My Worst Cases
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My Worst Cases Shin Hwang
Division of HBP Surgery and Liver Transplantation, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
1. Fatal portal flow steal 2. Advanced HCC beyond eligibility criteria 3. Aggressive HCC within eligibility criteria 4. Massive hepatic venous congestion without MHV reconstruction 5. Massive hemorrhagic Necrosis 6. Primary non-function
Case 1 Fatal portal flow steal
Clinical History & Lab. Data • Female / 37 years • 45 kg / 156 cm • Acute on chronic liver failure, HBV related • CC : Stuporous mentality • TB 39.8 mg/dL, PT 13% (INR 7.41), Cr 0.9 mg/dL • CTP : 13 points • MELD : 40 points
PV stenosis with large collaterals
Pre-OP Doppler USG PV velocity : 15 cm/sec
Operation • Adult LDLT • Donor : Her husband • Graft type : Left lobe with MHV • Graft weight : 440 gm • GRWR : 0.98% • Event : Distal MHV injury • Collateral ligation : Not done
Intra-OP Doppler USG Pre-anastomotic site
Post-anastomotic site
Good Portal Flow
POD # 1
Distal MHV injury
Distal MHV injury
S4a congestion
Changes of Liver Function
Total Bil.(mg/dL)
AST (IU/L)
50
2000 1800 1600
▪
▪
1400 1200
▪
▪
45
POD # 10 AST: 13758 IU/L
800
▪
600
▪
400
▪
▪
25
▪
20 15
▪
10 5
200 0
35 30
▪
1000
40
Pre- LT
1
2
3
4
5
6
Days
7
8
9
10
11
(Re-LDLT)
POD # 8
Intact hepatic artery Portal steal S-R shunt
POD # 10
Total infarct
POD # 11
Retransplantation
POD # 12
Die of septic shock
Graft : Left lobe with MHV Graft weight : 370 gm GRWR : 0.82
After this case, routine interruption of large portosystemic collateral shunt.
Case 2 Advanced HCC beyond eligibility criteria
Advanced HCC exceeding selection criteria
50 year-old male, 163 cm / 64 kg Known HBV-LC & HCC TACE # 12 times, TACI # 1 time AFP 14400 ng/mL CT : Suspicious PV invasion 8-cm sized multiple HCC TB 1.6 mg/dl, PT 68.2%(INR 1.38), Cr 0.8 mg/dl CTP score : 7 MELD score : 10
Posttransplant sequences 2 months
3 months
Miliary intrahepatic spread at 3 months
Survival only for 6 months
Case 3 Aggressive HCC within eligibility criteria
HCC with sarcomatous change
• S/P TACE • 3cm-sized HCC at S8 • 2.5cm-sized HCC at S4 with sarcomatous change
Early HCC recurrence after 3 months
• Omental infiltration • Massive ascites • Aortocaval lymphadenopathy
Pleural effusion Survival only for 5 mos
Mixed HCC & CCC
CCC component No tumor on CT & hepatic angiogram
HCC component
Incidental detection of 1 cm-sized mixed HCC
Early HCC recurrence after 3 months
Enlarging multiple intraperitoneal mass; Splenic infarct from SA ligation
Needle biopsy shows carcinoma: unclassified
Proportion of survival
Survival after HCC recurrence
CDLT LDLT Time-months
Case 4 Massive hepatic venous congestion Without MHV reconstruction
Right Lobe LDLT wothout MHV reconstruction
Ischemic Necrosis of Right Lobe Graft #3
#5
After 1 week
After 2 weeks
6000
60
5000
50
Mortality 40
4000
Case 5
3000
30 20
2000
Case 3
1000
10 0
0 0
2
4
6
8
10
12
Posttransplant days
14
16
18
serum total bilirubin (mg/dL)
serum AST (IU/dL)
Postoperative changes of serum AST and total bilirubin
Fates of Hepatic Venous Congestion in Right Lobe Graft and Remnant Donor Liver
Transplantation-related risk factors
Hepatic vein anatomy
Collateral formation Atrophy
Graft failure
Case 5 Massive hemorrhagic Necrosis 7th day fever syndrome
Lab Profiles
11502
4932
Steroid pulse OKT3
Fever
Biopsy
30 18% days
Cytokine-mediated inflammatory response leading to an univisceral Schwartzman reaction in the transplanted liver graft
Case 6 Primary non-function
Primary Non-Function of Living-donor Liver Graft • 1 Case out of first 163 cases - Male / 43 years old - HBV-LC with small HCC - LDLT: Left lobe (550g) from his brother (M/28) Fatty change of donor: right lobe 35% left lobe 20% - Course: Very easy operation & CIT 40 min -> Diffuse oozing since 2-3 hours after reperfusion -> Serum GOT > 750 IU/L (day 0) -> > 2000 (day 1) PT 15%, Ammonia > 200 umol/L -> at POD #2: Cadaveric retransplantation
Primary Non-Function of Living-donor Liver Graft 550gm
Resected graft
Total necrosis
Division of HBP Surgery and Liver Transplantation, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
1. Fatal portal flow steal 2. Advanced HCC beyond eligibility criteria 3. Aggressive HCC within eligibility criteria 4. Massive hepatic venous congestion without MHV reconstruction 5. Massive hemorrhagic Necrosis 6. Primary non-function
Case 1 Fatal portal flow steal
Clinical History & Lab. Data • Female / 37 years • 45 kg / 156 cm • Acute on chronic liver failure, HBV related • CC : Stuporous mentality • TB 39.8 mg/dL, PT 13% (INR 7.41), Cr 0.9 mg/dL • CTP : 13 points • MELD : 40 points
PV stenosis with large collaterals
Pre-OP Doppler USG PV velocity : 15 cm/sec
Operation • Adult LDLT • Donor : Her husband • Graft type : Left lobe with MHV • Graft weight : 440 gm • GRWR : 0.98% • Event : Distal MHV injury • Collateral ligation : Not done
Intra-OP Doppler USG Pre-anastomotic site
Post-anastomotic site
Good Portal Flow
POD # 1
Distal MHV injury
Distal MHV injury
S4a congestion
Changes of Liver Function
Total Bil.(mg/dL)
AST (IU/L)
50
2000 1800 1600
▪
▪
1400 1200
▪
▪
45
POD # 10 AST: 13758 IU/L
800
▪
600
▪
400
▪
▪
25
▪
20 15
▪
10 5
200 0
35 30
▪
1000
40
Pre- LT
1
2
3
4
5
6
Days
7
8
9
10
11
(Re-LDLT)
POD # 8
Intact hepatic artery Portal steal S-R shunt
POD # 10
Total infarct
POD # 11
Retransplantation
POD # 12
Die of septic shock
Graft : Left lobe with MHV Graft weight : 370 gm GRWR : 0.82
After this case, routine interruption of large portosystemic collateral shunt.
Case 2 Advanced HCC beyond eligibility criteria
Advanced HCC exceeding selection criteria
50 year-old male, 163 cm / 64 kg Known HBV-LC & HCC TACE # 12 times, TACI # 1 time AFP 14400 ng/mL CT : Suspicious PV invasion 8-cm sized multiple HCC TB 1.6 mg/dl, PT 68.2%(INR 1.38), Cr 0.8 mg/dl CTP score : 7 MELD score : 10
Posttransplant sequences 2 months
3 months
Miliary intrahepatic spread at 3 months
Survival only for 6 months
Case 3 Aggressive HCC within eligibility criteria
HCC with sarcomatous change
• S/P TACE • 3cm-sized HCC at S8 • 2.5cm-sized HCC at S4 with sarcomatous change
Early HCC recurrence after 3 months
• Omental infiltration • Massive ascites • Aortocaval lymphadenopathy
Pleural effusion Survival only for 5 mos
Mixed HCC & CCC
CCC component No tumor on CT & hepatic angiogram
HCC component
Incidental detection of 1 cm-sized mixed HCC
Early HCC recurrence after 3 months
Enlarging multiple intraperitoneal mass; Splenic infarct from SA ligation
Needle biopsy shows carcinoma: unclassified
Proportion of survival
Survival after HCC recurrence
CDLT LDLT Time-months
Case 4 Massive hepatic venous congestion Without MHV reconstruction
Right Lobe LDLT wothout MHV reconstruction
Ischemic Necrosis of Right Lobe Graft #3
#5
After 1 week
After 2 weeks
6000
60
5000
50
Mortality 40
4000
Case 5
3000
30 20
2000
Case 3
1000
10 0
0 0
2
4
6
8
10
12
Posttransplant days
14
16
18
serum total bilirubin (mg/dL)
serum AST (IU/dL)
Postoperative changes of serum AST and total bilirubin
Fates of Hepatic Venous Congestion in Right Lobe Graft and Remnant Donor Liver
Transplantation-related risk factors
Hepatic vein anatomy
Collateral formation Atrophy
Graft failure
Case 5 Massive hemorrhagic Necrosis 7th day fever syndrome
Lab Profiles
11502
4932
Steroid pulse OKT3
Fever
Biopsy
30 18% days
Cytokine-mediated inflammatory response leading to an univisceral Schwartzman reaction in the transplanted liver graft
Case 6 Primary non-function
Primary Non-Function of Living-donor Liver Graft • 1 Case out of first 163 cases - Male / 43 years old - HBV-LC with small HCC - LDLT: Left lobe (550g) from his brother (M/28) Fatty change of donor: right lobe 35% left lobe 20% - Course: Very easy operation & CIT 40 min -> Diffuse oozing since 2-3 hours after reperfusion -> Serum GOT > 750 IU/L (day 0) -> > 2000 (day 1) PT 15%, Ammonia > 200 umol/L -> at POD #2: Cadaveric retransplantation
Primary Non-Function of Living-donor Liver Graft 550gm
Resected graft
Total necrosis
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