1. An update on liver transplantation Joint Hospital Surgical Grand Round 19/7/2014

2. index Indication Work up Focus on adult liver transplantation Living donor liver transplant (LDLT) Right lobe graft Post-op and long term care

3. Indication Liver failure King’s college criteria (INR, age, bilirubin, speed of disease progression) Unacceptable QoL from liver disease Variceal bleed, ascites, jaundice etc Hep B/C, PBC, secondary biliary cirrhosis, BA, etc Tumor (mainly HCC, others as well) Milan’s criteria and others

4. Contra-indication Absolute Poor pre-morbid (CVS or respiratory) Malignancy (extra-hepatic mets) Infective (Extrahepatic sepsis, HIV) Psychological (compliance issues, substance abuse) Relative Advanced HCC (outside criteria) Age

5. Deceased vs living donor Deseased donor Critical issue of brain death Contra-indicated: malignancy, HIV, substance abuse, liver condition (cirrhosis, fatty change, deranged LFT), unstable hemodynamic, sepsis, ischemic time Graft allocation: MELD score

6. Donor safety is paramount Living donor: Workup Hx, PE, bloods (hematology, biochemistry, serology) Psychological Radiology esp CT (HA, HV, PV anatomy and volumetry) +/- Pathology Pre-requisite: Voluntary, healthy, ABO, no infection, no hepatitis, size of liver remnant (ESLW)

7. right lobe donor hepatectomy Right lobe versus left lobe Majority of chronic hep B patients are male

8. Cont. Adequate graft size (at least 40%) Small for size graft syndrome INR, HE, ascites and jaundice Remedy (inflow and outflow manipulation) SA ligation, splenectomy,

9. Middle hepatic vein controversy Relieve outflow obstruction (esp right ant sector) Can accommodate smaller graft (from 40 to 35%, widen applicability**) Only selected few can do without MHV

10. Cont. Perceived suboptimal venous drainage for donor liver remnant Undue worry esp. with segment IVb vein preserved no difference between donor with or w/out MHV in terms of blood loss complication rate biochemistry liver regeneration rate

11. Post-op care Daily Doppler Medication Extremely complex medication protocol with very specific dosage and duration of multiple meds (immunosuppression and antibiotics)

12. Complications Immunological Vascular Infective Late

13. Long term care minimal dose immunosuppression Cancer screening for HCC Prevent recurrence (autoimmune and viral hepatitis)