Transplant Center

The Operation

The liver transplant operation usually takes between five to seven hours to complete. The surgical incision is made underneath the rib cage and the next several hours are spent removing the old liver. It then takes about 45 to 60 minutes to sew the four blood vessels to the new liver and restore blood flow. Once the blood flow is re-established, there may be some bleeding which may last for several minutes or hours. Once all the bleeding is controlled, the bile duct will be reconnected.

There are two different ways to connect the bile duct to the intestine, depending on the liver disease of the patient. The first way is connecting the patient's own bile duct to the donor bile duct. If this is done, a small tube called a T-tube, is placed between the bile duct connections. The tube will then exit through the skin but is easily concealed by clothing. This allows the team to monitor the amount and consistency of bile being made by the liver. This tube is tied off within the first week and removed six months after transplantation. The second way to connect the bile duct to the intestine is used if a patient's own bile duct is diseased. In this situation, the new bile duct will be connected with the patient's intestine. A small tube called a stent, is placed at the connection site. It later falls out of the duct on its own and is passed in the stool sometime after the operation.

Before the abdomen is closed, the gallbladder is removed from the donor liver. If the gallbladder was not removed, there is a possibility that gallstones may form and cause problems with the new liver. The gallbladder is a small muscular pouch that is a storage organ for bile. Bile is made by the liver and excreted into the bile duct. The bile duct is a tube that carries the bile to the gallbladder and then to the intestinal tract. The gallbladder is stimulated to squeeze a large amount of bile into the bile duct by fat in the diet. Bile mixes with the ingested food and helps with digestion. If the gallbladder is removed, the liver will release bile directly into the intestines when it is stimulated by food or other substances. Few people notice any symptoms after removal of the gallbladder.

The final step of the operation is to close the abdomen. This is done with several layers of sutures and the skin being closed with staples. The closures take about one hour.

During the surgery, an operating room nurse will be calling your family with an update every two hours. If the family will not be in the waiting area, it is important to leave a contact number with the operating staff.

After the Operation

After surgery, you are taken directly to the intensive care unit (ICU). Generally, patients are in the ICU for one to two days before moving to the solid organ transplant unit. Once on the transplant unit, activity and diet are normalized as quickly as possible. Diet is advanced from clear liquids to no-added-salt diet as soon as a patient is able to tolerate solid foods. You will be encouraged to be out of bed and active as much as possible and physical therapy will be initiated to help with activity. The average stay in the hospital following liver transplantation is about two weeks.

Potential Complications

At The Nebraska Medical Center we have some of the most experienced physicians and nurses who take every step to prevent any of the potential complications that can occur following a liver transplant. However, like any major surgery, complications can arise. The most common complications after liver transplantation are:

1. Hypertension or high blood pressures
2. Rejection of the new liver
3. Infection
4. Kidney dysfunction
5. Diabetes

The severity of these complications in a particular patient varies and cannot be predicted prior to the operation.

High Blood Pressure or Hypertension

There are many causes for high blood pressure after transplantation. Hypertension generally occurs right after surgery but goes away in time. Patients usually leave the hospital on blood pressure medication, but over time, these drugs are usually eliminated. The only long-term medications patients will be required to take are anti-rejection. These medications are used to prevent the body from rejecting the transplanted liver. New medications are being tested, so the drug therapy after transplantation may change. Right now, anti-rejection medication therapy is considered lifetime medication.

Rejection of New Liver

Most patients have some degree of transplant rejection. Rejection is not something that you usually see or feel; it is something that the physician diagnoses by looking at liver function tests and a liver biopsy. Rejection is usually treated with medication. There are several different medications that may be used to reverse rejection. If these medications fail, patients may require retransplantation. A patient may need retransplantation of the liver for several reasons:

1. Rejection that cannot be reversed with medications.
2. If the new liver fails to work immediately after transplantation (Primary non-function of the liver or PNF) This occurs in less than three percent of transplant patients. It is a life-threatening situation that requires retransplantation in a number of days. It makes the patient a top priority to receive another liver transplant. The cause of PNF is unknown.
3. A blood clot obstructs the blood flow to the liver. Clotting of the artery or vein that supplies blood to the liver may be a set up for infection or lead to emergency replacement of a new liver. Sometimes retransplantation may be avoided through surgery and removal of the clots from the affected blood vessel.

About one patient in 10 will need a second liver transplant for one of the above problems. Other causes for retransplantation include reoccurrence of the original liver disease or chronic liver dysfunction.

The cause for the liver failure is not known. It can occur even when every test on the donor suggests the liver should work normally after transplantation. Usually, lack of adequate initial function requires urgent retransplantation of the liver. Clotting of the artery or vein that supplies blood to the liver also may lead to emergency replacement of a new liver. Sometimes retransplantation may be avoided if the surgeons can operate and clear the clots from the affected blood vessel.

Infection
Infection may occur in any body system and most of the infections are caused by organisms common in the environment or in and on the patient´s own body. These organisms include bacteria, fungi (molds and yeasts) and viruses. Other people (nurses, doctors, or family members and friends) who come into regular contact with you don't risk transmission of serious infections. Although you may get colds and flu, these are not the kinds of infections that are associated with serious threat to life; therefore you are not placed in isolation.

These complications can make the post transplant experience difficult. For example, one day you may feel well and the next, develop a fever and feel ill. Fever may be a sign of rejection so blood work will be drawn to assess liver function. Fever also may be a sign of infection. To accurately diagnose infection, more tests will need to be performed. These may include blood tests, X-rays, urine cultures, ultrasounds, CT scans (an imaging process allowing physicians to see inside your body) and biopsies of different tissues. It is important to discover the kind of infection present so that it can be treated with the appropriate antibiotic.

Kidney Dysfunction
Some of the medications used to prevent graft rejection and some antibiotics can cause kidney problems. The transplant team measures drug levels and monitors kidney function tests to try and avoid these problems.

Diabetes
Some of the anti-rejection medications may increase the possibility of a patient developing diabetes (high blood sugars). Other factors like weight and family history may also increase the possibility of developing diabetes after transplantation. Sometimes the blood sugars may be reduced through diet and exercise. Sometimes oral medications or injections are required. Special instruction will be given to any patient who may develop diabetes.

We make every effort to prevent complications. However, if they occur we have the available resources to provide the appropriate and necessary care.