Liver transplantation

　　In recent years, the types of diseases treated by in situ liver transplantation have been expanding. So far, according to incomplete statistics, liver transplantation has been successfully used in the treatment of more than 60 kinds of liver diseases. According to the nature of the disease, it can be summarized as: end-stage liver cirrhosis, liver malignant diseases, congenital metabolic diseases, and acute or subacute liver function failure. With the increase of experience in liver transplantation, the contraindications have also been decreasing. Many previously considered absolute contraindications have now become relative contraindications, and many relative contraindications have now become indications.

　　Liver function failure:Liver failure is a clinical syndrome characterized by widespread and severe damage to liver cells and severe disturbance of metabolic function, abbreviated as liver failure. Liver failure occurs in many severe liver diseases, with dangerous symptoms and poor prognosis. According to the pathological and histological characteristics and the speed of disease progression, liver failure can be divided into four types: acute liver failure, subacute liver failure, chronic-onset (subacute) liver failure, and chronic liver failure. The characteristic of acute liver failure is that it starts suddenly, and a liver failure syndrome with grade II or higher hepatic encephalopathy as the characteristic appears within 2 weeks of onset; subacute liver failure starts more acutely, and a liver failure syndrome appears within 15 days to 26 weeks of onset; chronic-onset (subacute) liver failure is the acute loss of liver function on the basis of chronic liver disease; chronic liver failure is the progressive decline of liver function on the basis of liver cirrhosis, leading to chronic liver dysfunction mainly manifested by abdominal distension or portal hypertension, coagulation dysfunction, and hepatic encephalopathy.

　　Principally, when various acute or chronic liver diseases cannot be cured by other medical or surgical methods, and it is predicted that death cannot be avoided in the short term (6-12 months), they are all indications for liver transplantation. Initially, liver transplantation was only a process to save lives, but now, with the continuous development of surgical technology, the application of new immunosuppressants, and the continuous accumulation of clinical experience, the perioperative complications and mortality of liver transplantation have significantly decreased, and the survival rate and survival time after surgery have been continuously improved. Therefore, when the symptoms caused by liver lesions lead to a serious decline in the quality of life of patients, it also becomes one of the main indications for liver transplantation.

　　After the patient is discharged from the hospital for recovery, self-care is necessary, and the medication should be taken strictly according to the doctor's instructions, absolutely not to believe others' advice to change or stop the medication; master the dosage, time, frequency, and method of taking medication. In addition, the patient should maintain a regular lifestyle, avoid overexertion, but this does not mean that the patient should lie in bed all day. Appropriate activities are beneficial. With the gradual recovery of the body, the patient can completely resume normal study and work.

　　1. Comprehensive systemic examination before liver transplantation:It mainly involves the assessment of the function of important organs such as the heart, lungs, and kidneys, the assessment of mental and psychological status, the assessment of nutritional status, and the assessment of infectious diseases. Specifically, it can be divided into routine examinations, special examinations, and individualized examinations.

　　1. Routine examination:It mainly includes blood, urine, feces, sputum tests, as well as chest X-ray, electrocardiogram, and abdominal ultrasound examination.

　　2. Special examination:It mainly includes liver color Doppler ultrasound and abdominal magnetic resonance or CT angiography (to understand the anatomy and blood flow of the portal vein, hepatic artery, hepatic vein, and inferior vena cava), as well as magnetic resonance imaging of the biliary tract (to understand the anatomical structure of extrahepatic and intraphepatic bile ducts).

　　3. Individualized examination:It is mainly to decide whether to conduct more in-depth examinations based on the results of preliminary examinations, such as additional HBV-DNA and virus resistance variant strain tests for patients with hepatitis B; selective lung function tests, echocardiography, coronary angiography, and 24-hour dynamic electrocardiogram for patients with pre-existing cardiovascular diseases.

　　Secondly, the examination required for liver transplantation in patients with liver cancer

　　In addition, for patients with liver cancer, liver transplantation is the best treatment method, as it can maximize the resection of tumors and cirrhotic liver, fundamentally eliminating the soil for the production of liver cancer; at the same time, it can avoid the occurrence of serious complications such as liver failure after liver resection. However, the biggest problem it faces is the recurrence of tumors after transplantation. It is generally believed that the cause of tumor recurrence after transplantation is the existence of metastatic foci that cannot be detected by routine methods during surgery, or tumor cells entering the blood circulation due to surgical manipulation. Therefore, patients with liver tumors must undergo a systematic and comprehensive examination before liver transplantation to exclude the existence of metastatic foci outside the liver and the possibility of multiple primary tumors.

　　The first is a comprehensive physical examination and serum tumor marker tests, including AFP, CA19-9, and so on; followed by a comprehensive imaging examination, such as chest X-ray and CT scan to exclude lung metastasis and primary lung tumors, cranial CT or MRI scan to exclude brain metastasis and primary brain tumors, isotope bone scan to exclude bone metastasis of tumors, abdominal CT and MRI scan to observe for abdominal lymph node metastasis and vascular invasion; finally, further examinations are selected based on medical history and examination results. In addition, PET-CT can complete a whole-body scan at one time, allowing for a detailed screening of various tissues and organs of the body during a single examination, which is helpful in detecting metastases in other parts of the body besides the primary tumor, and has higher sensitivity and accuracy than CT and MRI. It also overcomes the deficiency of the whole-body radionuclide bone scan in providing lesion information for other tissues besides bone tissue. It plays an increasingly important role in the pre-liver transplantation evaluation, and some patients have changed their diagnostic staging and corresponding treatment plans as a result.

　　After liver transplantation, due to the long-term use of immunosuppressants, the metabolism of the body is affected to varying degrees, including sugar, protein, lipids (such as cholesterol), uric acid, and so on. A reasonable diet can not only prevent and reduce the adverse reactions caused by immunosuppressants but also promote health and prolong the survival time of the transplanted liver.

　　Dietary principles:

　　Generally, after the gastrointestinal function recovers after liver transplantation, the diet can be gradually returned to normal. The starting diet should be easy to digest, such as egg custard, and gradually transition to normal diet. The diet should adhere to the principle of low sugar, low fat, high vitamins, and appropriate high-quality protein (animal protein).

　　1. Sodium salt:During the early postoperative period and the recovery period, a low-sodium diet is required, with about 3 to 4g of salt per day. If there is no hypertension, edema, oliguria, and so on, salt can be increased appropriately, but not more than 6 to 8g per day (calculation method: a common toothpaste cap can hold about 6g of salt).

　　2. Protein supply:Immunosuppressants can accelerate protein degradation and inhibit synthesis, thereby increasing protein consumption. It is advisable to increase the supply of high-quality protein appropriately, and for the supply of protein after liver transplantation, high-quality protein should be the main focus. High-quality protein mainly includes animal protein, such as fish, poultry, eggs, lean meat, and other animal foods; plant protein such as soybeans and peanuts, which produce a large amount of amines after metabolism, can increase the burden on the liver, so it is advisable to eat less. Among animal proteins, it is best to focus on fish, poultry, and eggs. Fish and poultry meat are also known as 'white meat', while pork and beef are known as 'red meat'. 'Red meat' contains more cholesterol and fat than 'white meat', so 'white meat' is more beneficial to health. Even if the liver function is normal after liver transplantation, the intake of protein should still be paid attention to, and it should not be too high. Excessive intake of protein can increase the burden on the liver. Generally, adults need to consume 1 to 1.2g of protein per kilogram of body weight per day, and children need 2 to 3g per kilogram of body weight per day. For patients with chronic liver transplant dysfunction, the daily protein intake should be controlled at about 0.5 to 0.6 grams per kilogram. Calculation method: 300 milliliters of milk or 2 eggs or 50 grams of lean meat can provide 9 grams of high-quality protein.

　　3. Strictly control the intake of sugar:Eating too much sugar is likely to trigger diabetes, and immunosuppressants themselves may also trigger diabetes. Diabetes not only affects the cardiovascular system but also affects the function of the transplanted liver, increasing the chance of rejection. Therefore, it should be paid attention to, and sugary foods should be eaten less. Some traditional Chinese medicines such as Isatis root,茵陈, compound biphenyl ester, etc., should also be used with caution. Fruits should be consumed at 150 to 200 grams per day, and it is generally advisable not to exceed 250 grams per day.

　　4. Limit cholesterol intake:Immunosuppressants themselves may cause hyperlipidemia, leading to atherosclerosis. Therefore, patients who have undergone transplantation should limit their intake of cholesterol, and their diet should be light and not greasy. Avoid fried and fried foods, and reduce the consumption of animal internal organs, egg yolks, crab roe, fish roe, pork knuckles, soft-bodied fish, and cuttlefish. At the same time, eat more fresh vegetables and fruits. It must be pointed out that 'less' does not mean 'prohibition'. Fats are still essential for the human body and must be consumed, but the amount should be limited, with vegetable oils as the main source, and animal fats should be used as little as possible. The egg yolk should not exceed one per day.

　　5. Foods to eat:Food with diuretic properties, such as winter melon, Job's tears, crucian carp, black carp, etc., can be consumed long-term.

　　Firstly, surgical treatment

　　The operation time for liver transplantation is much longer than that for conventional surgical operations. With the rapid development of surgical technology, in many liver transplantation centers, a classic orthotopic liver transplantation operation can now generally be successfully completed in 4 to 6 hours. Of course, the length of the operation time depends on many factors, including whether the patient has a history of upper abdominal surgery, the skillfulness of the physician, the method of surgery, whether extracorporeal veno-venous bypass is performed, etc. The more complex the surgery, the longer the time. The shorter the operation time, the more beneficial it is for the patient's postoperative recovery. The length of hospital stay after surgery often varies from person to person. Most patients can recover physically within 3 to 1 month after surgery and can be discharged smoothly. However, some patients may need to extend their hospital stay appropriately due to early postoperative complications or the need to adjust immunosuppressive drugs. Once the situation stabilizes, discharge can be arranged.

　　Secondly, postoperative follow-up

　　In the perioperative period of liver transplantation, comprehensive examinations are indispensable, enabling doctors to have a comprehensive and in-depth understanding of the patient's recovery at each stage postoperatively and to guide treatment correctly. Usually, the laboratory tests and examinations after surgery include the following content:

　　1. Vital signs:Including the regular measurement of body temperature, blood pressure, pulse, and respiration, and central venous pressure, pulmonary artery pressure, and other necessary measurements, which will gradually simplify as the patient's condition improves.

　　2. Urine, feces routine and culture:Measure 1 to 2 times a week.

　　3. Blood routine, electrolytes, and liver and kidney function:Check at least once a day, and twice a week after normalizing.

　　4. Coagulation function test:Check once a day in the early stage of treatment, and once or twice a week after normalizing.

　　5. Immunosuppressant blood drug concentration monitoring:Measure once in the morning each day. Once the blood drug concentration is basically stable and reaches the ideal level, it can be checked once a week.

　　6. Hepatitis virus detection:Routine determination of hepatitis B surface antigen, hepatitis C virus antibody, as well as the replication status of hepatitis B and C virus DNA. The first examination is performed within the first week after surgery, and follow-up examinations are scheduled regularly based on the situation.

　　7. Cytomegalovirus, EB virus detection:Determine once every 2-4 weeks during immunosuppressive therapy.

　　8. Blood ammonia test:Promptly measure and continuously observe when the patient shows changes in consciousness and spirit, and check once a week in normal times. Blood culture: Check and perform antibiotic sensitivity tests when systemic infection is suspected, to guide the use of antibiotics. Bacterial culture of drainage and secretions

　　9. Culture and fungal detection: Check once a week. Check again at any time when infection is suspected.

　　10. Chest X-ray:Early weekly chest X-rays 1-2 times, and once every 2 weeks after respiratory function is stable. Check at any time when lung lesions are suspected.

　　11. Ultrasound examination:Daily bedside color Doppler ultrasound for the first week after surgery, and it can be changed to a review every 2-4 weeks after multiple consecutive normal results. Ultrasound examination can help the transplant doctor understand whether the patient has pleural effusion or ascites without any pain to the patient.

　　12. Size and texture of the new liver, whether the vascular and biliary anastomosis is patent.The first week after surgery is often a high-risk period for complications such as bleeding, thrombosis, and rejection reactions. Color Doppler ultrasound can often detect abnormalities before the patient experiences discomfort symptoms and handle them in time.

　　13. Liver biopsy:If there is a possibility of rejection reaction in the liver, a liver biopsy should be performed. It is the gold standard for diagnosing whether the transplanted liver has rejected, so that it can be detected and treated in time. Normally, the various biochemical indicators of liver function in patients parallelly decrease, and it can recover to normal about 3-4 weeks after surgery, which is an indication of successful transplantation. Once complications such as infection, rejection, vascular and biliary complications occur, the recovery of liver function often requires a longer time.