Sinusoidal obstruction syndrome surgery: Difference between revisions
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==Surgery== | ==Surgery== | ||
The sinusoidal obstruction syndrome patients who don't respond to supportive care or defibrotide can undergo TIPS or liver tansplantion. | |||
===Transjugular intrahepatic portosystemic shunting=== | |||
* [[Transjugular intrahepatic portosystemic shunt|Transjugular intrahepatic portosystemic shunting (TIPS)]] is bypassing the high flow rate of [[portal vein]] into the [[Systemic vein|systemic veins]]. | |||
* [[TIPS]] would decrease the pressure over the [[portal system]] and a decreased risk of complications, such as:<ref name="pmid291109902">{{cite journal |vauthors=Lahat E, Lim C, Bhangui P, Fuentes L, Osseis M, Moussallem T, Salloum C, Azoulay D |title=Transjugular intrahepatic portosystemic shunt as a bridge to non-hepatic surgery in cirrhotic patients with severe portal hypertension: a systematic review |journal=HPB (Oxford) |volume= |issue= |pages= |year=2017 |pmid=29110990 |doi=10.1016/j.hpb.2017.09.006 |url=}}</ref> | |||
** [[Splenomegaly]] | |||
** [[Esophageal varices]] | |||
** [[Gastric varices]] | |||
** [[Collateral circulation|Collateral formations]] | |||
<br> | |||
{{#ev:youtube|O2u4_hF3234|500}} | |||
=== Liver Transplantation === | |||
=== Patient evaluation prior to transplantation === | === Patient evaluation prior to transplantation === | ||
Pre-transplant [[patient]] evaluation has the following objectives: | Pre-transplant [[patient]] evaluation has the following objectives: | ||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:
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Overview
Surgery
The sinusoidal obstruction syndrome patients who don't respond to supportive care or defibrotide can undergo TIPS or liver tansplantion.
Transjugular intrahepatic portosystemic shunting
- Transjugular intrahepatic portosystemic shunting (TIPS) is bypassing the high flow rate of portal vein into the systemic veins.
- TIPS would decrease the pressure over the portal system and a decreased risk of complications, such as:[1]
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Liver Transplantation
Patient evaluation prior to transplantation
Pre-transplant patient evaluation has the following objectives:
- Assesment of ability of the patient to withstand surgery
- Assesment of ability of the patient to withstand immunosuppression
- Assessment of patients demands of post-transplantation care
Pre-transplant evaluation is particularly aggressive in patients prior to transplantation to minimize post operative morbidity and mortality due to effects of surgery and immunosuppressive therapy.The following evaluations are required:
- Cardiopulmonary
- Screening for occult cancer
- Screening for occult infection
- Psychosocial evaluation
Laboratory investigations
Laboratory investigations essential for patient evaluation prior to liver transplantation are as follows:
General investigations
- Liver function tests:
- Bilirubin levels
- ALT levels
- AST levels
- ALP levels
- International normalized ratio [INR]
- ABO-Rh blood typing
- Calcium levels
- Vitamin D levels
- Complete blood count
- Creatinine clearance
Cause specific investigations
- Serum Na levels
- Serum alpha-fetoprotein
- Serology:
- Urinalysis
- Urine drug screen
Cardiopulmonary evaluation
Cardiopulmonary evaluation helps in the evaluation of the patient for pathologies that need to be ruled out prior to transplantation:[2][3]
- The following tests are done for the cardiopulmonary evaluation of a patient:[2][9][10]
- Pulse oximetry[11]
- Screening for hepatopulmonary syndrome:
- Indicates worse prognosis in cirrhotic patients and qualifies patients for standard Model for End-stage Liver Disease (MELD) exception points
- Hepatopulmonary syndrome is characterized by the following:
- Liver disease
- Intrapulmonary vascular dilatations
- Impaired oxygenation
- Hepatopulmonary syndrome is characterized by the following:
- Indicates worse prognosis in cirrhotic patients and qualifies patients for standard Model for End-stage Liver Disease (MELD) exception points
- Arterial blood gas (ABGs):
- ABGs are performed in patients with normal pulse oximetry in order to calculate age-adjusted alveolar-arterial gradient
- Chest imaging
- Pulmonary function testing
- Electrocardiogram:
- Electrocardiogram helps detect the presence of the following conditions:
- Cardiac arrhythmias
- Conduction defects
- Electrocardiogram helps detect the presence of the following conditions:
- Signs of the following:
- Hypertrophy of the cardiac chamber
- Prior cardiac ischemia
- Cardiac stress testing:[12]
- Noninvasive cardiac testing is performed in the following cases:
- Patients older than 40 years of age
- Patients younger than forty years of age, with multiple risk factors for coronary artery disease
- Noninvasive cardiac testing is performed in the following cases:
- If abnormalities are noticed on cardiac stress testing, the patient undergoes cardiac catheterization
- In case of presence of clinically significant coronary artery stenosis, revascularization before transplantation is considered
- Echocardiography:
- Transthoracic contrast-enhanced echocardiography:
- Valvular heart disease
- Suspected cases of hepatopulmonary syndrome:
- If the oxygen saturation on pulse oximetry is low (<96 percent)
- Portopulmonary hypertension:
- Pulmonary arterial hypertension (PAH) associated with portal hypertension
- Transthoracic contrast-enhanced echocardiography:
Cancer screening
Prior to transplantation, screening for the following carcinomas is recommended:
- Hepatocellular carcinoma (HCC):
- Investigations for the staging of HCC include:
- Investigations for the assessment of invasion of vasculature:
- Multiphase contrast-enhanced CT scanning
- Contrast-enhanced MRI
- Transabdominal ultrasonography with Doppler imaging
- Contrast-enhanced ultrasonography
- Investigations for the assessment of invasion of vasculature:
- Skin cancer:
- Skin examination
- Biopsy incase of suspected lesions
- Colon cancer:
- Colonoscopy for screening of colon cancer is done in case of:
- Age of 50 years
- History of colon cancer in a first-degree relative
- Patients with primary sclerosing cholangitis
- Colonoscopy for screening of colon cancer is done in case of:
- Screening is also done for the following:
Upper GI endoscopy
- To detect varices
Bone densitometry
- Screening for osteoporosis
- Osteoporotic patients are treated with bisphosphonates before transplanatation
Vaccinations and evaluation for infection
- Workup for tuberculosis:
- Skin testing
- Interferon-gamma release assay
- Screening in endemic areas for:
- Vaccinations recommended before liver transplantation include:
Psychosocial evaluation and education
- Discussion of risks and benefits of transplantation
- Ensuring social support
- Substance use disorders eg alcohol must be treated prior to transplantation:
- Rehabilitation
- Abstinence program
- Education of the family
- Patient compliance with elaborate behavioral and medical regimens
Techniques
- Before transplantation, liver support therapy might be indicated ( called bridging-to-transplantation).
- Artificial liver support like liver dialysis or bioartificial liver support concepts are currently under preclinical and clinical evaluation.
- Virtually all liver transplants are done in an orthotopic fashion, that is the native liver is removed and the new liver is placed in the same anatomic location.
- The transplant operation may be conceptualized as consisting of:[13][14][15][16][2]
- Hepatectomy (liver removal) phase
- Anhepatic (no liver) phase
- Postimplantation phase
- The surgery is done through a large incision in the upper abdomen.
- The hepatectomy involves the division of:[17][18]
- All ligamentous attachments to the liver
- Common bile duct
- Hepatic artery
- Portal vein
- Usually, the retrohepatic portion of the inferior vena cava is removed along with the liver, although an alternative technique preserves the recipient's vena cava ("piggyback" technique).
- The donor's blood in the liver is replaced by an ice-cold organ storage solution, such as UW (Viaspan) or HTK until the allograft liver is implanted.
- Implantation involves anastomoses (connections) of the inferior vena cava, portal vein, and hepatic artery.
- After blood flow is restored to the new liver, the biliary (bile duct) anastomosis is constructed, either to the recipient's own bile duct or to the small intestine.
- The surgery usually takes between five and six hours, but may be longer or shorter due to the difficulty of the operation and the experience of the surgeon.
- The large majority of liver transplants use the entire liver from a non-living donor for the transplant, particularly for adult recipients.[19][20]
- A major advance in pediatric liver transplantation was the development of reduced size liver transplantation, in which a portion of an adult liver is used for an infant or child.
- Further developments in this area included split liver transplantation in which one liver is used for transplants for two recipients and living donor liver transplantation, in which a portion of the liver of a healthy person is removed and used as the allograft.
- Living donor liver transplantation for pediatric recipients involves removal of approximately 20% of the liver (Couinaud segments 2 and 3).
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Orthotopic Liver Transplantation
- Donor selection based on biomarkers and risk indices is a crucial aspect of orthotopic liver transplantation and involves:
- Preference of younger over older donors
- Appropriate selection of recipients
- Age based matching of donors and recipients
- Surgery for liver transplantation involves the following steps:[21][22][23]
- Excision of the liver of the recipient
- Separation of:
- During surgery, venovenous bypass helps in diversion of flow from disrupted Inferior Vena Cava (IVC) and portal vein to Superior Vena Cava (SVC)
- In order to maintain blood flow of the hepatic artery, anastomosis of donor liver at vascular sites is performed
- Then, anastomosis of the bile ducts of the graft and recipient is performed
- In addition, choledochojejunostomy may also be performed incase of bile duct pathology
- Postoperatively, stenting of the bile duct using a T-tube may help monitor:
Immunosuppressive management
- Postimplant immunosuppression ensures survival of the patient and allograft
- Immunosuppressive agents used in patients receiving a liver transplant include the following:[24][25]
- Agents used for induction therapy include:
- High-dose corticosteroids
- Antithymocyte globulin
- Monoclonal antibody
- Azathioprine
- Cyclosporine/Tacrolimus (calcineurin inhibitors)
- Antiproliferative agents
- Agents for long-term immunosuppression:
- The risk of chronic rejection in patients with liver transplantation decreases with time, although recipients may need to take lifelong immunosuppresive therapy
Results
- The prognosis of liver transplantation is good:[26][27][28][29][30]
- 1-year survival is 83%
- 5-year survival is 76%
- 10-year survival is 66%
- Majority of deaths occur during the first three months after transplantation
Living donor transplantation
- Living donor liver transplantation (LDLT) has emerged in recent decades as a critical surgical option for patients with end stage liver disease, such as cirrhosis and/or hepatocellular carcinoma often attributable to one or more of the following:[18][31][32]
- Long-term alcohol abuse
- Long-term untreated Hepatitis C infection
- Long-term untreated Hepatitis B infection
- The concept of LDLT is based on:
- Remarkable regenerative capacities of the human liver
- Widespread shortage of cadaveric livers for patients awaiting transplant
- In LDLT, a piece of healthy liver is surgically removed from a living person and transplanted into a recipient, immediately after the diseased liver of the recipient has been entirely removed
- Historically, LDLT was used as a means for parents of children with severe liver disease to donate a portion of their healthy liver to replace the damaged liver of their children
- In 1986, the first successful LDLT was performed at the Universidade de São Paulo (USP) Medical School, by Dr. Silvano Raia.
- More technically demanding than standard, cadaveric donor liver transplantation
- Has faced several ethical problems[33]
Complications of Liver Transplantation
- Complications that may develop in transplant recipients include the following:[34]
- Acute rejection of the graft
- Adverse effects of immunosuppressive therapy
- Biliary stricture
- Biliary leak
- Vascular thrombosis
- Sepsis
- Malignancy
- Immediate postoperative complications of liver transplantation include:
- The most common causes of death in liver transplant patients are as follows:
- To monitor the patient for complications, the following investigations are used:
- Laboratory investigations
- The following laboratory investigations help in providing evidence of rejection, and also help in the assessment of drugs( Azathioprine, Cyclosporine and Tacrolimus) along with their effect on bone marrow and renal function:
- CBC
- Electrolyte panel
- Liver function tests
- Renal function tests (RFTs)
- Drug levels in case of altered renal function tests or suspected rejection:
- Cyclosporine levels
- Tacrolimus levels
- In case of suspected infection:
- The following laboratory investigations help in providing evidence of rejection, and also help in the assessment of drugs( Azathioprine, Cyclosporine and Tacrolimus) along with their effect on bone marrow and renal function:
Imaging studies
- Chest radiography:
- Abdominal ultrasonography
- Computed tomography scan
- Endoscopic retrograde cholangiopancreatography (ERCP)
Acute and chronic graft rejection
- Vigilance is required for detection of rejection due to subtle presentations
- Occurrence: roughly 20-70 percent patients
- Timing: 1-2 weeks post- transplantation, within first three months of transplantation
- Outcome: Graft dysfunction
- Clinical presentation:
- Jaundice
- Fever
- Right-upper-quadrant tenderness
- Generalized abdominal tenderness
- Eosinophilia
- In case of mild rejection, symptoms may be nonspecific and include:
- Laboratory evidence:
- Abnormal liver function tests
- Elevated Bilirubin
- Elevated alkaline phosphatase levels
- Elevation of hepatocellular enzymes:
- Treatment of acute rejection:[35]
- High-dose steroids:
- Prednisolone 200 mg
- Methylprednisolone 1 g for 3 days
- High-dose steroid bolus followed by a rapid taper over 1 week
- High-dose steroids:
- Alternative therapies include:
- Antibody treatments:
- Monoclonal therapy (OKT3 )
- Antithymocyte globulin
- Antibody treatments:
- Occurence: 5% of patients
- Main cause of late stage graft failure
- Features of chronic graft rejection include:
- Gradual obliteration of small bile ducts
- Microvascular changes
- Symptoms:
- Laboratory investigations:
- Elevated serum alkaline phosphatase
- Elevated bilirubin levels
- Gold standard diagnostic modality: Liver biopsy
Infection
Infections may be classified based on the duration post transplantation.
- <1 month : Common conditions developing in patients in the early posttransplant period include intra-abdominal infections such as:
- 1-6 months: Infections commonly occur due to:
- After the first 6 months, risk of infection in transplant patients is equal to that of the population
- Infection is primarily nosocomial. Common organisms responsible for causing infection post-transplant are as follows:[36]
- Bacterial (most common):
- Enterococci
- Staphylococci
- Gram-negative aerobes
- Anaerobes
- Fungal: Candida (75% of fungal infections)
- Presenting symptoms: May be non-specific[34]
- Fever (absent or low grade)
- Abdominal pain
- Jaundice
- Masking of symptoms may occur due to immunosuppression
- Minimal pain at infection site
- Bacterial (most common):
- Laboratory investigations:
- Complete blood count (CBC)
- Serum chemistries
- Liver function tests
- Coagulation panel
- Urinalysis
- Urine culture
- Blood culture
- Imaging:
- Abdominal radiographs
- Chest radiographs
- Computed tomography (CT)
- Abdominal ultrasonography
- T-tube cholangiography
- Endoscopic retrogrande cholangiopancreatography (ERCP)
- Liver biopsy
- Treatment of infection:[37]
- Antimicrobials prescribed for non-immunosuppressed patients
Cytomegalovirus (CMV)
- Most common viral infection (affects 25-85% patients)
- Occurrence: Between posttransplant months 1 and 3
- Infection may be:
- Primary
- Reactivated
- Clinical presentation:
- Laboratory investigations:
- Atypical lymphocytes
- Thrombocytopenia
- Mildly elevated transaminase levels
- Imaging findings:
- CXR: CMV pneumonitis patients may have bilateral infiltrates on CXR
- Serology: Indirect immunofluorescence testing method
- Treatment: Ganciclovir intravenously for 2-4 weeks
Pneumocystis carinii pneumonia (PCP)
- May occur along with CMV infection or alone
- Diagnosis: Bronchoalveolar biopsy
- Treatment: Trimethoprim-sulfamethoxazole
Other less common organisms causing infection include:
- Fungi (especially Candida species)
- Herpes simplex
- Herpes zoster
- Toxoplasma
- Hepatitis C virus (HCV)
- Hepatitis B infection
- Malignancy:
- In transplant patients, malignancy is the second leading cause of late mortality
- Common malignancies occuring in patients after transplantation include:
- Lymphomas
- Squamous cell carcinoma: SCC of skin is the most common malignancy that occurs pos-tranplantation
- Posttransplant lymphoproliferative disorder
References
- ↑ Lahat E, Lim C, Bhangui P, Fuentes L, Osseis M, Moussallem T, Salloum C, Azoulay D (2017). "Transjugular intrahepatic portosystemic shunt as a bridge to non-hepatic surgery in cirrhotic patients with severe portal hypertension: a systematic review". HPB (Oxford). doi:10.1016/j.hpb.2017.09.006. PMID 29110990.
- ↑ 2.0 2.1 2.2 Martin P, DiMartini A, Feng S, Brown R, Fallon M (2014). "Evaluation for liver transplantation in adults: 2013 practice guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation". Hepatology. 59 (3): 1144–65. PMID 24716201.
- ↑ Zoghbi GJ, Patel AD, Ershadi RE, Heo J, Bynon JS, Iskandrian AE (2003). "Usefulness of preoperative stress perfusion imaging in predicting prognosis after liver transplantation". Am. J. Cardiol. 92 (9): 1066–71. PMID 14583357.
- ↑ Guckelberger O, Mutzke F, Glanemann M, Neumann UP, Jonas S, Neuhaus R, Neuhaus P, Langrehr JM (2006). "Validation of cardiovascular risk scores in a liver transplant population". Liver Transpl. 12 (3): 394–401. doi:10.1002/lt.20722. PMID 16498651.
- ↑ Plotkin JS, Scott VL, Pinna A, Dobsch BP, De Wolf AM, Kang Y (1996). "Morbidity and mortality in patients with coronary artery disease undergoing orthotopic liver transplantation". Liver Transpl Surg. 2 (6): 426–30. PMID 9346688.
- ↑ Colle IO, Moreau R, Godinho E, Belghiti J, Ettori F, Cohen-Solal A, Mal H, Bernuau J, Marty J, Lebrec D, Valla D, Durand F (2003). "Diagnosis of portopulmonary hypertension in candidates for liver transplantation: a prospective study". Hepatology. 37 (2): 401–9. doi:10.1053/jhep.2003.50060. PMID 12540791.
- ↑ Krowka MJ, Mandell MS, Ramsay MA, Kawut SM, Fallon MB, Manzarbeitia C, Pardo M, Marotta P, Uemoto S, Stoffel MP, Benson JT (2004). "Hepatopulmonary syndrome and portopulmonary hypertension: a report of the multicenter liver transplant database". Liver Transpl. 10 (2): 174–82. doi:10.1002/lt.20016. PMID 14762853.
- ↑ Starkel P, Vera A, Gunson B, Mutimer D (2002). "Outcome of liver transplantation for patients with pulmonary hypertension". Liver Transpl. 8 (4): 382–8. doi:10.1053/jlts.2002.31343. PMID 11965583.
- ↑ Lentine KL, Costa SP, Weir MR, Robb JF, Fleisher LA, Kasiske BL, Carithers RL, Ragosta M, Bolton K, Auerbach AD, Eagle KA (2012). "Cardiac disease evaluation and management among kidney and liver transplantation candidates: a scientific statement from the American Heart Association and the American College of Cardiology Foundation". J. Am. Coll. Cardiol. 60 (5): 434–80. doi:10.1016/j.jacc.2012.05.008. PMID 22763103.
- ↑ Raval Z, Harinstein ME, Skaro AI, Erdogan A, DeWolf AM, Shah SJ, Fix OK, Kay N, Abecassis MI, Gheorghiade M, Flaherty JD (2011). "Cardiovascular risk assessment of the liver transplant candidate". J. Am. Coll. Cardiol. 58 (3): 223–31. doi:10.1016/j.jacc.2011.03.026. PMID 21737011.
- ↑ Arguedas MR, Singh H, Faulk DK, Fallon MB (2007). "Utility of pulse oximetry screening for hepatopulmonary syndrome". Clin. Gastroenterol. Hepatol. 5 (6): 749–54. doi:10.1016/j.cgh.2006.12.003. PMID 17392034.
- ↑ Prentis JM, Manas DM, Trenell MI, Hudson M, Jones DJ, Snowden CP (2012). "Submaximal cardiopulmonary exercise testing predicts 90-day survival after liver transplantation". Liver Transpl. 18 (2): 152–9. doi:10.1002/lt.22426. PMID 21898768.
- ↑ Eghtesad B, Kadry Z, Fung J (2005). "Technical considerations in liver transplantation: what a hepatologist needs to know (and every surgeon should practice)". Liver Transpl. 11 (8): 861–71. doi:10.1002/lt.20529. PMID 16035067.
- ↑ Tuttle-Newhall JE, Collins BH, Desai DM, Kuo PC, Heneghan MA (2005). "The current status of living donor liver transplantation". Curr Probl Surg. 42 (3): 144–83. PMID 15859440.
- ↑ Steadman RH (2004). "Anesthesia for liver transplant surgery". Anesthesiol Clin North America. 22 (4): 687–711. doi:10.1016/j.atc.2004.06.009. PMID 15541931.
- ↑ Park JI, Kim KH, Lee SG (2015). "Laparoscopic living donor hepatectomy: a review of current status". J Hepatobiliary Pancreat Sci. 22 (11): 779–88. doi:10.1002/jhbp.288. PMID 26449392.
- ↑ Adam R, McMaster P, O'Grady JG, Castaing D, Klempnauer JL, Jamieson N, Neuhaus P, Lerut J, Salizzoni M, Pollard S, Muhlbacher F, Rogiers X, Garcia Valdecasas JC, Berenguer J, Jaeck D, Moreno Gonzalez E (2003). "Evolution of liver transplantation in Europe: report of the European Liver Transplant Registry". Liver Transpl. 9 (12): 1231–43. doi:10.1016/j.lts.2003.09.018. PMID 14625822.
- ↑ 18.0 18.1 Shah SA, Levy GA, Adcock LD, Gallagher G, Grant DR (2006). "Adult-to-adult living donor liver transplantation". Can. J. Gastroenterol. 20 (5): 339–43. PMC 2659892. PMID 16691300.
- ↑ Reddy S, Zilvetti M, Brockmann J, McLaren A, Friend P (2004). "Liver transplantation from non-heart-beating donors: current status and future prospects". Liver Transpl. 10 (10): 1223–32. doi:10.1002/lt.20268. PMID 15376341.
- ↑ Martinez OM, Rosen HR (2005). "Basic concepts in transplant immunology". Liver Transpl. 11 (4): 370–81. doi:10.1002/lt.20406. PMID 15776458.
- ↑ Friend PJ (1997). "Liver transplantation". Transplant. Proc. 29 (6): 2716–8. PMID 9290801.
- ↑ McCaughan GW, Koorey DJ (1997). "Liver transplantation". Aust N Z J Med. 27 (4): 371–8. PMID 9448876.
- ↑ Middleton PF, Duffield M, Lynch SV, Padbury RT, House T, Stanton P, Verran D, Maddern G (2006). "Living donor liver transplantation--adult donor outcomes: a systematic review". Liver Transpl. 12 (1): 24–30. PMID 16498709.
- ↑ Perry I, Neuberger J (2005). "Immunosuppression: towards a logical approach in liver transplantation". Clin. Exp. Immunol. 139 (1): 2–10. doi:10.1111/j.1365-2249.2005.02662.x. PMC 1809260. PMID 15606606.
- ↑ Papadopoulos-Köhn A, Achterfeld A, Paul A, Canbay A, Timm J, Jochum C, Gerken G, Herzer K (2015). "Daily low-dose tacrolimus is a safe and effective immunosuppressive regimen during telaprevir-based triple therapy for hepatitis C virus recurrence after liver transplant". Transplantation. 99 (4): 841–7. doi:10.1097/TP.0000000000000399. PMID 25208324.
- ↑ Chen XB, Xu MQ (2014). "Primary graft dysfunction after liver transplantation". HBPD INT. 13 (2): 125–37. PMID 24686540.
- ↑ Liu JH, Yan S, Zheng SS (2014). "[Application of transient elastography in early prognosis after liver transplantation]". Zhejiang Da Xue Xue Bao Yi Xue Ban (in Chinese). 43 (6): 678–82. PMID 25644567.
- ↑ Lindström L, Jørgensen KK, Boberg KM, Castedal M, Rasmussen A, Rostved AA, Isoniemi H, Bottai M, Bergquist A (2018). "Risk factors and prognosis for recurrent primary sclerosing cholangitis after liver transplantation: a Nordic Multicentre Study". Scand. J. Gastroenterol.: 1–8. doi:10.1080/00365521.2017.1421705. PMID 29301479.
- ↑ Germani G, Becchetti C (2017). "Liver transplantation for non-alcoholic fatty liver disease". Minerva Gastroenterol Dietol. doi:10.23736/S1121-421X.17.02467-9. PMID 29249127.
- ↑ Egeli T, Unek T, Ozbilgin M, Agalar C, Derici S, Akarsu M, Unek IT, Aysin M, Bacakoglu A, Astarcıoglu I (2017). "De Novo Malignancies After Liver Transplantation: A Single Institution Experience". Exp Clin Transplant. doi:10.6002/ect.2017.0111. PMID 29237362.
- ↑ Nadalin S, Capobianco I, Panaro F, Di Francesco F, Troisi R, Sainz-Barriga M, Muiesan P, Königsrainer A, Testa G (2016). "Living donor liver transplantation in Europe". Hepatobiliary Surg Nutr. 5 (2): 159–75. doi:10.3978/j.issn.2304-3881.2015.10.04. PMC 4824742. PMID 27115011.
- ↑ Brown RS, Russo MW, Lai M, Shiffman ML, Richardson MC, Everhart JE, Hoofnagle JH (2003). "A survey of liver transplantation from living adult donors in the United States". N. Engl. J. Med. 348 (9): 818–25. doi:10.1056/NEJMsa021345. PMID 12606737.
- ↑ Krahn LE, DiMartini A (2005). "Psychiatric and psychosocial aspects of liver transplantation". Liver Transpl. 11 (10): 1157–68. doi:10.1002/lt.20578. PMID 16184540.
- ↑ 34.0 34.1 34.2 Savitsky EA, Uner AB, Votey SR (1998). "Evaluation of orthotopic liver transplant recipients presenting to the emergency department". Ann Emerg Med. 31 (4): 507–17. PMID 9546022.
- ↑ Levitsky J, Cohen SM (2006). "The liver transplant recipient: what you need to know for long-term care". J Fam Pract. 55 (2): 136–44. PMID 16451781.
- ↑ Greendyke WG, Pereira MR (2016). "Infectious Complications and Vaccinations in the Posttransplant Population". Med. Clin. North Am. 100 (3): 587–98. doi:10.1016/j.mcna.2016.01.008. PMID 27095647.
- ↑ Muñoz SJ (1996). "Long-term management of the liver transplant recipient". Med. Clin. North Am. 80 (5): 1103–20. PMID 8804376.