Liver is the largest solid organ in the body and has many important functions which are necessary for life. It has many functions some of which include:
- Detoxification of toxins produced in the body as well as those consumed
- Builds special proteins to prevent bleeding
- Makes bile to break down fats from food
- Stores and metabolizes sugar for energy
- Metabolizes drugs consumed
- Stores vitamins and minerals
- Break down proteins in absorbed food
Liver transplantation is the replacement of a diseased liver with a healthy liver from another person (allograft). The most commonly used technique is orthotropic transplantation, in which the native liver is removed and replaced by the donor organ in the same anatomic location as the original liver. Liver transplantation is a viable treatment option for end-stage liver disease and acute liver failure. The surgical procedure is very demanding and ranges from 4 to 18 hours depending on the outcome.
People who need liver transplant include the following:
- Acute liver failure
- Chronic liver failure
Symptoms that a patient with Cirrhosis may have include
- Ascites (fluid in the abdomen)
- Change in sleep patterns
- Easy bruising
- Nausea and vomiting
- Muscle cramping
- Swollen ankles
- Dark urine
- Fever and infections
- Pain over the liver
- Internal bleeding
- Jaundice (yellow color of the skin or the white part of the eyes)
- Spider veins” (broken blood vessels on the face, arms & chest)
- Change in appearance of bowel movements (pale stools, black stools or fatty stools)
However, not all patients are symptomatic and some of them may have no or minimal symptoms. Liver transplantation is a life-saving procedure for people with liver disorders. Liver cirrhosis which was at one time considered a terminal disease is now completely curable if treated at the right time.
When disease damages the liver, it does not function normally. Some of the causes of Liver damage include:
- Hepatitis B
- Hepatitis C
- Chronic alcohol consumption
- Nonalcoholic steatohepatitis ( Fatty Liver )
- Autoimmune disorders
- Cryptogenic Cirrhosis
- Drug induced
- In addition to liver failure, liver cancer may develop as a result of many of these diseases. There are also cases of sudden liver failure with unknown causes called acute or sub-acute fulminant liver failure.
Each patient is assessed individually for their suitability for transplant. Basic requirements for liver transplant are:1.The transplant assessment shows that the patient: a. Has liver failure (or a complication of liver disease) that will not improve without transplantation b. Is able to safely tolerate anesthesia and surgery. 2. The patient who is willing to have a transplant understands and accepts the responsibilities required before and after the transplant.
Our goal is to make transplant as safe and successful as possible. We involve the patients in their treatment decisions and regularly check with them to make sure that the treatment plan is working. The patient’s commitment is absolutely vital to make any transplant successful as it will significantly alter the lifestyle of the patient. Before undergoing transplant, the patient must be willing to take medications regularly for life time. Any problems must be reported immediately to the transplant team and their advice must be followed diligently.
The transplant assessment process helps to determine if the patient is a transplant candidate. An important part of this assessment is to try to ensure that he/she can tolerate the physical and emotional stress of the operation and the post-operative recovery. The assessment includes extensive medical tests and interviews with members of the family and the transplant team. We try to make sure that the patient does not have any other conditions or health problems that would be too high a risk for a liver transplant. It is important to stress that a liver transplant is a very major operation with significant risks at the best of time.
Blood Tests – All Patients need to undergo a whole panel of tests to check their Blood group, Liver function, Kidney function, Sugar levels, blood counts, urine analysis and cultures. Along with these, the work up includes tests to detect the etiology for cirrhosis/liver failure. Other blood tests will be performed which might be detrimental to the aftercare.
Radiological tests include a Contrast Enhanced CT scan of the Chest and Abdomen with Liver protocol to look for any evidence of cancer and the anatomy. An MRCP and Doppler of the Liver are also done to delineate the biliary anatomy and Portal flow.
Cardiac tests – ECG, 2D Echo, Stress Thallium
Pulmonary function test
The patient will then meet with various physicians for assessment for fitness for surgery which include
- ENT Physician
- Gynecologist ( for women )
Any additional tests or treatment (dental extraction) will be done as needed to optimize the patient. This process takes about two days and once the patient is declared fit for surgery, we progress to the next step.
Deceased donor Liver transplantation
- If there are no living donors or the patient opts for a deceased donor, the patient will be listed as per the Blood group with the Zonal Co-ordination Committee of Karnataka which overlooks the fair distribution of all availablecadaver livers among the hospitals offering LiverTransplantation in Karnataka.
- There is usually a waiting period of a few months for this type of Transplant. This is not particularly suitable for patients with HCC (Hepatocellular Carcinoma) where the long waiting times may be detrimental to the patient.
- However, if no suitable donors are available, we perform TACE/TARE/RFA on these patients to slow the progression of HCC.
- Once registered, patient will be on the List as per his or her blood group. The allocation of liver is on a rotation basis among the hospitals offering transplant.
- When an organ is available, the patient is called to the hospital. We expect the patient to respond immediately and reach the hospital at the earliest.
- This type of Liver transplant involves harvesting the liver from a brain dead donor whose family is willing for organ donation. The Liver is harvested and transplanted to a suitable candidate. Usually the whole of the Liver is transplanted to a single recipient however in some cases; the liver may be split to give benefit to two recipients.
Living Donor Liver transplantation (LDLT)
LDLT involves removal of a part of the living related donor and transplanting the same to the patient in need of Liver transplant. Living donor liver transplants are as successful as deceased donor liver transplants and significantly reduce the risk of health deterioration and death for patients who would otherwise wait on the list for the next available deceased donor organ.
Benefits of Living Donor Liver Transplant
- The recipient receives a high quality organ with excellent graft function
- Decreased recipient waiting time for liver transplant
- The capacity for the team to plan the transplant before the recipient’s health deteriorates further
- Reduced risk of death while waiting for transplant
- High success rates for donor and recipient
- The opportunity for the donor to restore good health to a close family member.
Disadvantages of Living Donor Liver Transplantation
- Placing an otherwise healthy individual (the donor) at risk
- Risk of complications
Assessment of Living donor
- Potential donors have a thorough evaluation by the health care team. They undergo a series of blood tests, x-rays, ultrasounds and consultations with specialists to provide information about the procedure.
- Donors must be in excellent physical and emotional health.
- Donors cannot have any history of cancer, or any active infection at the time of donation
- Donors must have normal liver function.
- The blood vessels to the liver and bile ducts in the liver must be suitable for transplantation. (Which is determined by a Contrast Enhanced CT scan of the abdomen and MRCP)
- Donors should have family and friends who can provide support before, during and after surgery
Principles Guiding Living Donor Selection
- Living donor must be between the ages of 18 and 50 years
- Should be a blood relative or spouse of the recipient(HLA typing is routinely performed for assessing the relation). First degree relatives can get clearance for donation from a committee within the Hospital. However any second degree relative will have to obtain clearance from the state government. The Transplant coordinator will assist the family in providing guidance but it should be noted that the onus of obtaining the clearance rests solely with the family and the transplant team cannot be involved in obtaining the same.
- Living donor donation must be completely voluntary
- Donor safety is the priority during assessment & donation
- It is the donor’s responsibility to communicate if there are any concerns or issues that need to be addressed regarding the assessment or he/she has a change of heart and does not want to donate.
- At any point, if the Surgeon feels that the donor may not be a suitable candidate, he will not go ahead with the procedure as donor safety is paramount.
The risks to the donor include: The same risks as with other major surgeries (these will be discussed with the donor during assessment).
Once the tests and consultations are completed, the transplant team will meet to review the results. If there are no contraindications and the recipient is prepared to go forward, he/she will be placed on the waiting list for liver transplant. The liver transplant surgeon will review the patient and explain the following facts regarding the transplant surgery.
About the successes and risks of liver transplant as well as:
- Risk of death during transplant surgery
- Primary non-function of the liver
- Hepatic artery and Portal vein thrombosis
- Neurologic & other complications
- Severe infections
- Prolonged stay in Intensive Care Unit
- Need for re-operation
On the waiting list
If the patient is on the waiting list he/she
- Must lead as healthy a life as possible.
- Take all medications regularly as prescribed
- Follow the diet as advised
- Follow up regularly with the transplant team
- Absolute alcohol abstinence is a must
- Smoking cessation is strongly advised
- Avoid over the counter medications. They must contact the transplant team or a qualified physician before taking any new medications.
- Avoid alternate forms of medicine as their effect on the liver may not be studied and they may be detrimental to it.
- Must be available to receive calls at all times. If one recipient is unavailable when or cannot be contacted, we will have to offer the liver to the next recipient on the list.
What Happens when the patient reaches the hospital?
- The patient is immediately admitted and blood tests are requested which include CBC, LFT, Coagulation profile, Electrolytes, Cultures among others. At the same time, he is assessed by the anesthetist. The patient is started on antibiotics and is prepared for surgery.
Living Donor Liver transplantation
Two sterile operation theaters are booked for Living Donor Liver Transplant – OT 1 for the recipient and OT 2 for the donor. The movement within these OTs is highly restricted and only a few select OT staff members are allowed to move through these operating rooms. The Donor is first taken up for surgery in the morning. After induction and putting in all the necessary lines/tubes required for intraoperative and post op monitoring, the surgery begins with a midline incision and right subcostal extension. Once the Liver is visualized and the quality is confirmed, the recipient is taken up for surgery. Both the procedures now run simultaneously. The donor team does the Hepatectomy (usually right side of the liver is taken). The recipient team meanwhile removes the whole of the liver of the patient. Once this is completed, the donor liver is sewn into the recipient. This involves joining the hepatic vein, portal vein, hepatic artery and bile duct. We initiate immunosuppression with IV Solumedrol intra-operatively. Once the liver is transplanted, an intra-operative Doppler and Cholangiogram procedure is done to look at the blood flow in the blood vessels and the biliary tract respectively. Meanwhile the donor operation is completed and after insertion of an abdominal drain, the donor is extubated and shifted a separate room in ICU. Once the Doppler and cholangiogram confirm that the anastomoses are fine, two drains are placed in the abdomen and the surgery is completed.
The recipient is also shifted to a separate room in the ICU (There are two side rooms especially for Donor and Recipient)
Deceased Donor Liver Transplantation
The overall procedure remains the same except for a few salient features. The organ is harvested from a deceased donor and the whole liver is brought to the OT in a sterile container. The organ is prepared on a back table and once the recipient Hepatectomy is completed, the organ is transplanted as described earlier.
The patient is started on Prophylactic Antibiotics and Antifungals.
Immunosuppression is maintained with Solumedrol, Mycophenolate Mofetil and Tacrolimus.
Patients are restarted on their cardiac/hypertensive medications and diabetes controlled with Insulin.
The entry to the recipient room is highly restricted and only a select few nursing staff are allowed. All handling of the patient is under strict aseptic conditions.
The Blood tests are performed daily to monitor Liver function. Doppler study of the liver is done regularly to monitor the blood flow into and out of the liver.
As the patient recovers, he is gradually started on oral feeds with the help of the dietician and the physiotherapist is actively involved in the physical rehabilitation.
As the patient improves, he/she is prepared for discharge.
Patients are sent home on oral medications. Steroids are tapered off and immunosuppression is maintained with tacrolimus and Mycophenolate.
Mr. Arun Kumar
A year ago, Mr. Arun Kumar had weakness and loss of appetite. During his routine health check-ups, he was diagnosed with liver cirrhosis, due to autoimmune hepatitis. After further investigations he was placed on the Liver Transplant waiting list in USA. With time running out, he did not get any organ offers and returned to India, for liver transplant surgery.
Mr. Arun Kumar worked in the pharma industry in the US. He is only 36 years old. The patient contacted Dr. Basant Mahadevappa from HCG to seek his consultation and guidance. After examining his reports Dr. Basant decided to conduct a complicated liver transplant surgery, which lasted for marathon 16 hours. Mr. Arun Kumar's case is especially interesting as his donor was his wife, Mrs. Shilpa Arun Kumar.
Mr. Arun Kumar, recipient, said, "I was diagnosed with liver cirrhosis, and the only medical solution was liver transplant. With my condition worsening and surgery being an emergency I was lucky to find a donor in my wife. She came forward to donate her liver, though it was high risk surgery. I have recovered and got a new lease of life."
Dr. Basant Mahadevappa, Consultant, Liver Transplant Surgeon, HCG Hospitals, said, "The patient was in a difficult situation, as he was decompensated with severe ascites (liquid in the abdomen). His wife was worked up for donation. Anatomy of the donor was complicated, and was left with no other donor. With a multi-disciplinary team approach we took up the challenge and performed the transplantation. The patient and the donor are doing well and are on regular follow up."