Optimisation of graft function in liver transplantation: functional and metabolic aspects
(Optimalisatie van de functie van de transplantatielever na levertransplantatie: functionele en metabole aspecten)
View PDF Version
(020403_Jonge, Jeroen de.pdf, 4.1MB)
View PDF Version
(stellingen de Jonge.pdf, 0.0MB)
Part one of this thesis contains the general introduction to partial and whole liver transplantation. Chapter 2 addresses the concept of auxiliary partial liver transplantation. Auxiliary partial heterotopic liver transplantation was first introduced as a less invasive procedure for patients who could not tolerate a standard orthotopic liver transplantation. Later on the technique was proposed for patients with acute liver failure in whom regeneration of the native liver was expected, but due to its complications it never gained wide acceptance. Since 1990 a new concept of auxiliary partial liver transplantation was introduced where the graft is placed in the orthotopic position. In chapter 3 the development and current surgical technique of orthotopic liver transplantation are discussed. Initially the diseased liver was removed with the vena cava and replaced by a whole liver graft. With increasing waiting lists for donor organs, surgical techniques were developed to split the donor liver and transplant both partial liver grafts in the orthotopic position. In part two three studies regarding experimental auxiliary partial liver transplantation are presented. In chapter 4 we report the long-term correction of an inborn error of metabolism with an auxiliary partial liver graft placed in a heterotopic position. Since the distribution of portal blood flow between liver graft and native liver remains controversial in auxiliary liver transplantation, the success of metabolic correction was related to four different forms of portal inflow. With the introduction of auxiliary partial orthotopic liver transplantation several disadvantages of the placement of the graft in heterotopic liver transplantation were overcome. In chapter 5 we therefore assess the importance of portal flow diversion in an experimental model of auxiliary partial liver transplantation in the orthotopic position. The portal blood flow was measured with Doppler ultrasonography and changes in portal flow distribution were recorded after surgical intervention in the portal blood flow. In chapter 6 the metabolic correction following these interventions in portal flow were reported. Part three contains three studies performed in patients receiving an orthotopic whole liver transplantation. In chapter 7 we present the problem of graft dysfunction in the first 7 days after liver transplantation. We report our data on mitochondrial dysfunction in patients with primary graft dysfunction and the relation with toxic reaction products of the nitric oxide radical. In chapter 8 we report an increased incidence of fibrinolysis, the most prominent coagulation disorder during orthotopic liver transplantation, after introduction of virus inactivated plasma. Consequences of fibrinolysis and treatment options are discussed. In chapter 9 we evaluate patient and graft survival between patients transplanted with standard liver replacement or a vena cava preserving technique. Chapter 10 provides an overview of the development of different techniques for splitting of the donor liver in an attempt to alleviate the shortage of donor organs in paediatric and adult liver transplantation. Chapter 11 summarises the previous studies, bringing the data in perspective and provides future perspectives.
The Michael van Vloten Foundation and the Sophia Research Foundation financially supported parts of the studies described here.
- liver transplantation
- orthotopic liver transplantation
- heterotopic liver transplantation
- portal vein
- portal flow