LIVER TRANSPLANTATION SURGERY AFTERCARE

Aftercare
Following surgery, the patient will wake up in the surgical intensive care unit (SICU). During this time, a tube will be inserted into the windpipe to facilitate breathing. It is removed when the patient is fully awake and strong enough to breathe on his or her own. There may be other tubes that are removed as the patient recovers. When safe to leave the SICU, the patient is moved to the transplant floor. Walking and eating will become the primary focus. Physical therapy may be started to help the patient become active, as it is an important part of recovery. When the patient begins to feel hungry and the bowels are working, regular food that is low in salt will be given.

A patient should expect to spend about 10 to 14 days in the hospital, although some stays may be shorter or longer. Before leaving the hospital, a patient will be advised of: signs of infection or rejection, how to take medications and change dressings, and how to understand general health problems. Infection can be a real danger, because the medications taken compromise the body’s defense systems. The doctors will conduct blood tests, ultrasounds, and x rays to ensure that the patient is doing well.

The first three months after transplant are the most risky for getting such infections as the flu, so patients should follow these precautions:
• Avoid people who are ill.
• Wash hands frequently.
• Tell the doctor if you are exposed to any disease.
• Tell the doctor if a cold sore, rash, or water blister appears
on the body or spots appear in the throat or on the tongue.
• Stay out of crowds and rooms with poor circulation.
• Do not swim in lakes or community pools during the three months following transplant.
• Eat meats that are well-cooked.
• Stay away from soil, including those in which houseplants are grown, and gardens, during the three months following transplant.
• Take all medications as directed.
• Learn to report the early symptoms of infection.

To ensure that the transplant is successful and that the patient has a long and healthy life, a patient must get good medical care, prevent and treat complications, keep in touch with doctors and nurses, and follow their advice. Nutrition plays a big part in the success of a liver transplant, so what a patient eats after the transplant is very important.

Medications needed following liver transplantation
Successfully receiving a transplanted liver is only the beginning of a lifelong process. Patients with transplanted livers have to stay on immunosuppressant drugs for the rest of their lives to prevent organ rejection. Although many patients can reduce the dosage after the initial few months, virtually none can discontinue drugs altogether. For adolescent transplant recipients, post transplantation is a particularly difficult time, as they must learn to take responsibility for their own behavior and medication, as well as balance their developing sexuality in a body that has been transformed by the adverse effects of immunosuppression. Long-term outcome and tailoring of immunosuppression is of great importance.

Cyclosporine has long been the drug of experimentation in the immunosuppression regimen, and has been well-tolerated and effective. Hypertension, nephrotoxicity, and posttransplant lymphoproliferative disease (PTLD) are some of the long-term adverse effects. Tacrolimus has been developed more recently, and has improved the cosmetic adverse effects of cyclosporine, but has similar rates of hypertension and nephrotoxicity, and possibly a higher rate of PTLD. Prednisone, azathioprine, and tacrolimus are often combined with cyclosporine for better results. Newer immunosuppressive agents promise even better results.

There has been a recent, welcome development in renal sparing drugs, such as mycophenolate mofetil, which has no cosmetic adverse effects, does not require drug level monitoring, and is thus particularly attractive to teenagers. If started prior to irreversible renal dysfunction, recent research demonstrates recovery of renal function with mycophenolate mofetil. There is little published data on the use of sirolimus (rapamycin) in the pediatric population, but preliminary studies suggest that the future use of interleukin-2 receptor antibodies may be beneficial for immediate post-transplant induction of immunosuppression. When planning immunosuppression for adolescents, it is important to consider the effects of drug therapy on both males and females in order to maintain fertility and to ensure safety in pregnancy. Adequate practical measures and support should reduce noncompliance in this age group, and allow good, longterm function of the transplanted liver.

Risks
Early failure of the transplant occurs in every one in four surgeries and has to be repeated. Some transplants never work, some patients succumb to infection, and some suffer immune rejection. Primary failure is apparent within one or two days. Rejection usually starts at the end of the first week. There may be problems like bleeding of the bile duct after surgery, or blood vessels of the liver may become too narrow. The surgery itself may need revision because of narrowing, leaking, or blood clots at the connections. These issues may be solved with or without more surgery depending on the severity.

Infections are a constant risk while on immunosuppressive agents, because the immune system is supposed to prevent them. A method has not yet been devised to control rejection without hampering immune defenses against infections. Not only do ordinary infections pose a threat, but because of the impaired immunity, transplant patients are susceptible to the same opportunistic infections (OIs) that threaten acquired immune deficiency syndrome (AIDS) patients—pneumocystis pneumonia, herpes and cytomegalovirus (CMV) infections, fungi, and a host of bacteria.

Drug reactions are also a continuing threat. Every drug used to suppress the immune system has potential problems. As previously stated, hypertension, nephrotoxicity, and PTLD are some of the long-term adverse effects with immunosupressive drugs like cyclosporine. Immunosuppressants also hinder the body’s ability to resist cancer. All drugs used to prevent rejection increase the risk of leukemias and lymphomas.

There is also a risk of the original disease returning. In the case of hepatitis C, reoccurrence is a risk factor for orthotropic liver transplants. Newer antiviral drugs hold out promise for dealing with hepatitis. In alcoholics, the urge to drink alcohol will still be a problem. Alcoholics Anonymous (AA) is the most effective treatment known for alcoholism.

Transplant recipients can get high blood pressure, diabetes, high cholesterol, thinning of the bones, and can become obese. Close medical care is needed to prevent these conditions.

Normal results
For a successful transplant, good medical care is important. Patients and families must stay in touch with their medical teams and drugs must be taken as advised to prevent infection and rejection of the new organ. However, sometimes because of the way it is preserved, the new liver doesn’t function as it should, and a patient may have to go back on to the waiting list to receive a new liver.

Morbidity and mortality
Twenty-five million or one in 10 Americans are or have been afflicted with liver or biliary diseases. As of June 2003, there were 17,239 patients on the UNOS National Transplant Waiting List who were waiting for a liver transplantation. For the previous year (July 1, 2001 to June 30, 2002), there were a total of 5,261 liver transplants performed. Of those, 4,785 were cadaver donors (already deceased) and 476 living donors. For liver transplants performed from July 1, 1999 to June 30, 2001, the one-year survival rate was 86% for adults; 1,861 patients died while on the UNOS waiting list for the year ending June 30, 2002. More than 80% of children survive transplantation to adolescence and adulthood.

Since the introduction of cyclosporine and tacrolimus (drugs that suppress the immune response and keep it from attacking and damaging the new liver), success rates for liver transplantation have reached 80–90%. Infections occur in about half of transplant patients and often appear during the first week. Biliary complications are apparent in about 22% of recipient patients (and 6% of donors), and vascular complications occur in 9.8% of recipient patients. Other complications in donors include re-operation (4.5%) and death (0.2%). There are potential social, economic, and psychological problems, and a vast array of possible medical and surgical complications. Close medical surveillance must continue for the rest of the patient’s life.

Alternatives
There is no treatment that can help the liver with all of its functions; thus, when a person reaches a certain stage of liver disease, a liver transplant may be the only way to save the patient’s life.