Role of Liver Transplantation in Portal Hypertension

Abstract

Liver transplantation is the treatment of choice for both adult and pediatric patients with decompensated cirrhosis and complications of portal hypertension. These complications include hepatic encephalopathy, jaundice, bleeding gastrointestinal varices, ascites, and other organ system manifestations such as hepatopulmonary syndrome, portopulmonary hypertension, and hepatorenal syndrome. Allocation of the limited supply of liver allografts is based on medical urgency as assessed by the Model for End-stage Liver Disease in adults and the Pediatric End-stage Liver Disease score in children. The hepatectomy can be broken down into incision and exposure, mobilization of the liver, and dissection of the porta hepatis and vena cava to remove the diseased liver. Implantation of the healthy liver allograft involves reconstruction of the hepatic venous outflow, portal and hepatic artery inflow, and biliary drainage. Complications arise from the liver allograft itself (e.g., rejection, dysfunction, nonfunction) or from technical issues with the anastomoses. Living donor liver transplantation is a viable option for select patients with indications for liver transplantation provided there is a healthy, fully informed, and voluntary donor who can safely donate a partial liver allograft of sufficient volume and quality. Safety of the living donor is of paramount importance. With advances in the perioperative care of patients with end-stage liver disease, survival after liver transplantation continues to improve despite the high acuity of many recipients. Future challenges include addressing the shortage of liver allografts, mitigating the side effects of immunosuppression, and ensuring long-term living donor and recipient survival with excellent quality of life.