Long-term outcome of living related river transplantation for patients with intrapulmonary shunting and strategy for complications

Background, In 320 living related liver transplantation performed between J une? 1990 and September 1997, there were 21 living related liver transplant ation for patients with intrapulmonary shunting, manifested by digital club bing, cyanosis, and dyspnea. We report the long-term outcome for more 6 mon ths and our strategy to overcome complications in these recipients. Patients. A total of 21 patients (age range 2-33 years, 19 children and 2 a dults, 6 males and 15 females) were: classified into three grades according to shunt ratio calculated by TcMAA pulmonary scintigraphy; 5 in mild group (shunt ratio: less than 20%), 6 in moderated group (20%-40%), and 10 in se vere group (more than 40%). The original underlying liver disease was bilia ry atresia in all patients. Results, Spearmen's correlation coefficient rank test revealed that shunt r atio correlated significantly with PaO2 in room air (P=0.0001), PaO2 in 100 % oxygen (P=0.0004), hematocrit (P=0.0276), and period of dyspnea before tr ansplantation (P=0.023). Complications Wound infection occurred in 80, 66, and 80%, and bile leakage in 20, 0, 40% in mild, moderate, and severe group, respectively. Patients who hall postal vein thrombosis, and intracranial complication were classif ied as severe group and the incidence was 20 and 20%, respectively. The pat ient actuarial one year survival was 80, 66.7, and 48%, in mild, moderate, and severe group, respectively, although there was no significant differenc e, All patients who survived improved hepatopulmonary syndrome and the leng th of period required for the resolution was significantly correlated to th e preoperative shunt ratio (P=0.023). Comments. Patients with severe shunting are susceptible to wound infection and bile leak. The trend of higher incidence of portal thrombosis and intra cranial complications in the severe group was closely related high hematocr it, Secure surgical technique to reduce bile leak and delayed primary wound closure to reduce wound infection were found to be effective. Anticoagulan t therapy by infusing heparin through the portal vein followed by coumadin could prevent fatal portal vein thrombosis without counter risk of fatal ce rebral hemorrhage.