الفهرس 
LIVER ANATOMYOnly 14 pages are availabe for public view
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Abstract
Liver transplantation is a therapeutic option of choice for acute and chronic end-stage liver disease. Living donor liver transplantation is a powerful tool for the treatment (Broering et al., 2003).
The advantages of LDLT are that almost all transplants are planned and elective, the recipient’s functional status can be optimized before surgery, and the graft cold ischemia time is reduced (Soin et al., 2010). Acute liver failure, viral hepatitis, chronic liver disease, cholestatic liver disease, hepatic malignancy, metabolic liver disease, vascular disorders and alcoholic liver disease are indications for liver transplantation. Autoimmune hepatitis and Nonalcoholic steatohepatitis are another causes of cirrhosis, which might require transplantation. Complicated polycystic liver disease with hemorrhage, infection, pain, massive cystic enlargement, portal hypertension, biliary obstruction, and rarely malignant transformation also forms an indication for liver transplantation. On the other hand contraindications to liver transplantation include alcohol and substance abuse, obesity, HIV infection. Pneumonia, sepsis, bacteremia, osteomyelitis, and fungal infection should be treated adequately before transplantation and the ongoing presence of any of these is an absolute contra-indication (Varma et al., 2011).
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The donor, a perfectly healthy volunteer, faces unequivocal risks of morbidity and even mortality. Living donor liver transplantation also carries certain increased risks for the recipients. It is technically more complex than whole-organ cadaveric transplantation.
Careful evaluation and selection of the donor minimizes the risk to the donor and maximizes the benefit to the recipient. All potential donors therefore undergo a strict multi-step evaluation protocol, which normally includes exhaustive medical and psychological evaluations of the donor, as well as a precise anatomical study of the liver (Nadalin et al., 2005).
The study of vascular and biliary anatomy of the liver can be performed in different ways (e.g. angiography, angio-CT, magnet resonance imaging, etc.). The preferred one is the ‘all-in-one’ CT procedure (Schroeder et al., 2005).
Liver transplantation candidates today are older, have greater medical acuity, and have more comorbidities, including cardiovascular disease, than ever before.
In addition to advanced age several systemic diseases that cause cirrhosis may also induce specific cardiac diseases such as hemochromatosis, and non-alcoholic fatty liver disease. Excessive alcohol consumption may lead to cirrhosis and alcoholic cardiomyopathy (Lazarevic et al., 2000).
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This contributes to the potential for cardiovascular complications, particularly with the altered hemodynamic stresses that LT patients face in the immediate postoperative period (Shi et al., 2006).
Metabolic syndrome is common among LT recipients before and after transplantation. And add a significant risk of developing atherosclerosis and cardiovascular complications
after liver transplantation (Oliveira et al., 2013).
The pre-transplant cardiovascular evaluation and the post-transplant accurate monitoring followed by a careful choice of the immunosuppressive therapeutic regimen, drug level monitoring, educational efforts to ameliorate life style and risk factors are mandatory for a satisfactory outcome (Rossetto et al., 2012).
Most liver transplant recipients have advanced cirrhosis. Such patients’ cardiovascular status before transplantation is generally abnormal, so they may respond poorly to the stress of transplantation.
Because of this situation, the ability to predict which individuals will develop cardiovascular events during and after liver transplantation is hugely important in the patient selection process. Transplant candidates undergo a rigorous pretransplant workup that includes a careful cardiovascular history and investigations such as standard or dobutamine stress echocardiography, nuclear heart scans, and even coronary
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angiography if there is any lingering doubt about the presence of atherosclerotic coronary artery disease (Harinstein et al., 2008).
As liver transplantation is one of the most cardiovascular stressful events that a patient with cirrhosis may undergo. After liver transplantation, the progression of pre-existing or the development of new-onset cardiac disease may occur (Ripoll et al., 2008).
Patients who undergo liver transplantation have an around doubled risk of developing cardiovascular disease if compared to non-transplanted population. Indeed, such complications occur in 25% to 70% of patients after LT (Fouad et al., 2009).
Moreover, mortality associated with cardiac causes accounts for up to 11% of deaths in the early to medium term post-transplant period. In some centers, all cardiovascular events are the third leading cause of death after infection and rejection (Watt et al., 2010).
Cardiac complications after transplantation may include myocardial infarction or reversible ischemia, cardiogenic shock, symptomatic rhythm disturbances that response to medical cardioversion, pericardial effusion, heart failure, pulmonary edema, pulmonary embolism, hypertension, transient hypotension (postreperfusion syndrome) which respond to vasopressin and/or methylene blue when refractory to catecholamine therapy, and cardiac arrest.
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Vascular complications include hepatic artery thrombosis which is managed either by Endovascular intervention or Open surgery, hepatic artery stenosis, spasm, and kinks. Complications involving portal vein are portal vein thrombosis, portal vein stenosis in which urgent management may be necessary and require a return to the operating room for portal vein thrombectomy.