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Table 9.17. Causes of hepatic dysfunction Immediate

1. Primary allograft nonfunction

2. Primary allograft dysfunction

3. Hepatic artery thrombosis

4. Portal vein thrombosis

5. Hepatic vein and caval thrombosis

6. Biliary tract obstruction/leak

Delayed

1. Rejection

2. Infection

3. Biliary tract obstruction

4. Recurrent disease

5. Graft Dysfunction

Table 9.18. Signs of primary non-function

1. Failure to regain consciousness

2. Hemodynamic instability

3. Poor quality and quantity of bile

4. Increasing prothrombin time

5. Renal dysfunction

6. Rise in transaminases and bilirubin

7. Acid-base imbalance

8. Persistent hypothermia

Vascular Complications

Hepatic artery thrombosis can present with a variety of liver test abnormalities including very subtle elevations in transaminases and, therefore, may go undiag-nosed in the early period and become manifest later with biliary complications such as bile leaks, bilomas, liver abscess, and biliary strictures.(Table 9.19)

Therefore, any abnormal trend in liver function tests should be investigated immediately with ultrasound/doppler and, if the hepatic arterial signal is not clearly seen, then an angiogram should be performed. The role of lytic therapy and/or urgent reoperation for thrombectomy remains controversial. Retransplantation may be necessary especially if liver function is severely compromised in the early postoperative period. Hepatic artery thrombosis is usually related to technical complications and, therefore, a satisfactory pulse in the hepatic artery should be obtained before leaving the operating room at the time of transplantation. There is increasing data to suggest that the use of flow probes and the measurement of hepatic artery flow may predict the risk of hepatic artery thrombosis.24

Portal venous thrombosis is less common, but can occur in the setting of significant portal vein stenosis or previous portal vein thrombosis in the recipient, especially in the pediatric recipient. Typically, severe elevations in transaminases are observed in the early period and ascites is a manifestation in delayed portal vein thrombosis. Also, acute portal hypertension manifested by variceal bleeding should alert the surgeon to the possibility of acute portal vein thrombosis. In the acute setting, thrombectomy should be attempted in an effort to save the graft, although retransplantation may be necessary especially if the graft is compromised.

Finally, venous outflow obstruction causing a Budd-Chiari-like congestion of the liver can be seen either following standard hepatic transplantation with end-to-end SVC anastomosis, but has been more commonly described in the setting of piggyback operations. Several innovative techniques have been advocated for repair. In the early postoperative period, a significant elevation in transaminases results from the acute congestion, whereas delayed manifestations consist primarily of ascites and evidence of portal hypertension.

Biliary Tract Complications

Anastomotic biliary leaks may occur early in the postoperative period resulting in either localized or generalized peritonitis. Biliary output from the drains and elevation in serum bilirubin out of keeping with elevation in the other liver function tests should raise this diagnostic possibility. These biliary leaks can occur either as a result of technical problems or as a result of hepatic artery thrombosis

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