Liver Transplant (cont.)
What Happens During Liver Transplant Surgery?
The incision on the belly is in the shape of an upside-down Y. Small, plastic, bulb-shaped drains are placed near the incision to drain blood and fluid from around the liver. These are called Jackson-Pratt (JP) drains and may remain in place for several days until the drainage significantly decreases. A tube called a T-tube may be placed in the patient's bile duct to allow it to drain outside the body into a small pouch called a bile bag. The bile may vary from deep gold to dark green, and the amount produced is measured frequently. The tube remains in place for about 3 months after surgery. Bile production early after the surgery is a good sign and is one of the indicators surgeons look for to determine if the liver transplant is being "accepted" by the patient's body.
After surgery, the patient is taken to the intensive care unit, is monitored very closely with several machines. The patient will be on a respirator, a machine that breathes for the patient, and will have a tube in the trachea (the body's natural breathing tube) bringing oxygen to the lungs. Once the patient wakes up enough and can breathe alone, the tube and respirator are removed. The patient will have several blood tests, X-ray films, and ECGs during the hospital stay. Blood transfusions may be necessary. The patient leaves the intensive care unit once he or she is fully awake, able to breathe effectively, and has a normal temperature, blood pressure, and pulse, usually after about 1-2 days. The patient is then moved to a room with fewer monitoring devices for a few days longer before going home. The average hospital stay after surgery is about 2 weeks.
What Is the Follow-up for Liver Transplantation?
After liver transplantation, the patient must visit the transplant surgeon or hepatologist frequently, about 1-2 times a week over about 3 months. After this time, the primary doctor may also see the patient, but the transplant doctor the patient about once a month for the remainder of the first year after transplantation.
Ideally, the transplant surgeon and hepatologist monitor the patient's progress through blood tests and contact with the primary doctor. One year after transplantation, follow-up care is individualized. If a patient ever requires a visit to an emergency department, and is discharged from there, he or she should generally follow up with his or her primary transplant doctor in 1-2 days.
How Can I Prevent Liver Disease?
Before undergoing liver transplantation, people who have liver disease should avoid medications that may further damage the liver.
- Large amounts of acetaminophen (Tylenol) may be harmful and can damage the liver. (Acetaminophen is contained in many over-the-counter drugs; therefore, patients with liver disease must be particularly watchful.) Sleeping pills and benzodiazepines (Valium and similar medicines) can build up faster in the blood when the liver doesn't work well. They can make a person confused, worsen existing confusion, and, in some cases, cause coma. If possible, try to avoid taking these medicines.
- Alcohol is an ingredient in some cough syrups and other medications. Alcohol can severely damage the liver, so it is best to avoid alcohol-containing medications.
- The female transplantation patient should not take oral contraceptives because of the increased risk of blood clot formation.
- No transplant recipient should receive live virus vaccines (especially polio), and no household contacts should receive these either.
- Pregnancy should be avoided by transplant recipients until at least 1 year after transplantation. If a woman wants to become pregnant, she should speak with her transplantation team regarding any special risks, as the immunosuppressive medications may need to be changed. In many cases, women successfully become pregnant and give birth normally after transplantation, but they should be carefully monitored because of the higher incidence of premature births. Mothers should avoid breastfeeding because of the risk of the baby's exposure to the immunosuppressive medicines through the milk.
What Is the Prognosis for Liver Transplantation Recovery?
The 1-year survival rate after liver transplantation is about 88% for all patients, but will vary depending on whether the patient was at home when transplated or critically in the intensive care unit. At 5 years, the survival rate is about 75%. Survival rates are improving with the use of better immunosuppressive medications and more experience with the procedure. The patient's willingness to stick to the recommended posttransplantation plan is essential to a good outcome.
Generally, anyone who develops a fever within a year of receiving a liver transplant is admitted to the hospital. Patients who cannot take their immunosuppressive medicines because they are vomiting should also be admitted. Patients who develop a fever more than a year after receiving a liver transplant and who are no longer on high levels of immunosuppression may be considered for management as an outpatient on an individual basis.
Complications are problems that may arise after liver transplantation. Many should be recognizable by the patient, who should call the transplantation team to inform them of the changes.
Possible complications after liver transplantation:
- Infection of the T-tube site: This tube drains bile to the outside of the body into a bile bag. Not all patients require such a tube. The site may become infected. This can be recognized if the patient notices warmth around the T-tube site, redness of the skin around the site, or discharge from the site.
- Dislodgement of the T-tube: The tube may come out of place, which may be recognized by breakage of the stitch on the outside of the skin that holds the tube in place or by an increase in the length of the tube outside the body.
- Bile leak: This may occur when bile leaks outside of the ducts. The patient may experience nausea, pain over the liver (the right upper side of the abdomen), or fever.
- Biliary stenosis: This is narrowing of the duct, which may result in blockage. The bile may back up in the body and result in yellowing of the skin.
- Infections: Infections may result from being on the immunosuppressive medications. Although these medications are meant to prevent rejection of the liver, they also decrease the ability of the body to fight off certain viruses, bacteria, and fungi. The organisms that most commonly affect patients are covered with preventive medications. Notify the transplantation team if any of the following infections arise:
- Herpes simplex viruses (types I and II): These viruses most commonly infect the skin but may occur in the eyes and lungs. Type I causes painful, fluid-filled blisters around the mouth, and type II causes blisters in the genital area. Women may have an unusual vaginal discharge.
- Herpes zoster virus (shingles): This is a herpesvirus that is a reactivated form of chickenpox. The virus appears as a wide pattern of blisters almost anywhere on the body. The rash is often painful and causes a burning sensation.
- Cytomegalovirus: This is one of the most common infections affecting transplant recipients and most often develops in the first months after transplantation. Symptoms include excessive tiredness, high temperature, aching joints, headaches, abdominal problems, visual changes, and pneumonia.
- Fungal infections: Candida (yeast) is an infection that may affect the mouth, esophagus (swallowing tube), vaginal areas, or bloodstream. In the mouth, the yeast appears white, often on the tongue as a patchy area. It may spread to the esophagus and interfere with swallowing. In the vagina, a white discharge that looks like cottage cheese may be present. To identify yeast in the blood, the doctor will obtain blood cultures if the person has a fever.
- Bacterial infections: If a wound (including the incision site) has drainage and is tender, red, and swollen, it may be infected by bacteria. The patient may or may not have a fever. A wound culture (test for the organism) will be obtained and appropriate antibiotics given.
- Other infections: Pneumocystis carinii is similar to a fungus and may cause pneumonia. The patient may have a mild, dry cough and a fever. This infection is prevented with sulfamethoxazole-trimethoprim (Bactrim, Septra). If the patient develops this infection, it may be necessary to give higher doses or intravenous antibiotics.
- Diabetes: Diabetes is a condition in which blood sugar levels are too high. This may be caused by the medications the person takes. Patients may experience increased thirst, increased appetite, blurred vision, confusion, and frequent, large volumes of urination. The transplantation team should be notified if these problems occur. They can perform a quick blood test (a fingerstick glucose test) to see if the blood sugar level is elevated. If it is, they may start the patient on medications to prevent it and recommend diet and exercise.
- High blood pressure: This may be a side effect of the medications. The patient's doctor will monitor the blood pressure with each clinic visit and, if it is elevated, may start medications to lower blood pressure.
- High Cholesterol: This may be a side effect of the medications, the patient's doctor will monitor the cholesterol levels periodically with blood tests and may recommend diet changes or start medications if necessary.
Medically reviewed by John A. Daller, MD; American Board of Surgery with subspecialty certification in surgical critical care
"Liver transplantation: Diagnosis of acute cellular rejection"
"Liver transplantation: Donor selection"
Medically Reviewed by a Doctor on 11/21/2017
Robert M McNamara, MD, FAAEM
Francisco Talavera, PharmD, PhD
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