Download Perioperative management of liver transplantation

Aimee M. Crago, HMS IV
Gillian Lieberman, MD
March 17, 2003
Perioperative management of
liver transplantation
Aimee M. Crago, HMS Year IV
Gillian Lieberman, MD
Aimee M. Crago, HMS IV
Gillian Lieberman, MD
J.I. is a 66y.o. man with liver mass
• The patient presented to his PCP for an annual examination
and routine follow-up.
• His PMH was significant for hepatitis B virus (HbsAg
positive at time of presentation) and cirrhosis.
• Blood tests detected elevated levels of the tumor marker
AFP (24.3 compared to a normal value between 0-7). This
result raised concern that the patient had developed
hepatocellular carcinoma (HCC), a common sequela of
cirrhosis.
• The patient underwent ultrasound which demonstrated a
10cm mass in the right hepatic lobe.
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Aimee M. Crago, HMS IV
Gillian Lieberman, MD
This is a classic presentation for HCC.
• Chronic hepatitis B or C virus infection and cirrhosis are
risk factors for the disease.
• Patients such as J.I. are asymptomatic until late in the
course of the disease.
• Because of this fact, unless regular surveillance is
performed, at time of presentation on 30% are surgically
resectable.
• Symptoms in advanced disease may present as
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Obstructive jaundice representing bile duct obstruction
Diarrhea representing malabsorption or paraneoplastic syndrome
Bone pain or dyspnea reflecting metastasis
Peritoneal bleed from tumor rupture
Paraneoplastic syndromes (hypoglycemia, erythrocytosis,
hypercalcemia, watery diarrhea, cutaneous change).
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Aimee M. Crago, HMS IV
Gillian Lieberman, MD
Four main roles for imaging in this patient’s
medical management
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III.
IV.
Identification and diagnosis of HCC
Staging and determination of therapeutic strategy
Identification of anatomical variants of import in
surgical planning
Post-operative surveillance and diagnosis of
complications
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Aimee M. Crago, HMS IV
Gillian Lieberman, MD
Differential diagnosis of a liver mass
Vascular lesions
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Cavernous hemagioma
Hemangioendothelioma
Hepatocellular carcinoma
Metastases
Adenoma
Hamartoma
Hemangiosarcoma
Focal nodular hyperplasia
Avascular lesions
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Cholangiocarcinoma
Hepatocellular carcinoma
Extrinsic mass
Fatty infiltrate
Hydatid cyst
Liver abscess
Metastases
Regenerative nodular hyperplasia
Polycystic disease
Traumatic liver cyst
Lymphoma
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Aimee M. Crago, HMS IV
Gillian Lieberman, MD
I. Identification and characterization of a liver mass
In context of cirrhosis, diagnosis is made by findings
consistent with HCC (mass with irregular margins,
heterogenous composition, hypervascularity) on two imaging
modalities, one of which demonstrates hypervascularity.
Aimee M. Crago, HMS IV
Gillian Lieberman, MD
Menu of tests to characterize a liver mass
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Ultrasound
CT scan
MRI
Angiography (if other modalities fail to demonstrate hypervascularity)
Nuclear medicine scan utilizing Tc99-labeled AFP (experimental)
Histopathology under CT or ultrasound guidance (for small lesions)
Biopsy of the mass is avoided unless the mass is <2cm and is unable to be
adequately evaluated by non-invasive measures. This prevents possible
complications related to seeding along the biopsy needle track.
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Aimee M. Crago, HMS IV
Gillian Lieberman, MD
Ultrasound evaluation of a liver mass
• Advantages
– Readily available, low cost
– Can be used intra-operatively or for screening
– Can be used to evaluate vessel patency
• Disadvantages
– Difficult to determine identity of mass
• Ultrasound appearance of hepatocellular carcinoma
– Hypo-, iso-, or hyperechoic mass
– Irregular echoes or margins
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Aimee M. Crago, HMS IV
Gillian Lieberman, MD
US identification of hepatic mass
hepatic mass – note irregular margins, heterogenic echogenicity
Beth Israel-Deaconess Medical Center, PACS System
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Aimee M. Crago, HMS IV
Gillian Lieberman, MD
CT evaluation of a HCC
• Advantages
– 90% sensitivity
• Disadvantages
– Does not detect lesions which are isoattenuating on non-contrast and
venous phase CT
– Difficulty in differentiating carcinoma from cirrhotic nodules
– Reduced availability compared to ultrasound
• CT appearance of hepatocellular carcinoma
– Enhancing lesions observed in arterial phase of CT with contrast
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Aimee M. Crago, HMS IV
Gillian Lieberman, MD
CT evaluation of HCC
arterial phase
venous phase
hepatic mass – note mass is readily apparent in arterial phase CT, but
difficult to visualize in the venous phase
Kemmerer, S.R., et al. Radiol. Clin. of North America. 1998; 247-61.
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Aimee M. Crago, HMS IV
Gillian Lieberman, MD
MR evaluation of a liver mass
• Advantages
– Improved ability to differentiate hepatocellular carcinoma and cirrhotic
nodules
– No nephrotoxic agents
• Disadvantages
– Decreased availabity versus US and CT
• MR appearance of hepatocellular carcinoma
– High density appearance on T2-weighted images, low density on T1weighted images.
– Cirrhotic nodules appear hypodense on both T1- and T2- weighted
images.
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Aimee M. Crago, HMS IV
Gillian Lieberman, MD
MRI evaluation of HCC
hepatic mass
T1-weighted
T2-weighted
Beth Israel-Deaconess Medical Center, PACS System
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Aimee M. Crago, HMS IV
Gillian Lieberman, MD
II. Staging and determination of therapeutic strategy
Imaging studies are essential for determination of tumor
resectability and for appropriate use of hepatic
transplantation.
Aimee M. Crago, HMS IV
Gillian Lieberman, MD
Treatment of hepatocellular carcinoma
• Medical therapy
– Systemic chemotherapy
• Minimally invasive therapy
– Percutaneous ethanol injection
– Radioablation therapy
– Trans-arterial chemoembolization
• Surgical therapy
– Resection
– Consider transplantation if tumor is unresectable or
patient has concurrent Child’s class C cirrhosis.
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Aimee M. Crago, HMS IV
Gillian Lieberman, MD
Resection is performed based on the Couniard
segments defined by branches of the portal vein.
Meyers, W.C., et al. In: Townsend: Sabiston Textbook of General Surgery, 16th ed. pp. 997-1005. 16
Aimee M. Crago, HMS IV
Gillian Lieberman, MD
Contraindications to resection of HCC
• Multifocal intrahepatic disease
• Extrahepatic extension (local invasion of adjacent organs or
visceral peritoneum)
• Inadequate functional reserve (can resect less than 50% of the
liver in patients with cirrhosis)
• Inability to obtain adequate margins (1cm)
• Involvement of confluence of hepatic/portal veins
• Nodal involvement
• Metastases
Resectability is confirmed by intraoperative ultrasound which may
change management in many cases.
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Aimee M. Crago, HMS IV
Gillian Lieberman, MD
Contrandications for liver transplantation
in treatment of HCC
• General
– Active drug or alcohol abuse
– Extrahepatic malignancy
– Severe heart or lung disease
• HCC-specific
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Size of tumor >5cm
Vascular invasion
Metastases (CT lung and abdomen, consider bone scan)
HCV infection is a relative contraindication
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Aimee M. Crago, HMS IV
Gillian Lieberman, MD
Liver transplantation for HCC
• Major benefit is concurrent treatment of HCC and cirrhosis
therefore can be performed in patients with poor functional
reserve.
• Comparable 5yr. survival when compared to non-malignant
causes.
• Comparable outcomes as compared to resection in most studies.
• HCC patients are given extra points toward severity of need as
compared to others awaiting transplant.
• Poor prognostic indicators include
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High histologic grade
Tumor >5cm
Bilobar tumor
Lymph node involvement
Vascular invasion
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Aimee M. Crago, HMS IV
Gillian Lieberman, MD
Chemoembolization of HCC is sometimes
used as a bridge to transplant
The protocol involves selective cannulation of the hepatic artery feeding a tumor and
injection of chemotherapeutic agents (e.g., adriamycin), a contrast agent such as ethiodol,
and Gelfoam which causes decrease in blood flow through the cannulated artery.
common hepatic artery
right hepatic artery
hepatic mass
branches of gastroduodenal artery
Beth Israel-Deaconess Medical Center, PACS System
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Aimee M. Crago, HMS IV
Gillian Lieberman, MD
Chemoembolization of HCC
Ethiodolenhanced
hepatic lesion –
note significant
reduction in size
of lesion over
time
immediately
post-chemoembolization
Beth Israel-Deaconess Medical Center, PACS System
6 months
post-chemoembolization
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Aimee M. Crago, HMS IV
Gillian Lieberman, MD
Liver transplantation procedure
Barker, C.F., et al. In: Townsend: Sabiston Textbook of
General Surgery, 16th ed., 1999. pp. 429-46.
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Aimee M. Crago, HMS IV
Gillian Lieberman, MD
III. Identification of anatomical
variants of import in surgical planning
• Pre-transplant work-up should include assessment of
vascular anatomy as variants may require vessel
reconstruction at the time of surgery.
• Can generally be assessed by CTA or MRA
• Includes evaluation for
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variant hepatic artery anatomy
celiac axis stenosis
absent IVC
thrombosis portal vein
splenic artery aneurysm
Aimee M. Crago, HMS IV
Gillian Lieberman, MD
CTA of classic arterial supply to the liver
right and left hepatic arteries
common hepatic artery
celiac trunk
proper hepatic artery
Beth Israel-Deaconess Medical Center, PACS System
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Aimee M. Crago, HMS IV
Gillian Lieberman, MD
Variations in the anatomy of the hepatic artery
Meyers, W.C., et al. In: Townsend: Sabiston Textbook of General Surgery, 16th ed. pp. 997-1005.25
Aimee M. Crago, HMS IV
Gillian Lieberman, MD
IV. Post-operative surveillance and diagnosis
of complications
Post-operative period
Late complications
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Infection
Post-operative bleeding
Graft failure
Acute rejection
Biliary leak
Vascular thrombosis
Hepatic artery stenosis
Hepatic artery pseudoaneurysm
Bile duct stenosis
Recurrent disease
Opportunistic infection
New malignancy
Chronic rejection
Post-operative screening performed with ultrasound at 24 to
48h after procedure and at least weekly until discharge.
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Aimee M. Crago, HMS IV
Gillian Lieberman, MD
Hepatic artery thrombosis and stenosis
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Clinical presentation of hepatic artery thrombosis and stenosis
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Thrombosis
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Elevation in LFTs
Bile leaks or bile duct stricture
Hepatic necrosis
Relapsing septicemia
Results in graft ischemia and failure
Occurs in 3-12% of adult orthotopic liver transplantations
Most common cause of graft loss
Mortality greater than 50% if not retransplanted
Stenosis
– Occurs in first three months post-transplantation
– 5% incidence
– Sequelae similar to those of hepatic artery thrombosis
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Aimee M. Crago, HMS IV
Gillian Lieberman, MD
Hepatic artery Doppler
Rapid upstroke
Continuous flow
Resistive index = (peak systolic flow – end diastolic flow)/end diastolic flow
Normal value is >0.5 and <0.8
• In HA thrombosis, see absent blood flow
• In HA stenosis see prolonged upstroke with increased diastolic flow
(parvis and tardus pulse)
Beth Israel-Deaconess Medical Center, PACS System
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Aimee M. Crago, HMS IV
Gillian Lieberman, MD
CT findings in hepatic artery thrombosis
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Infarction (peripheral wedge or large periportal hypodensities)
Bilioma
Bile duct dilitation
Abscesses
Hypodensity in the periportal
region reflecting ischemiarelated necroses and edema
Hypodense fluid collection
Olliff, S. In: Grainger and Allison’s Diagnostic Radiology, 4th ed. 2001; pp. 1333-40.
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Aimee M. Crago, HMS IV
Gillian Lieberman, MD
Normal angiogram
Angiogram evaluation of
hepatic artery patency is
gold standard for diagnosis.
Proper hepatic artery
Hepatic artery stenosis
Celiac trunk
Celiac trunk
Absent hepatic
flow
Splenic artery
Right and left hepatic arteries
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Beth Israel-Deaconess Medical Center, PACS System
Aimee M. Crago, HMS IV
Gillian Lieberman, MD
Treatment of hepatic artery stenosis
or thrombosis
• Consider angioplasty or stent placement
• Thrombolysis
• Normally require retransplantation
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Aimee M. Crago, HMS IV
Gillian Lieberman, MD
Portal vein thrombosis/stenosis
• Incidence is 1-3% of orthotopic liver transplants
• Treat by
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percutanous angiography/stent placement
thromboembolectomy
venous graft placement
shunt placement
retransplant
• US seeks to define portal vein thrombosis or
stenosis as manifest by absent blood flow through
the vessel.
• Portal vein patency can also be visualized by CT.
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Aimee M. Crago, HMS IV
Gillian Lieberman, MD
Doppler of the portal vein
Normal ultrasound of the portal vein shows
constant flow with minimal respiratory variation.
Beth Israel-Deaconess Medical Center, PACS System
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Aimee M. Crago, HMS IV
Gillian Lieberman, MD
Bile leak
• Most common complication of orthotopic liver
transplantation
• Occurs at site of T-tube placement or bile duct anastamosis
• Can reflect hepatic ischemia so must evaluate for hepatic
artery patency
• Hypoechoic fluid collection observed on ultrasound
• Diagnosis made definitively by cholangiography with
contrast placed via T-tube or percutaneous route.
• Treat with observation, drainage, stent placement or
surgical revision of the duct anastamosis.
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Aimee M. Crago, HMS IV
Gillian Lieberman, MD
Cholangiography
Contrast extravasation at the site
of anastamosis between the bile
duct and the duodenal Roux
loop in a hepatojejunostomy
reconstruction.
Olliff, S. In: Grainger and Allison’s Diagnostic Radiology, 4th ed. 2001; pp. 1333-40.
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Aimee M. Crago, HMS IV
Gillian Lieberman, MD
Bile duct stricture
• Often due to ischemia so must rule out hepatic artery
stenosis.
• Other causes include
– Recurrent sclerosing cholangitis
– Sphincter of Oddi dysfunction
– Biliary sludge/stones
• Diagnosis made by observation of stricture and dilation of
the bile ducts seen by US or CT and then on ERCP or
MRCP.
• Treat with balloon dilation or stent placement.
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Aimee M. Crago, HMS IV
Gillian Lieberman, MD
ERCP
Bile duct stricture
Balloon dilation
Bile duct postprocedure
demonstrating
improved patency
Rerknimitr, R., et al. Gastrointestinal Endosc. 2002; 55:224-31.
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Aimee M. Crago, HMS IV
Gillian Lieberman, MD
Conclusions:
Role of imaging in the perioperative
management of liver transplantation for HCC
I.
II.
III.
IV.
Identification and diagnosis of tumor
Staging and determination of therapeutic strategy
Identification of anatomical variants of import in
surgical planning
Post-operative surveillance and diagnosis of
complications
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Aimee M. Crago, HMS IV
Gillian Lieberman, MD
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References
Barker, C.F., Brayman, K.L., Markmann, J.F., et al. Transplantation of abdominal organs. In:
Townsend: Sabiston Textbook of General Surgery, 16th ed. W.B. Sauders, 1999. P. 429-46.
Curley, S.A., Barnett, C.C., and Abdalla, E.K. Liver transplantation for hepatocellular carcinoma.
www.UpToDate.com 2003.
Ferris, J.V., Marsh, J.W., and Little, A.F. Presurgical evaluation of the liver transplant candidate.
Radiologic Clinics of North America. 1995; 33:497-520.
Garcia-Criado, A., Gilabert, R., et al. Radiology in liver transplantation. Semin. in US, CT, and
MRI. 2002; 23:114-129.
Holbert, B.L., Campbell, W.L., and Skolnik, M.L. Evaluation of the transplanted liver and
postoperative complications. Radiologic Clinics of North America. 1995; 521-540.
Kemmerer, S.R., Mortele, K.J., and Ros, P.R. CT scan of the liver. Radiol. Clin. of North America.
1998; 247-61.
Meyers, W.C., Ricciardi, E., and Chari, R.S. Liver. In: Townsend: Sabiston Textbook of General
Surgery, 16th ed. W.B. Sauders, 1999. P. 997-1005.
Olliff, S. The radiology of liver transplantation. In: Grainger and Allison’s Diagnostic Radiology: A
textbook of medical imaging, 4th ed. Churchill-Livingstone, 2001; pp. 1333-40.
Quiroga, S., Sebastia, C., Margarit, C., et al. Complications of orthotopic liver transplantation:
spectrum of findings with helical CT. Radiographics. 2001; 76:1085-102.
Reeder, M.M. and Felson, B. Vascular lesions of the liver. In: Gamuts in Radiology. Audiovisual
radiology of Cinncinnati, 1992.
Rerknimitr, R., Sherman, S., Fogel, E., et al. Biliary tract complications after orthotopic liver
transplantation with choledochocholedochostomy anastamosis: endoscopic findings and results of
therapy. Gastrointestinal Endosc. 2002; 55:224-31.
Schwartz, J.M., and Carithers, R.L. Clinical features, diagnosis, and screening for primary
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hepatocellular carcinoma. www.UpToDate.com 2003.
Aimee M. Crago, HMS IV
Gillian Lieberman, MD
Acknowledgements
• Larry Barbaras and Cara Lyn D’amour
• Gillian Lieberman, MD
• Pamela Lepkowski
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