Complications précoces après transplantation Hépatique

Complications précoces
après transplantation Hépatique
Alexis Laurent
Hôpital Henri Mondor
APHP – Université Paris 12
Plan
Plan
Hémorragie postopératoire
• 100% !!!!
• 10 to 15% nécessite une reoperation
• Facteur de risque préop++++ =
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trouble de l’hémostase préop (MELD)
thrombopénie
Hémorragie postopératoire
Causes chirurgicales
Prélèvement
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Décapsulation (Foie droit ++)
Lit vésiculaire
Artère cystite
Veines segt I
Veines diaphragmatiques
Transplantation
• Anastomoses vasculaires
• Glande surrénale droite
Hémorragie postopératoire
Causes non chirurgicales
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Coagulopathie
thrombopénie
Dysfonction primaire et non fonction primaire
Fuite anatomotiques
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Héparine
Biopsies
Anévrisme mycotiques (rare)
Sténose ou thrombose Artère hépatique
Hémorragie postopératoire
Diagnostic
• CLINIQUE ++++
• hypotension, tachycardie, distension abdominale
• Diminution de la SvO2
• détérioration de la fonction rénale
• La fonction hépatique reste le plus souvent normale
• Les drains = source de piège +++ faussement rassurant
• ECHOGRAPHIE
• Angio scann
Hémorragie postopératoire
Traitement : réanimation -chirurgie
• Une équipe réa / chirurgien
• Qui réopérer ? Très difficile
• 4-6 CG / 24 H
• instabilité hémodynamique
• Quand réopérer
• Patient stable
• Produits sanguins disponibles (en salle)
• le même chirurgien
• pas de délais quand décision prise
• intervention rapide # 1 heure
Plan
Complications Vasculaires
Précoces
Thromboses
Tardives
Sténose
Thrombose artérielle précoce
Incidence :
adultes : 2.5 - 10%
enfants : 15 - 20%
Although, a native non-transplanted liver might
function very well without arterial blood supply
….. this does not apply for a transplanted liver
Thrombose artérielle précoce
§ S1 &S2 ==> dysfunction – non fonction
§ ????
§ > S4 ==> complications biliaires à distance
(cholangite ischémique)
Thrombose artérielle précoce
Haemetoma
Thrombose artérielle précoce
Sténose du tronc coeliaque
Thrombose artérielle précoce
Causes non chirurgicales
 Rejet
 Initiale dysfonction ==> œdème du greffon
 Hypercoagulopathie
Early portal vein thrombosis
Incidence :
0.3-2.2%
(2.5-10% artery)
15% if pre-existing portocaval shunt.
“As with the arterial blood supply, efficient perfusion of
the portal vein is most important during the early
postoperative period”
Early portal vein thrombosis
§ most detrimental
• severe allograft dysfunction
• haemodynamic instability
• varioceole haemorrhage
• Lingerie
§ Mortality is high
Early portal vein thrombosis
Risk factors
§ pre-existing portal vein thrombosis
§ Thrombectomy of pre-existing portal vein thrombosis
at the time of transplantation (denudation of the epithelium)
§ decrease the portal vein blood flow
• large portosystemic collaterals (ligation)
• other large collaterals
• previous splenectomy
§ hypoplastic portal vein
§ mismatch in size of the donor and recipient portal vein
Early portal vein thrombosis
Technical factors
§ redundancy of portal vein
§ Kinking
§ Torsion
§ Stenosis
Early portal vein thrombosis
Medical factors
§ Rejection
§ Poor initial graft function ==> graft oedema
§ Hypercoagulopathy
Venocaval stenosis and obstruction
§ rare 1-2%
§ very high mortality of 50–75%
§ suprahepatic more dangerous than infrahepatic
affect
venous outflow and function of the liver graft
heart function ==> severe haemodynamic instability
Venocaval stenosis and obstruction
Etiologies
§ Technical (if accute => Budd-chiari)
• narrowing and stenosis: supra- or infrahepatic venocaval anastomosis
(excessive length and/or kinking)
•mechanical obstruction ( too large graft for a small recipient)
§ Medical ( rare )
•Poor initial graft function ==> graft oedema.
•recurrence of Budd-Chiari
Supra Venocaval stenosis and obstruction
Clinic
§ massive swelling of the liver, despite
normal pulmonary pressure
§ Hepatomegaly
§ peripheral oedema
§ persisting or new onset of ascites
§ decrease urine output
Supra Venocaval stenosis and obstruction
Biology
§ decrease in hepatic function
§ decrease in renal function
SURGERY
Infra Venocaval stenosis and obstruction
§ usually less dangerous.
§ decreased renal function without signs of hepatomegaly and ascites
§ oedema of the lower extremities
can be huge
seriously compromise quality of life
§ Decrease of kidney
if complete obstruction ==> risk of renal vein thrombosis
Biliary tracts complications
Biliary tracts complications
§ Starzl : ‘Achilles’ heel’ of liver transplantation
§ Despite attempts to repair the biliary tract, morbidity and mortality
remain high in this group of patients
§ Many patients die between 1 and 6 months after diagnosis
§ ascending or systemic infection
Biliary tracts complications
§ Biliary complications
2.3 and 50%
§ Biliary leaks
1.3 and 10%.
§ Biliary stenosis
2.6 and >20%.
Biliary tracts complications
Clinical picture
§ broad spectrum
§ Strictures:
• asymptomatic cholestasis
• cholangitis
• severe biliary peritonitis and sepsis
§ Leaks:
• asymptomatic
• biliary peritonitis
Biliary tracts complications
Imagery
§ Echo, TDM, ERC
Biliary tracts complications
Biliary leak
Biliary tracts complications
Treatment
Biliary tracts complications
Treatment
Non-specific surgical complications
§ Injury of intra-abdominal organs (immediate)
Previous operations
§ Infections (early/late)
§ Small bowel obstruction (early/late)
+++ if Roux-en-Y
Practice points
§ Abdominal bleeding
• Anastomoses (immediate)
• Site of implantation (immediate)
§ Vascular complications
• Hepatic artery thrombosis (early)
• Hepatic artery stenosis (late)
• Portal vein thrombosis (early)
• Portal vein stenosis (immediate)
• Suprahepatic/infrahepatic vena caval obstruction (immediate)
§ Biliary complications
• Biliary leakage (early)
• Biliary strictures (late)
• Stenosis of papilla vateri (early)
§ Non-specific surgical complications
• Infections (early/late)
• Small bowel obstruction (early/late)
• Injury of intra-abdominal organs (immediate)
• Previous operations (immediate)
Keep in mind……..
If things go well..
it was a surgical success!
If things go not-so-well it was...
ANES
THES
IA ’ S F
AULT
!!!
Keep in mind……..
Indeed
it is a Team success
Anesthesia
CCM
Radiologist
nurses
…… Surgeon