My Worst Cases

Shin Hwang

Division of HBP Surgery and Liver Transplantation,

Department of Surgery, University of Ulsan College of
Medicine and Asan Medical Center, Seoul, Korea
1. Fatal portal flow steal
2. Advanced HCC beyond eligibility criteria
3. Aggressive HCC within eligibility criteria
4. Massive hepatic venous congestion
without MHV reconstruction
5. Massive hemorrhagic Necrosis
6. Primary non-function
 Case 1
Fatal portal flow steal
 Clinical History & Lab. Data
• Female / 37 years
• 45 kg / 156 cm
• Acute on chronic liver failure,
HBV
related
• CC : Stuporous mentality
• TB 39.8 mg/dL, PT 13% (INR 7.41),
Cr 0.9 mg/dL
• CTP : 13 points
• MELD : 40 points
PV stenosis with large collaterals
 Pre-OP Doppler USG

PV velocity : 15 cm/sec
 Operation

• Adult LDLT
• Donor : Her husband
• Graft type : Left lobe with MHV
• Graft weight : 440 gm
• GRWR : 0.98%
• Event : Distal MHV injury
• Collateral ligation : Not done
 Intra-OP Doppler USG

Pre-anastomotic site Post-anastomotic site

Good Portal Flow
 POD # 1

Distal MHV injury Distal MHV injury S4a congestion

 Changes of Liver Function

AST (IU/L) Total Bil.(mg/dL)

2000 50

1800 ▪ 45
▪
1600 ▪ ▪ POD # 10
40

1400 AST: 13758 IU/L 35

1200 30
▪
1000 25

▪ ▪ 20
800
▪
600
▪ 15
▪ ▪
400 10

200 5

0
Pre- LT 1 2 3 4 5 6 7 8 9 10 11
(Re-LDLT)
Days
 POD # 8

Intact hepatic artery

Portal steal
S-R shunt
POD # 10

Total infarct
 POD # 11 POD # 12

Retransplantation Die of septic shock

Graft : Left lobe with MHV
Graft weight : 370 gm
GRWR : 0.82

After this case,

routine interruption of
large portosystemic collateral shunt.
 Case 2
Advanced HCC
beyond eligibility criteria
Advanced HCC exceeding selection criteria

50 year-old male, 163 cm / 64 kg

Known HBV-LC & HCC
TACE # 12 times, TACI # 1 time
AFP 14400 ng/mL
CT : Suspicious PV invasion
8-cm sized multiple HCC
TB 1.6 mg/dl, PT 68.2%(INR 1.38), Cr 0.8 mg/dl
CTP score : 7
MELD score : 10
Posttransplant sequences
2 months

3 months
Miliary intrahepatic spread at 3 months

Survival only for 6 months

 Case 3
Aggressive HCC
within eligibility criteria
 HCC with sarcomatous change

• S/P TACE
• 3cm-sized HCC at S8
• 2.5cm-sized HCC at S4
with sarcomatous
change
Early HCC recurrence after 3 months

• Omental infiltration
• Massive ascites
• Aortocaval lymph- Pleural effusion
adenopathy Survival only for 5 mos
 Mixed HCC & CCC

CCC HCC
component component

No tumor on CT & Incidental detection of

hepatic angiogram 1 cm-sized mixed HCC
Early HCC recurrence after 3 months

Enlarging multiple
intraperitoneal mass; Needle biopsy shows
Splenic infarct from carcinoma: unclassified
SA ligation
 Survival after HCC recurrence
Proportion of survival

CDLT

LDLT

Time-months
 Case 4
Massive hepatic venous congestion
Without MHV reconstruction
Right Lobe LDLT wothout MHV reconstruction
 Ischemic Necrosis of Right Lobe Graft
#3

#5

After 1 week After 2 weeks

Postoperative changes of serum AST and total bilirubin

6000 60

serum total bilirubin (mg/dL)

5000 50
serum AST (IU/dL)

Mortality
4000 40

3000 Case 5 30

2000 20

1000
Case 3 10

0 0
0 2 4 6 8 10 12 14 16 18
Posttransplant days
 Fates of Hepatic Venous Congestion in Right Lobe Graft
and Remnant Donor Liver

Hepatic vein anatomy Transplantation-related

risk factors

Collateral formation
Atrophy Graft failure
 Case 5
Massive hemorrhagic Necrosis

7th day fever syndrome

 11502
Lab Profiles

4932

Steroid pulse

OKT3 Fever
Biopsy

30
18%
days
Cytokine-mediated inflammatory response leading to an univisceral Schwartzman
reaction in the transplanted liver graft
 Case 6
Primary non-function
 Primary Non-Function
of Living-donor Liver Graft
• 1 Case out of first 163 cases
- Male / 43 years old
- HBV-LC with small HCC
- LDLT: Left lobe (550g) from his brother (M/28)
Fatty change of donor: right lobe 35%
left lobe 20%
- Course: Very easy operation & CIT 40 min
-> Diffuse oozing since 2-3 hours after reperfusion
-> Serum GOT > 750 IU/L (day 0) -> > 2000 (day 1)
PT 15%, Ammonia > 200 umol/L
-> at POD #2: Cadaveric retransplantation
 Primary Non-Function
of Living-donor Liver Graft

550gm

Resected graft Total necrosis