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My Worst CasesMy Worst Cases

Division of HBP Surgery and Liver Transplantation,Department of Surgery, University of Ulsan College of

Medicine and Asan Medical Center, Seoul, Korea

Shin Hwang

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Case 1

Fatal portal flow steal

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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

Clinical History & Lab. Data

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PV stenosis with large collaterals

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Pre-OP Doppler USG

PV velocity : 15 cm/sec

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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

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Intra-OP Doppler USG

Pre-anastomotic site Post-anastomotic site

Good Portal FlowGood Portal Flow

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POD # 1

Distal MHV injury Distal MHV injury S4a congestion

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Changes of Liver Function

0

200

400

600

800

1000

1200

1400

1600

1800

2000

Pre- LT 1 2 3 4 5 6 7 8 9 10 11

5101520253035404550

Days

AST (IU/L) Total Bil.(mg/dL)

(Re-LDLT)(Re-LDLT)

POD # 10

AST: 13758 IU/L

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POD # 8

Intact hepatic artery

Portal steal

S-R shunt

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POD # 10

Total infarct

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RetransplantationRetransplantation

POD # 11

Graft : Left lobe with MHV

Graft weight : 370 gm

GRWR : 0.82

POD # 12

Die of septic shockDie of septic shock

After this case,After this case,

routine interruption ofroutine interruption oflarge portosystemic collateral shunt.large portosystemic collateral shunt.

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50 year-old male, 163 cm / 64 kgKnown HBV-LC & HCCTACE # 12 times, TACI # 1 timeAFP 14400 ng/mLCT : Suspicious PV invasion

8-cm sized multiple HCCTB 1.6 mg/dl, PT 68.2%(INR 1.38), Cr 0.8 mg/dlCTP score : 7MELD score : 10

Advanced HCC exceeding selection criteria

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Posttransplant sequences

2 months

3 months

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Miliary intrahepatic spread at 3 months

Survival only for 6 months

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Case 3

Aggressive HCC

within eligibility criteria

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HCC with sarcomatous change

S/P TACES/P TACE 3cm-sized HCC at S83cm-sized HCC at S8

2.5cm-sized HCC at S42.5cm-sized HCC at S4with sarcomatouswith sarcomatous

changechange

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Early HCC recurrence after 3 months

Omental infiltrationOmental infiltration

Massive ascitesMassive ascites Aortocaval lymph-Aortocaval lymph-

adenopathyadenopathy

Pleural effusion

Survival only for 5 mos

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Mixed HCC & CCC

No tumor on CT &No tumor on CT &hepatic angiogramhepatic angiogram

Incidental detection ofIncidental detection of1 cm-sized mixed HCC1 cm-sized mixed HCC

CCCcomponent

HCCcomponent

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Early HCC recurrence after 3 months

Enlarging multipleEnlarging multiple

intraperitoneal mass;intraperitoneal mass;

Splenic infarct fromSplenic infarct from

SA ligationSA ligation

Needle biopsy showsNeedle biopsy showscarcinoma: unclassifiedcarcinoma: unclassified

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LDLT

CDLT

Proportion

ofsurvival

Time-months

Survival after HCC recurrence

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Case 4

Massive hepatic venous congestion

Without MHV reconstruction

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Right Lobe LDLT wothout MHV reconstruction

I h i N i f Ri ht L b G ft

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After 1 week After 2 weeks

#3

#5

Ischemic Necrosis of Right Lobe Graft

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serumtotalbilirubin(mg/dL)

Posttransplant daysPosttransplant days

0

1000

2000

3000

4000

5000

6000

0 2 4 6 8 10 12 14 16 18

30

40

0

10

20

60

50

Case 5Case 5

Case 3Case 3ser u

mA

ST( I

U /d

L)

Postoperative changes of serum AST and total bilirubin

MortalityMortality

FatesFates ofof Hepatic Venous CongestionHepatic Venous Congestion in Right Lobe Graftin Right Lobe Graft

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FatesFatesofofHepatic Venous CongestionHepatic Venous Congestion in Right Lobe Graftin Right Lobe GraftandandRemnant Donor LivRemnant Donor Liv

Collateral formation

Graft failureAtrophy

Hepatic vein anatomyTransplantation-relat

risk factors

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Case 5Massive hemorrhagic Necrosis

7th day fever syndrome

1150211502

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Lab Profiles1150250

4932

30

18%

days

Steroid pulse

OKT3

Biopsy

Fever

Cytokine-mediated inflammatory response leading to an univisceral Schwartzman

reaction in the transplanted liver graft

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Case 6

Primary non-function

Primary Non-Function

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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

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Primary Non-Function

of Living-donor Liver Graft

550gm550gm

Resected graftResected graft Total necrosis