Liver

Significance of MELD Scoring in Liver Transplant

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Q) The significance of MELD Scoring in Liver transplant is :

a) Less ill patients are given more priority in liver transplant

b) Set threshold for patients who are too ill to undergo transplant.

c) To access  mortality in the waiting list.

d) To list patients in cadaveric deceased donor program

d

MELD score takes into account  three factors. Bilirubin, INR and creatinine. Recently MELD Na is also included. Model for end stage Liver Disease (MELD) was initially developed to evaluate three months prognosis in patients undergoing TIPS. 
It ranges from 6 (3 months survival = 90%) to 40 (3 months survival =7%).

In countries where DDLT is more common MELD Score is used to allot grafts to people in the cadaveric list. More severe is the MELD, earlier is the allotment of cadaveric graft.

Sicker patients are given priority

 

Hemodynamic changes after pedicular clamping of Portal structures

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Q) 33 year old male is undergoing resection of right lobe of liver Which of the following hemodynamic  happens during pedicular clamping in liver transaction? 

a) Systemic vascular resistance decreases by 20%

b) Mean arterial pressure decreases

c) Cardiac index decreases by 10%

d) Preload to the heart increases

c-  Cardiac index decreases by 10%

Portal triad clamping is done to decrease blood loss during hepatic transaction. With the advancement in techniques in donor resection in living donor liver transplants, many centers are shifting away from this but in most centers this is still practiced.

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Contraindication of liver transplantation

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Q)Contraindications of liver transplantation have changed over the years. Which is an absolute contraindication of  liver transplantation

a) Previous breast cancer

b) Portal vein thrombosis

c) Active tuberculosis

d) Active substance abuse

d

Previous history of breast cancer if completely treated is not an contraindication of liver transplant. Portal vein thrombosis was earlier considered a relative contraindication but almost all series have shown similar results in patients with PVT than patients without PVT.

IN portal vein thrombosis, inflow to the new liver can me taken in many ways

a) thrombectomy

b) Jump grafts from Superior mesenteric vein 

c) Anastomosis have been done from big collaterals

Active tuberculosis can be managed after transplant.

Modified ATT regimens without INH and Rifampicin are being  used.  Any kind of active substance abuse alcohol,  drugs etc are absolute contraindications for liver transplant because the disease will recur.

Hydatid liver

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Q) Not an indication of surgery in hydatid cyst liver

a) CE2 cyst with multiple daughter cysts

b) Large 10 cm cyst situated peripherally

c) Infected cyst

d) 6 cm asymptomatic cyst

Hemangioma Liver

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Q) A 38 year lady undergoes USG  abdomen for vague pain abdomen. ON USG she has a large 12 cm lesion in the right lobe of liver, which on CT turns out to be hemangioma.  True about management of hemangioma liver

a) All hemangioma more than 10 cm should be resected

b) OCPs and pregnancy should be avoided in young females as there is risk of rupture

c) Arterial embolization should be routinely done in large hemangiomas

d) If surgery is decided  hemangioma located at the periphery should be enucleated

Ans) d

Whatever the size there is no role of resection for asymptomatic hemangioma. Risk of rupture is very small and therefore there is no rationale for stopping OCPS, pregnancy or physical activities.

 Arterial embolization, which may be considered for temporary control of hemorrhage has limited success and is occasionally associated with morbidity

In symptomatic hemangioma liver resection is the treatment of choice, in peripheral tumors enucleation and in centrally placed tumors, formal resection should be done

REf  Blumgart Surgery of liver 7th  page 1184

HCC Cancer

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Q) Which of the following is true about screening in hepatocellular carcinoma (HCC Cancer) 

a) Alpha feto protein should be done 6 monthly

b) Ultrasound abdomen should be done 6 monthly

c) Candidates for liver transplant should be screened every 3 months

d) Nodules more than 2 cm should be followed up  more regularly

Answer b

Cirrhosis is prone for development of HCC. Screening has to be stringent.  Earlier ultrasound of liver and alpha feto protein were both used for screening

In 2009 Marrero et al demonstrated the suboptimal accuracy of AFP and after that it has been removed from the screening protocol and now only ultrasound is being done.

The screening recommendation is not for those patients with severe associated conditions and with advanced liver disease who are already considered for  transplant. So there is no screening for those who are already listed. Nodules more than 1 cm are highly suspicious where as in nodules less than 1 cm only 40% will be malignant.

Ref: blumgart 6th edition

 

 

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