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Extrahepatic Complications of Liver Transplantation

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Extrahepatic Complications of Liver Transplantation SEMINARS IN LIVER DISEASE-VOL. 5, NO.4, 1985 Extrahepatic Complications of Liver Transplantation R. PATRICK WOOD, M.D., BYERS W. SHAW Jr., M.D., and THOMAS E. STARZL, M.D., Ph.D. Few operative procedures performed today retransplantation, or hepatic artery thrombosis, subject a patient to such extensive physiologic because these subjects are presented in other articles stresses as does liver transplantation. In addition, in this issue of Seminars. patients with end-stage liver disease are often nu­ All body systems are stressed in patients under­ tritional cripples and profoundly debilitated before going liver transplantation, either by the severe pre­ being subjected to an operative procedure of im­ existing liver failure, during the operative procedure mense proportions. These patients are expected not itself, or in the postoperative period. Those body only to recover from the operative procedure, but systems most often affected will be considered in­ also to do so under the added stress of immuno­ dividually. suppression. It is therefore not surprising that, in a review of 225 randomly selected patients receiving trans­ PULMONARY COMPLICATIONS plants at the University of Pittsburgh between June 1982 and January 1985, only 12.80/0 recovered Infection without at least one significant complication. A re­ view of the patient's hospital and office records was The most common pulmonary complications used to identify complications. The age range of the were infections. A total of 42 patients (18.7%) in patients studied ranged from 1 to 56 years. Thirty­ this series had pulmonary infections, including eight patients required a second liver transplanta­ pneumonia, empyema, and lung abscess. The in­ tion and nine patients underwent three liver trans­ fectious causes included a variety of bacterial, viral, plantations. The follow-up ranged from 6 months and fungal agents, as well as Legionella and Penu­ to almost 3 years. The actual mortality rate for mocystis carinii. Isolated bacterial pneumonias oc­ these patients was 28 0J0. curred in only five patients and comprised only Although these patients had numerous minor 11.9% of the pulmonary infections. However, bac­ complications, only those complications that terial pneumonia was frequently present in patients required additional therapy or prolonged a patient's dying of multisystem failure in the intensive care hospital course were considered significant in this unit after liver transplantation. Herpetic and cyto­ review. As is true for any retrospective chart review, megalvirus (CMV) infections also comprised 11.9% the actual incidence of any complication may be of the pulmonary infections, and 26.2% (11 pa­ higher than the incidence reported, since the identif­ tients) of these infections were secondary to Penu­ ication of a complication requires that it be mocystis. Only 2 of the 11 Pneumocystis infections recorded in some manner in the patient's chart and occurred in the immediate post-transplantation identified by the reviewer. This article will not deal period. More commonly, in 9 of the 11 patients, with those complications directly related to the these infections occurred after discharge from the hepatic allograft, such as the incidence of rejection, hospital in patients with well-functioning hepatic allografts. Legionella infections were relatively rare and occurred in only four patients, but resulted in From the Department of Surgery, University of Pittsburgh significant morbidity in three of the four patients. Health Center, University of Pittsburgh, Pittsburo/" Pennsyl­ vanta. The incidence of clinically significant pulmonary Reprint requests: Dr. Wood, Dept. of Surgery, 3601 Fifth fungal infections was difficult to determine because Ave., Room 103, Falk Clinic, Pittsburgh, PA 15213. Candida overgrowth of the tracheobronchial tree Publisher: Thieme Inc., 381 Park Avenue South, New York, NY 10016 377 378 SEMINARS IN LIVER DISEASE-VOL. 5, Nq: 4, 1985 was common in these patients, especially those Miscellaneous experiencing serious complications. However, at autopsy, seven patients were proved to have severe Other isolated pulmonary complications in­ Candida pneumonia, four patients had significant cluded seven patients who had severe aspiration aspergillosis infections, and two patients had lung pneumonia requiring reintubation and mechanical abscesses, one with Cryptococcus and one with ventilation, three patients who required multiple Mucor. chest tubes for persistent pneumothorax (no patient required thoracotomy), two patients who required Pleural Effusions thoracotomy for vascular injuries that occurred during central line placement, one patient who re­ Pleural effusions occur in almost all patients quired extensive debridement of his chest wall for undergoing liver transplantation. However, only 40 infected costal cartilages after thoracotomy, and patients (17.8 0/0) in this series required a thoracente­ one patient who required multiple thoracotomies sis or placement of a chest tube as treatment for the for persistent bleeding after 12th rib resection for a effusion. The remaining patients either had spon­ left subphrenic abscess. taneous resolution of the effusion or responded to diuretic therapy. Eight patients had significant com­ plications related directly to the treatment of the ef­ GASTROINTESTINAL TRACT fusions. These complications included bleeding re­ COMPLICATIONS quiring thoracotomy in two cases and pneumo­ thorax occurring in six patients during either thora­ Gastrointestinal tract complications can be centesis or chest tube removal. divided into those occurring spontaneously or those secondary to technical complications in the per­ formance of the liver transplantation. Atelectasis Technical Complications Atelectasis of a segment or of a complete lobe results in significant respiratory embarrassment in Bleeding these already compromised patients. Over the last several years fiberoptic bronchoscopy has been The most frequent technical complication was utilized for all patients with atelectasis unresponsive bleeding requiring reoperation in the early post­ to the usual methods of pulmonary toilet. Of the operative period. This occurred in 19 patients patients in this series, at least 45 (200/0) underwent (8.4%). Bleeding was most often diffuse (15 pa­ fiberoptic bronchoscopy. The actual incidence may tients) and related to a continued coagulopathy, be higher, since this procedure is often carried out with multiple areas of oozing identified. Correction repetitively at the bedside in the intensive care unit of the coagulopathy coupled with oversewing of all until there is complete resolution of the atelectasis. bleeding points was usually successful in stopping The aggressive application of this useful technique the hemorrhage. However three patients required may have contributed to the relatively low incidence multiple explorations for continued bleeding despite of pneumonia in this series of patients. the fact that no specific bleeding site could be located at the time of exploration. These patients did poorly, with all three dying of sepsis in the early Respiratory Failure postoperative period. True surgical bleeding oc­ curred in five cases and was related to bleeding at Severe respiratory failure in patients having the vascular anastomoses in four patients. Two of liver transplantation leads to long-term ventilator these patients also had bleeding from the right dependency. Two patients in this series had vocal adrenal gland, which may have been injured during cord paralysis secondary to prolonged intubation. the recipient hepatectomy. One patient experienced In order to avoid this complication, tracheostomies early postoperative hemorrhage when a tie came off are performed early in the course of patients who the splenic artery stump on the donor liver. If a seem destined to have prolonged respiratory failure. specific site of hemorrhage was identified at the Tracheostomies were performed in 25 (11.1 0/0) time of reexploration, no patient required an addi­ patients, and there were no operative complications. tional operation for persistent bleeding. However, Of the patients who required a tracheostomy, more reexploration for postoperative hemorrhage from than 50% eventual1y died. any cause carried a poor prognosis, with 26% of ·.EXTRAHEPATIC COMPLICATIONS-WOOD, SHAW 379 the patients in this series who died having required tient was found to have developed common bile reexploration for bleeding in the early postoperative duct stones and the duct-to-duct reconstruction was period. converted to a Roux-en-Y choledochojejunostomy. In the later postoperative period six patients Of the 113 Roux-en-Y choledochojejunostomies died as the result of massive hemoperitoneum. In performed, complications developed in 13 patients three of these patients the bleeding was the result of (11.5%). Seven patients developed leaks at the disruption of the arterial reconstruction and in one jejunojejunostomy and two of these patients also case disruption of the portal vein. Of these patients had leaks at the choledochojejunostomy. These pa­ three were in the intensive care unit with peritonitis tients required operative revision or repair of these and overwhelming sepsis at the time of the rupture leaks. Four patients developed strictures at the of the vascular anastomosis, but one was several choledochojejunostomy, two of which were months post-transplant when the arterial recon­ successfully dilated percutaneously and two of struction ruptured. This patient had received
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