 10.7 ± 9.6 (range,2-39)
In-hospital stay (days) 46.5 ± 32.6(range,20-110)
Explanted Biopsy
Age (years) 47.1 ± 10.8 48.6 ± 9.9 ns
Male / Female 8 (M) / 12 (F) 13 (M) / 7 (F) ns
MELD score 27.0 ± 8.1 31.6 ± 4.6 0.02
Type of LT LDLT 15 / DDLT 5 LDLT 17 /DDLT 3 ns
RBC transfus. 29.4 ± 24.2 U 15.5 ± 7.2 U 0.019
Operation time 1017 ± 201 min.
(No dual-graft LT)
927 ± 431 min.
(Dual-graft LT 4)
In-Hosp. days 46.5 ± 32.6 33.5 ± 15.9 ns
Complications 16 (80.0%) 14 (70.0%) ns
Re-operation 6 (30.0%) 5 (25.0%) ns
In-hospital death 5 (25.0%) 2 (10.05) ns
Mortality Cases in 2ndary BC
Pts. Age/Sex Time of death Cause of death
1 56/F Early Graft failure & sepsis after LDLT
2 53/F Early Intra-OP massive bleeding & PNF
3 57/M Early Intra-OP massive bleeding & PNF
4 49/M Early Rupture of hepatic artery aneurysm
5 42/F Early Rupture of hepatic artery aneurysm
6 42/M Early Massive bleeding from gastric varix
7 50/F Late Recurrence of cholangiocarcinoma
8 50/F Late Recurrence of cholangiocarcinoma
9 53/M Late Recurrence of cholangiocarcinoma
10 52/M Late Congestive heart failure due to MS
0 25 50 75 100 125
0.0
0.2
0.4
0.6
0.8
1.0
47.4%
Summary & Conclusions • Although MELD score of 2ndary BC is lower than
Acute-on-chronic liver failure, RBC transfusion amounts is much more, and Operation time might be longer in case of single donor LDLT.
• As a result, Cell-Saver & RIS, and Veno-Venous bypass were essential for successful LT.
• Post-LT major complication rate is very high (80%), and particularly post-OP bleeding including HA aneurysm rupture is most common.
• PNF among OLT patients were common (40%). It might be related to massive bleeding and long operation time. Therefore, particular efforts and supports from other organ harvest team to minimize the cold ischemic time is essential.