title: WoS Regional Teaching - Liver Transplant - Organ Donation tags: FFICM notebook: ð-FFICM

Surgical Perspective

There are different regions within the UK, and a retrieval team for each.

The retrieval team for scotland is Edinburgh and covers NI also.

Theres an abdo team: Liver, Kidneys, Pancreas Theres a cardiothoracic team: Heart, Lungs

After brain stem death:

Practicalities for Brainstem Death

Incision from xiphisternum to pubis for abdominal

You need to be able to clamp aorta

They infuse perfusion fluid

Cardiothoracic: Echo, Bronchoscopy, PA Catheter (All done in theatres)
Abdo: Cannulate aorta for perfusion fluid
Abdo: Hour to prepare organs
Abdo: Opening chest (lungs get put down)
Abdo: Then aorta cross clamps
Abdo: Infuse perfusion fluid (similar electrolytes to other fluid)
Abdo: Ice put into abdomenAbdo: Organ retrieval itself

In that hour to prepare organs they look for lesions for cancer.

If cancer found, may stop there, or may be able to get urgent pathology.

Logistics

Cardiothoracics don't have long between organ coming out and organ going in

So they try and get patient receiving it to be ready in hospital before they start!

Practicalities after Circulatory Death

Increased over last 10 years or so.

Can be very challenging to watch, its psychologically distressing to see an operating theatre interfere with a "dead body"

You need to be clinically dead with asystole and 5 mins stand down before moving through to theatre.

Sometimes care can be withdrawn in the anaesthetic room, which can minimise time between asystole and organs on ice.

The person who certifies death needs to come to theatre and verbally say it.

They want everything to be cleared that can be to make things easier (gown off, ecg leads in accessible place)

The practicalities are very similar in theatre.

Cannulation of aorta should happen in less than 5 mins after knife to skin. Then perfusion with 6L of perfusion fluid with heparin in that. The difference is no time to prepare organs like you would have in after brainstem death

Normothermic regional perfusion (a technique to improve liver outcomes after retrieval)

Patients' abdominal organs are started on a ECMO style device, ensuring that it's only the abdominal organs in isolation (aorta is crossclamped, and a balloon, and arch vessels cannulated to prefent pressure of blood to head)

The abdominal organs are put on that circuit for a couple of hours before retrieval.

There is a whole body NRP style device used in a couple of places in the world, success there is limited by bleeding

There are 26 Scottish ICUs

Livers

Edinburgh usually has 30-40 on their list

They would usually do around 100 / year

Patients can either be on for acute liver failure or chronic liver disease (Alcohol, NAFLD, Hep C, PBC/PSC, HCC)

The criteria for Acute Liver Failure transplant is the Kings College Criteria

The operation to receive a liver is involved.

The hepatectomy can take up to 5 hours, can involve major major blood loss (30litres!)

These patients are usually coagulopathic as well.

They do a portocaval shunt first when removing, and then they do a "piggyback" where they insert the new liver onto this shunt.

There is a really nasty repurfusion hit for this liver.

Then they rejoin the systemic circulation after the hepatic circulation.

In intensive care: you need LOADS of fluid afterwards

They usually get extubated about 24-48hrs after

Bleeding post op is quite common. Drains are inserted but that would capture everything.

Hepatic Artery Thrombosis is a big fear, will cause failure

Bile duct complications can require intervention for stenosis and leakage

Dying from a liver transplant (1/10 at one year)

Remember pre op optimisation for retrieval can't happen specifically for optimisation whilst still alive.

Post Op

Immunosuppression and infection prevention:

Azathioprin/Tacrolimus/Prednisolone
Fluconazole/Cotrimoxazole

You want fluid replete, low haematocrit

Doppler very early on

No specific rules for nutrition