Thursday, September 22, 2011

لقاء د سامى حبيب فى العاشره مساء الجزء الثانى

لقاء د سامى حبيب فى العاشره مساء الجزء الاول.wmv

Thursday, September 8, 2011

Liver Transplant Complete Guide

Liver Transplant Complete Guide

Before Liver Transplant
During Liver Transplant
After Liver Transplant

A number of diseases can directly damage the liver. Damage to the liver can seriously affect the absorption of vitamins and nutrients, prevent waste products from being effectively removed from the system, and reduce the production of proteins needed to clot the blood.

If the damage is severe enough, transplantation may be necessary. A transplant provides a patient with a liver that can keep up with the demands of a full, active life.

What the Liver Does

The liver is the largest organ in the body. It is located on the right side of the abdomen (to the right of the stomach) behind the lower ribs and below the lungs. The liver performs more than 400 functions each day to keep the body healthy. Some of its major jobs include:

• converting food into nutrients the body can use (for example, the liver produces bile to help break down fats)
• storing fats, sugars, iron, and vitamins for later use by the body
• making the proteins needed for normal blood clotting
• removing or chemically changing drugs, alcohol, and other substances that may be harmful or toxic to the body

Basic Functions of the Liver

The liver is the largest and one of the most complex organs in the body. It is located on the right side of the abdomen. The liver performs four basic functions:

• It aids in digestion by helping in the absorption of fat and certain vitamins, including vitamins A, D, E, and K
• It helps distribute the nutrients found in food
• It helps "clean" the blood by removing medications and toxins
• It produces important proteins that affect the blood, such as factorsthat are essential in making the blood clot after an injury.

The liver produces bile, which aids in the digestion and absorption of fats. Bile
also aids inthe absorption of substances such as vitamins A, D, E, and K and
medication that patients take as an immunosuppressive agent following liver
transplantation. The bile is stored in the gallbladder (which is located just below the liver) and then released into the intestines as needed. Together, these organs process the nutrients found in the foods we eat.
The liver also helps filter many chemical substances and waste products from the blood. Most medicines are cleaned from the bloodstream by the liver. The liver also removes any alcohol that's consumed.

Symptoms of Liver Disease

• jaundice (yellowing of eyes and skin)
• severe itching
• dark urine
• mental confusion or coma
• vomiting of blood
• easy bruising and tendency to bleed
• gray or clay-colored stools
• abnormal buildup of fluid in the abdomen

Before Liver Transplant

Pretransplant Evaluation
The Transplant Team
Preparing and Waiting for a Transplant


Pretransplant tests, as well as giving a clear picture of the patient's overall health status, help in identifying potential problems before they occur. They also help in determining whether transplantation is truly the best option. This increases the likelihood of success.

The following procedures help in evaluating a patient's health status:

Chest x-ray - Determines the health of the patient's lungs and lower respiratory tract.

Electrocardiogram (EKG or ECG) - Determines how well the patient's heart is working and may reveal heart damage that was previously unsuspected.

Ultrasound with Doppler examination - Determines the openness of the bile ducts and major vessels. It is commonly done in all liver transplant recipients before and after transplantation.

CT (CAT) scan - This computerized image will show the size and shape of the patient's liver and major blood vessels.

MRI (magnetic resonance imaging) - May be used in place of CT scan or ultrasound to see inside the patient's body.

Total-body bone scan - If the patient has a liver tumor, ensures that it has not spread to his bones.

Blood tests - The patient's blood count, blood and tissue type, blood chemistries, and immune system function will all be checked. In addition, blood tests for certain infectious diseases will be performed.

Pulmonary function test - The patient will be asked to breathe into a tube attached to a measuring device, which will reveal how well his lungs are working and determine his blood's capacity to carry oxygen.

Hepatic angiograph - Dye injected into the patient's arteries will enable the transplant physician to see if there are any abnormalities or blockages in the patient's blood vessels.

Cholangiogram - Reveals any obstructions or growths in the patient's bile ducts.

Gallium, colloidal gold, or technetium scan - Gives the transplant physician a view of the patient's liver, gallbladder, and pancreas.

Peritoneoscopy - By inserting a flexible tube through a tiny incision in the patient's abdomen, the transplant physician will be able to see any structural changes in the liver.

Upper gastrointestinal (GI) series - This will show whether the patient's esophagus and stomach are disease free.

Lower GI series - Ensures that the patient is free of intestinal abnormalities.

Renal function studies - Urine may be collected from the patient for 24 hours in order to determine if the kidneys are working correctly. Blood tests such as serum creatinine are also performed to measure kidney function.

The Transplant Team

• Transplant Surgeon
• Transplant Physician (Hepatologist)
• Transplant Coordinator
• Nurse Practitioner
• Floor or Staff Nurse
• Physical Therapist • Floor or Staff Nurse
• Dietician
• Psychologist / Psychiatrist
• Pharmacist

Each of the skilled health care professionals who make up the transplant team take a personal interest in answering a patient's questions and taking care of his medical needs. They will also help the patient keep his spirits up along the way.
The patient is the most important member of the transplant team. To a certain extent, all the other team members will respond to his cues. The patient's physical, emotional, and practical needs will help them shape a personalized pretransplant and posttransplant treatment program.

Preparing and Waiting for A Liver Transplant

Days and weeks may pass while the transplant team waits?to locate the right liver for a specific patient. During this time, the patient should prepare as much as possible and take positive steps to deal with the stresses of waiting, always staying focused on reaching the goal of transplant.

During Liver Transplant

Getting the Go-Ahead
At the Hospital
Preparing the Patient for Surgery
Liver Transplant Surgery Procedure
T-Tube Placement and Bile Drainage

Getting the Go-Ahead

When that important phone call comes, the patient should make sure to bring the following to the hospital:

• A list of all the medications the patient is taking
• A list of the patient's drug allergies, if he has any
• The patient's health insurance information

IMPORTANT: As soon as a liver is available, the patient should stop all eating and drinking immediately. The patient's stomach must be empty when he is taken into the operating room.

At the Hospital

After admission, the patient will have a thorough physical examination, including more blood work, a chest x-ray, and EKG, and, possibly, other tests.

Unfortunately, surgery must be postponed in some cases. The patient will be sent home again if:

• he has an infection or has developed any other medical problem that would interfere with surgery or recovery
• The donor liver shows signs of deterioration or poor function

If surgery is postponed, the transplant team can help the patient through the disappointment. This is only a temporary setback, and the search for a new liver will go on.

Preparing the Patient for Surgery

The patient may receive an enema to clean out his intestines and prevent constipation after surgery. His chest and abdomen will be shaved clean to prevent infection, and an intravenous (IV) line will be inserted in his arm or just under his collarbone to give medication and keep him from getting dehydrated. The patient will also be given a sedative to help him relax and feel sleepy before going to the operating room.

Because transplantation is a major surgical procedure, the patient may need a transfusion. Today, all blood is screened very carefully; the likelihood of contracting a disease is very small. Any concerns that the patient has regarding the source of the blood should be relayed to the transplant team during the waiting period, before getting to the hospital. Most hospitals offer the option of "autotransfusion" - this is when the patient donates his own blood before surgery. His own blood is stored and hen used during transplantation.

The Liver Transplant Surgery Procedure

The patient will be under general anesthesia throughout the surgery. Once asleep, the transplant surgeon will make an incision shaped like a boomerang on the upper part of the abdomen. The surgical team will then remove the patient's old liver, leaving portions of his major blood vessels in place. The new liver will then be inserted and attached to these blood vessels and to the patient's bile ducts. To help with bile drainage, a tube will also be inserted in the bile duct during surgery.

T-Tube Placement and Bile Drainage

During liver-transplant surgery, the surgeon may find it necessary to place a small tube, called a T-tube, into the bile duct. The T-tube allows bile to drain out of the patient's body into a small pouch, known as a bile bag. The amount of bile, which varies in color from deep gold to dark green, can then be measured. If a T-tube is put in place, it may remain attached to a bile bag for a week or possibly longer. When the bile bag is removed the T-tube will be tied or capped. It will remain in place for several months so that it can be used for special testing.

The T-tube is attached to the skin with a stitch. The dressing around the tube should be changed at least once daily, and more often if it becomes moist. The transplant nurse will show the patient how to change the dressing without pulling out the T-tube.

Other drains may be in the patient's abdomen during the postoperative period. A common name for these drains is Jackson-Pratt (JP). They are used to drain fluid from around the liver. Generally, these drains are removed before the patient goes home.

The surgical team will then place the donor kidney into the abdomen and connect the kidney's blood vessels to the recipient's iliac artery and vein. The surgeons will then connect the ureter to the bladder. A small drain, called a Jackson Pratt, may be placed into the abdominal cavity to drain any excess fluid.

After Liver Transplant

Waking Up in the Intensive Care Unit
Medical Management in the Acute Care Unit
Clinic and Follow-Up Visits
Lab Tests
Additional Tests and Procedures
Monitoring at Home
Resuming Normal Activities
Avoiding Infection
Communicating with the Healthcare Team

Waking Up in the Intensive Care Unit (ICU)

After the surgery, the patient will wake up in the intensive care unit after the anesthesia wears off.

This is what the patient should expect:

• Some pain and discomfort, which medication will help to relieve.
• A tube will be inserted through the patient's nose. This tube will run down the patient's throat and into his stomach. This tube will keep the stomach empty, to help prevent nausea and vomiting.
• A tube may be inserted into the patient's throat to help him get enough oxygen. It will be connected to a breathing machine called a ventilator. The patient should try to relax and let the machine breathe for him. The patient will not be able to talk with this tube in place, but he will only need it for a few days. Nurses will do everything they can to help the patient communicate. The patient's throat may feel sore or scratchy for a few days afterward.
• The patient will be asked to cough periodically to keep his lungs clear. If it hurts to cough, the patient should ask someone to support his abdomen.
• The patient will have an IV line in his arm or neck under the collarbone, which will be used to give fluids and medication for the first few days after surgery.
• For several days after surgery, the patient will have a catheter in his bladder to drain urine. He may feel uncomfortable, and may feel that he has to urinate constantly, but it is only temporary.
• During surgery, several drains will be placed in or near the incision. These drains will be removed 5 to 10 days after surgery.

Medical Management in the Acute Care Unit

After the patient's medical condition has stabilized, he will be transferred from the ICU to the acute care unit. During the patient's stay on this unit, his laboratory studies, medications, nutritional status and exercise tolerance will be monitored. As soon as the patient is able, discharge instructions will begin to prepare him for going home.

Clinic and Follow-up Visits

Upon leaving the hospital, the patient will receive a schedule of follow-up clinic visits for lab tests and checkups. The purpose is to track your progress and detect potential complications as early as possible.

On days when the patient is scheduled for follow-up visits, he should bring his medication list and his surgery handbook. He will be given specific instructions for routine lab work or special tests that he might need.

Lab Tests

A usual lab test monitors blood count, clotting, kidney function, liver function, electrolytes, and medication levels in the patient's blood. Other tests may be ordered as necessary.

Tests for BLOOD COUNT:

WBC tell if the patient's white blood cells have increased (usually a sign of infection) or decreased (indicating a lower defense against infection).
HCT measures the hematocrit, which is the percentage of red blood cells in the blood. Red blood cells carry oxygen to all parts of the body. When a patient's HCT is low, he may feel tired or have little energy.
PLTmeasures the level of platelets. Platelet cells form a blood clot when the body is injured. Low platelet levels may cause someone to bruise easily and to bleed for a longer time when injured.


Creatinine and BUN tell how well the kidneys work by measuring levels of creatinine and blood urea nitrogen, waste products normally removed from the blood by the kidneys.


Bili measures the level of bilirubin, a normal byproduct when hemoglobin from red blood cells breaks down. The liver removes bilirubin from the blood and excretes it in the bile. When the liver is not functioning normally, bilirubin levels can increase, often resulting in jaundiced (yellowed) skin and eyes.
Alk Phos measures alkaline phosphatase, which is made in the bones, liver, pancreas, and intestines and removed from the blood by the liver.
AST, ALT, and GGTP test enzymes that are made in the liver. These tests tell how well the liver is working. K measures potassium, which is needed for normal heart and muscle function.

Tests for ELECTROLYTES (dissolved minerals):

Ca measures calcium, which is necessary for strong bones and teeth, blood clotting, and heart and nerve function. NOTE: The desired level (normal range) will differ for each person, depending on the combination of immunosuppressive medications and the length of time since the transplant.
PO4 measures phosphate, which works closely with calcium to strengthen bones.
Mg measures magnesium, which is necessary for normal functioning of muscles and for blood clotting.
K measures potassium, which is needed for normal heart and muscle function.
Na measures sodium, which helps maintain the balance of salt and water in the body.

Other blood tests:

Drug levels measure PROGRAF or SANDIMMUME in the blood. PROGRAF or SANDIMMUNE blood levels must be checked regularly to avoid levels that are too high or too low. High levels could lead to toxicity or over-immunosuppression, and low levels may lead to rejection.
NOTE: The desired level (normal range) will differ for each person, depending on the combination of immunosuppressive medications and the length of time since the transplant.
Glu measures glucose, levels of sugar in the blood; some medications may produce a diabetes-like condition in which blood-sugar levels are too high.

Additional Tests and Procedures

The transplant team may perform one or more of the following tests and procedures to monitor a patient's transplant:

Ultrasound - This test is performed to make sure all the main blood vessels leading to the liver are functioning normally. This test is also used to check for collections of fluid, such as blood or bile. The procedure consists of placing a cool gel on the patient's abdomen, over which a wand (transducer) is moved to transmit sound waves. These are converted into images of the liver and projected onto a television screen.

Percutaneous transhepatic cholangiogram (PTC) - This is an X ray that shows the patient's bile ducts to check for leaks, blockages, or other potential problems. The procedure starts with a dye injection into the T-tube. The dye makes the ducts easy to see on X ray. If a T-tube was not placed during your surgery, this X ray will be performed after dye has been injected directly into the liver-bile ducts.

Liver biopsy (test sample) This test is usually performed to check for rejection, hepatitis, or other possible problems. This may be done in the hospital or in the outpatient/short-stay unit. The patient will receive special instructions regarding the procedure. Before the procedure, the patient will receive a numbing injection (local anesthetic) on the right side of his abdomen. Then a special needle will be inserted to withdraw a small sample of liver tissue that will be examined with a microscope. After this procedure, the patient must lie on his right side for at least 1 hour and stay in bed for about 4 hours.

Computerized tomography (CT) scan - This is a type of X ray that allows the physician to view the patient's liver from many different angles to detect infections, fluid collections, or other problems. The procedure requires that the patient drink a liquid that outlines his stomach and intestines and makes his liver more visible; then he lies flat for 1 hour while the machine takes X rays around him.

Magnetic resonance imaging (MRI) - This is another type of test that produces an image. Somewhat like a CT scan, it also allows a patient's liver to be viewed from different angles and in three-dimensional images. An MRI shows soft tissues, such as the liver, more clearly than a CT scan does.

Endoscopic retrograde cholangiopancreatogram (ERCP) - This test allows the physician to see the patient's biliary tree (the various ducts in and around the liver), as well as the ducts from the pancreas. The patient will be given medicine to relax him before the procedure. An endoscope (a type of tube) is placed in his mouth; it is advanced through to his stomach and into his intestine to the liver. A dye is then infected through the endoscope that makes the ducts visible in X rays.

Monitoring Health and A New Liver at Home

After a patient is discharged from the hospital, he may be asked to monitor:

Temperature - A patient should check and record temperature any time he feels chilled, hot, achy, or ill. This may be the first sign of infection.

WARNING: DO NOT USE TYLENOLR, ADVILR (Ibuprofen), aspirin, or other such products except under the direction of a physician, as these drugs may cause further symptoms.

If a patient's temperature is higher than normal at any time, he should notify his transplant coordinator immediately. This is considered an emergency, because an elevated temperature could indicate a serious infection or rejection.

Blood pressure - A nurse or transplant coordinator will show how to measure blood pressure, if necessary. The top number (systolic) is noted at the first sound, and the bottom number (diastolic) is noted when the sound changes (not stops). It is important that a patient knows his normal blood pressure, normal changes, and when he should be concerned.

Pulse - If a patient is taking medication that affects heart rate, the nurse or coordinator will show how to check his own pulse at home.

NOTE: If a patient experiences chest pain or has difficulty breathing, he should call 911 for an ambulance and go to the nearest emergency room. He SHOULD NOT attempt to drive himself.

Weight - The patient may weigh himself on a standard bathroom scale at the same time every morning (after going to the toilet). If he gains more than 2 pounds per day, he could be retaining fluid. This should be reported to the transplant coordinator.

Resuming Normal Activities

Although the patient is encouraged to resume normal activities after recovery, it is important to understand that having a new liver brings new responsibilities.

• Skin and Hair Care
• Sexual Activity
• Smoking
• Vacations and Travel
• Dental Care
• Pregnancy
• Exercise
• Diet and Nutrition
• Alcoholic Beverages

Signs to Watch Out For

While primary concerns involve infection and rejection, many other problems, such as colds or flu, adjustment of other medications, and minor infections can be handled by a local physician. A patient needs to take precautions and learn to watch for signs of infection and rejection that necessitate notifying a local physician or transplant team immediately. These include:

• a fever that continues for more than 2 days
• shortness of breath
• a cough that produces a yellowish or greenish substance
• a dry cough that continues for more than 1 week
• prolonged nausea, vomiting, or diarrhea
• an inability to take prescribed medication
• bleeding, bruising, black stools, red or rusty-brown urine
• a rash or other skin changes
• pain, discharge, or swelling at the T-tube site
• vaginal discharge or itching
• burning discomfort with urination
• exposure to mumps, measles, chicken pox, or shingles
• unusual weakness or light-headedness
• emergency-room treatment or hospitalization

Avoiding Infection

Because immunosuppressive medications interfere with a patient's natural immune system, he needs to protect himself consciously from infection after the surgery by taking the following precautions:

• Wash hands often.
• Keep hands away from face and mouth.
• Stay away from people with colds or other infections.
• Ask friends to visit only when they are well.
• If the patient has a wound and must change his own dressing, wash hands before and after.
• Wash hands after coughing or sneezing, and throw tissues into the trash immediately.
• If someone in the patient's family becomes ill with a cold of flu, have that individual follow normal precautions (use separate drinking glasses, covering their mouths when coughing, etc.)
• Avoid working in the soil for 6 months after the transplant. Thereafter, wear gloves.
• Avoid handling animal waste and avoid contact with animals who roam outside. Do not clean bird cages or fish or turtle tanks or cat litter. The cat litter box should be covered and taken out of a patient's home before it is changed.
• Avoid vaccines that consist of live viruses, such as Sabin oral polio, measles, mumps, German measles, yellow fever, or smallpox. The live virus can cause infections. If a patient or any family member intends to receive any vaccinations, they should notify the transplant team or local physician.


Ask the school nurse or other official to notify you immediately of any communicable diseases (for example, measles, chicken pox) that may be circulating in your school.

Communicating with the Healthcare Team

Communication and cooperation between the transplant team, local physician, pharmacist, dentist, and the patient himself is vital to his well-being. Having a transplanted liver and taking the medications needed to prevent rejection put a patient at risk for a number of complications. It is important to follow the instructions that will help prevent or lessen complications.

One of a patient's most important jobs is to make certain that all members of his local healthcare team - family physician, dentist, local pharmacist, and any other healthcare professionals he sees - are aware of the transplant, the medications he takes each day, and the precautions he must follow to stay healthy. Each of his local healthcare providers should be given the telephone number of his transplant team. He should ask that they contact the transplant center for specific information.

Anxiety and Depression

A serious procedure such as the one just experienced can create many personal and family stresses. It is not uncommon for transplant patients to experience anxiety and perhaps depression following their surgery, hospital confinement, and return home. To help a patient adjust to life at home and an eventual return to work or school, counseling and support group services are available. The patient should consult the transplant social worker or coordinator for information regarding services available to help resolve stress and anxiety.


Medication Guidelines
Postoperative Complications

Medication Guidelines

The patient is responsible for taking the medications that have been prescribed for him. He should talk to his physician, pharmacist, transplant nurse, and/or coordinator to understand fully:

• the name and purpose of each medication
• when to take each medication
• how to take each medication
• how long to continue taking each medication
• principal side effects of each medication
• what to do if he forgets to take a dose
• when to order more medication so it doesn't run out
• how to order or obtain medications
• what to avoid while taking medications

At home, the recovering patient will continue taking most of the medicines he began taking in the hospital after the transplant surgery, especially the anti-rejection medications. His immune system recognizes the new liver as foreign and will try to reject it. Therefore, his immune system must be controlled with immunosuppressive medications. The patient probably will have to take one or more of these drugs for the rest of his life, in addition to other medications.

REMINDER : Never stop taking medication or change the dosage without a physician's approval.

Before taking medications:

• Ask the nurse, coordinator, or pharmacist to help in selecting the best times to take medications.
• Try to take each medication at the same time every day.
• Follow a written schedule.
• DO NOT cut or crush a tablet unless advised to do so.

Storing medications

• Keep medications in the original container, tightly capped. If a special container is used to hold the pills, keep the container tightly sealed.
• Store in a cool, dry place away from direct sunlight.
• Do not store medications in the bathroom -- moisture can cause medications to lose their strength.
• Do not allow liquid medications to freeze.
• Do not store medications in the refrigerator unless the physician or pharmacist advises to do so.
• Keep all medications away from children.

Postoperative Complications

A number of postoperative complications are possible:

• Infection of the T-tube site and dislodgment of the T-tube
• Bile leak and biliary stenosis (narrowing of the bile duct)
• Infections
• High blood pressure
• Rejection
• Diabetes

There is no way to predict accurately which patients will have problems. The transplant team will do their best to reduce the likelihood of complications and to treat them promptly if they occur. Following instructions carefully and keeping the transplant team informed of any difficulties will help a patient return quickly to a normal, active life.

A patient should notify the transplant team if he:

• has prolonged illness (nausea, vomiting, diarrhea)
• is unable to take medicines by mouth due to illness
• thinks the directions on the label may be different from what he was told
• has trouble removing child-resistant caps
• has a reason to take aspirin, TYLENOLR (acetaminophen), other pain relievers, cold remedies, or diet pills
• feels he is having a reaction to the medications
• has had a change in health or eating habits
• has a new prescription from his local doctor or a change in a current prescription
• experiences any unusual symptoms or side effects, as they may be related to the medications he is taking
• is undergoing dental work of any kind

About Me

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Dr. Samy Habib - MD. Consultant of General and Liver Surgery - Society of Laparoscopic Surgeons Membership, USA - Middle East Representative of liver Transplant at China - Great Specialist of Surgery, Gamal Abd Elnaser Hospital, Alex, Egypt - Clinic Address : 47 Elnabi Danial street, Elraml Station, Alexandria, Egypt - Mobile : +20123475523 Tel : +2034869770 Fax : +2034836888 - E Mail : دكتور/ سامى حبيب - أستشارى الجراحة العامة وجراحة الكبد - عضو جمعية الجراحين الأمريكية - مسئول الشرق الأوسط لزراعة الكبد بالصين - كبير جراحين مستشفى جمال عبد الناصر بالاسكندرية مصر - العيادة: 47ش النبى دانيال محطة الرمل اسكندرية مصر - محمول:0020123475523 تليفون: 002034869770 فاكس : 002034836888البريد الاليكترونى