My Worst Case

My Worst Case Antalya, Turkey September 4, 2007 Charles B. Rosen, MD Surgical Director, Liver Transplantation Mayo Clinic Rochester Mayo Clinic College of Medicine

My Worst Case 48 year old male, ABO:B • March 2007: jaundice, weight loss, abdominal discomfort – ERCP: malignant appearing hilar stricture » Pancreatitis after endoscopic intubation – CT: right and left portal vein encasement – CA 19-9: 151 – Percutaneous biopsy: negative – Percutaneous intubation

My Worst Case 48 year old male, ABO:B • May 2007: referred to Mayo Clinic – Clinical diagnosis of de novo hilar cholangiocarcinoma – Unresectable due to right and left portal vein encasement – CT chest and abdomen, bone scan: no metastases – EUS: negative regional hepatic lymph nodes

My Worst Case 48 year old male, ABO:B, de novo CCA • Neoadjuvant therapy • 50 year old brother potential living donor – Right hepatectomy: 60% resection, 1.2% GBWR, normal vascular and biliary anatomy

• July 2007: operative staging negative

My Worst Case August 27, 2007: living donor liver transplantation • Donor RHA noted to have dissection at completion of parenchymal division • Difficult recipient hepatectomy • Radiation changes to recipient hepatic artery

My Worst Case August 27, 2007: living donor liver transplantation • Deceased donor iliac vein graft to donor RPV • Reperfusion on PV • Recipient artery dissection precludes direct anastomosis • Deceased donor iliac artery to infrarenal aorta

My Worst Case August 27, 2007 living donor liver transplantation • Portal vein thrombosis prior to rearterialization – Urgent thrombectomy – Heparinization

• Recurrent portal vein thrombosis – Thrombectomy – IOUS: residual thrombus, slow flow in RHV

My Worst Case August 27, 2007 living donor liver transplantation • Right hepatic vein anastomosis revision • Portal vein thrombectomy • Hepatic artery thrombosis: thrombectomy

My Worst Case August 27, 2007 living donor liver transplantation • Right hepatic vein anastomosis revision • Portal vein thrombectomy • Hepatic artery thrombosis: thrombectomy • Satisfactory graft function, patent vessels by US at one week