Liver & intrahepatic bile ducts

Liver transplantation

Early onset graft injury

Transplantation - surgical / vascular complications



Last author update: 4 October 2023
Last staff update: 4 October 2023

Copyright: 2022-2024, PathologyOutlines.com, Inc.

PubMed Search: Liver transplantation complications

Rui Caetano Oliveira, M.D., Ph.D.
Cite this page: Oliveira RC. Transplantation - surgical / vascular complications. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/livertransplantcomplications.html. Accessed December 23rd, 2024.
Definition / general
  • Complications after liver transplantation
  • Biliary and vascular complications are common
  • Important cause of posttransplant morbidity
Essential features
  • Biliary and vascular complications are common events after liver transplantation
  • These events have implication on overall survival and quality of life of patients
  • Retransplantation may be necessary
Terminology
  • Post liver transplantation biliary complications include:
    • Anastomotic strictures
    • Nonanastomotic strictures
    • Bile leaks
    • Bile duct stones
    • Bilomas
    • Sphincter of Oddi dysfunction
    • Ischemic cholangiopathy
  • Thrombosis
  • Ischemia reperfusion injury
  • Lipopeliosis
ICD coding
  • ICD-10: T86.4 - complications of liver transplant
Epidemiology
Sites
  • Liver
  • Bile ducts
  • Hepatic artery
  • Portal vein
Pathophysiology
  • Bile duct injury is the result of a multifactorial process
  • Cold / warm ischemia, perfusion injury, bile salt toxicity and immune mediated lesions have been described as causative factors, especially for nonanastomotic strictures (Virchows Arch 2012;461:41)
  • Lesions of the peribiliary vascular plexus and deep biliary glands are thought to be the main cause of nonanastomotic strictures (J Hepatol 2014;60:1172)
  • Graft injury, especially with prolonged cold (> 12 hours) and warm (> 90 minutes) ischemia time, is prone to induce biliary injury (Clin Liver Dis (Hoboken) 2016;7:73)
  • Donor graft quality: donors with older age with steatosis > 30% and hypotension are described as smaller for size allograft (Clin Liver Dis (Hoboken) 2016;7:73)
Etiology
  • Ischemia
  • Inflammation
  • Infection
  • Surgery complications
  • Rejection
Clinical features
  • If thrombosis
    • Abdominal pain
    • Fever (if infection)
  • If biliary complications
    • Jaundice
    • Fecal acholia
    • Brown urine
  • Ischemia reperfusion injury
    • Fatigue
    • Jaundice
Diagnosis
  • Usually by a combination of clinical, laboratory and radiologic findings
Laboratory
  • If biliary complications
    • Alkaline phosphatase, gamma glutamyl transferase, total bilirubin and conjugated bilirubin increase
  • Nonspecific changes (Ann Hepatobiliary Pancreat Surg 2022;26:76)
    • Liver enzyme increase, namely aspartate aminotransferase (AST)
    • International normalized ratio (INR) increase
    • Acidosis
Radiology description
Radiology images

Contributed by Ricardo Martins, M.D.

Portal vein thrombosis

Hepatic artery thrombosis

Acute portal vein thrombosis

Nonanastomotic strictures

Prognostic factors
Case reports
Treatment
Gross description
  • Biliary complications
    • Liver explant with biliary obstruction / fibrosis of the bile duct; on cut section, the liver shows mild to moderate fibrosis with bile casts and green tone
  • Vascular complications
    • Liver explant with hepatic artery / portal vein thrombosis, with complete / partial occlusion of vessel(s); on cut section, the liver is hemorrhagic and congestive
Gross images

Contributed by Rui Caetano Oliveira, M.D., Ph.D.
Bile casts in ischemic cholangiopathy

Bile casts in ischemic cholangiopathy

Liver necrosis

Liver necrosis

Liver necrosis cut section

Liver necrosis cut section

Liver necrosis cut section

Liver necrosis cut section

Liver thrombosis

Liver thrombosis

Microscopic (histologic) description
  • Ischemia reperfusion injury appears as perivenular ballooning and cholestasis, neutrophilic infiltrate or hepatocyte necrosis in centrolobular regions (in the more severe lesions)
  • Lipopeliosis corresponds to the release of fat from ischemia reperfusion hepatocytes in to the extracellular space, inducing sinusoidal compression, blood flow obstruction and ischemic necrosis
  • Biliary pattern of fibrosis is common in ischemic cholangiopathy
  • Ductular reaction and hepatocyte biliary metaplasia in cases of bile duct obstruction, associated with portal tract edema
  • Sinusoidal dilation and congestion are common in venous drainage complications
  • Ischemic necrosis is common in thrombosis
  • Reference: Diagn Histopathol 2018;24:508
Microscopic (histologic) images

Contributed by Rui Caetano Oliveira, M.D., Ph.D. and @RaulSGonzalezMD on Twitter

Ischemic cholangiopathy

Sinusoidal dilation

Hemorrhage

Foci of necrosis

Severe necrosis

Extensive necrosis


Extensive liver necrosis

Venous portal tract thrombosis

Major portal branch thrombosis

Bile duct ulceration

Extensive ulceration

Bile duct necrosis


Lipopeliosis following liver transplantation

Lipopeliosis following liver transplantation

Biliary cirrhosis

Ductular reaction and biliary metaplasia

Copper accumulation

Positive stains
  • CK7 may be useful in demonstrating ductular reaction and hepatocyte biliary metaplasia in cases of biliary obstruction
  • Rhodanine stain usually demonstrates copper deposits in periportal hepatocyte in cases of chronic biliary obstruction
Sample pathology report
  • Liver, retransplant:
    • Biliary cirrhosis due to ischemic cholangiopathy (see comment)
    • Comment: There is ulceration of the right biliary duct, with severe inflammation consisting of neutrophils and foamy histiocytes. Hepatic parenchyma exhibits architectural changes, with bridge forming cirrhosis in a jigsaw pattern. CK7 demonstrates a ductular reaction and there is copper accumulation in the periseptal hepatocytes.
Differential diagnosis
Board review style question #1

Liver retransplantation is performed and the image above shows the gross examination. Which of the following is the probable cause?

  1. Acute rejection
  2. Biliary complications
  3. Portal thrombosis
  4. Primary non function
Board review style answer #1
B. Biliary complications. The evidence of bile casts and biliary dilation in the context of liver transplantation is highly suggestive of ischemic cholangiopathy.

Comment Here

Reference: Transplantation - surgical / vascular complications
Board review style question #2
Which of the following is thought to be the main cause of nonanastomotic strictures following liver transplantation?

  1. Cytomegalovirus infection
  2. Lesions of the peribiliary vascular plexus and deep biliary glands
  3. Liver size
  4. Rejection
Board review style answer #2
B. Lesions of the peribiliary vascular plexus and deep biliary glands. Nonanastomotic strictures are usually associated with vascular injury of the peribiliary vascular plexus, inducing a hypoxia environment. The lesion of the deep biliary glands, a niche for stem cells, is also associated with the impairment of tissue repair.

Comment Here

Reference: Transplantation - surgical / vascular complications
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