Liver Transplant

Liver Transplant Procedure

Liver transplant procedure begins with assessment of patient and donor, counselling of the family regarding the procedure, financial counselling, surgery, post operative course and life after transplantation.A systematic process, which is in accordance with all major centers across the world.

Assessment for Liver Transplantation

Every patient need to undergo assessment for liver transplantation as it is a major surgical undertaking. The aim of liver transplantation assessment is

• To confirm the needs for transplant.
• To confirm that the patient is fit enough to survive the operation

The assessment process involves a detailed evaluation of

1) Severity of liver disease MELD score

2) Evaluation of other organ systems such as the heart, lungs, kidneys.

The patient is seen by consultants of all specialties to identify any risk factors that can increase the risk of surgery and treat them so that patient is in an optimal condition to undergo the surgery. The team in the pre-transplant meeting discusses the entire clinical information and reports before the patient is listed for liver transplantation.

Types of Liver Transplantation

There are two types of liver transplantation

• Cadaveric liver transplantation (brain dead donor)
• Living donor liver transplantation (family members donates part of liver).

Most commonly performed type is living donor liver transplantation, as number of cadaveric donors is very less.

Deceased Donor Liver Transplantation.

Deceased donor liver transplantation or cadaver liver transplantation involves transplanting a healthy liver from a brain dead patient. The reason of death is usually severe head injury due to road traffic accident or a fall. CVA is also cause of irreversible brain damage. The treating team performs series of tests according to guidelines to confirm that the brain damage is irreversible.

After confirmation of brain death, family of the patient is counseled regarding organ donation. If the family is willing and gives written consent for organ donation, surgical team will carefully perform the operation of removing the organs in the operation theatre and place them in a special cold preservative solution. The organ is transported to the recipient hospital by road or air.

Wait-listing for a organ

Once the patient is considered suitable for transplantation, he/she is registered on the official state-wise waiting list. Liver is allocated by blood group matching and waiting time. Offer of a donor liver is based on the blood group and the time for which the patient is on the waiting list. Considerations such as size of donor and recipient, quality of organ and acuteness of illness is also taken into consideration.

Life on the Waiting List

Waiting for an organ is very frustrating and difficult. Patients have to be in stable condition to get the organ. They need to have regular follow up with the transplant team and continue their medication as advised. Any concerns should be immediately brought to notice so that it can be managed early. All these patients are very prone to infection; some may need regular ascetic tapping. Patients may have intermittent infections and deterioration of liver function on the waiting list needing hospitalization or intensive care admissions. The aim is to stabilize the condition so that transplant can proceed when the organ becomes available. If the patient gets admitted in a local hospital the treatment should be with collective effort involving local team and transplant team.

Organ call

When a suitable blood group matched donor liver is available the recipient is informed. He is advised to come to the hospital immediately. The call may come at any time. Patient has to reach hospital as early as possible so if you are in different city it is advised check for transport before hand. To avoid last minute rush it is advised to stay in same city if you in top 3 of the list. The patient should always be contactable while on the waiting list. It is important that the transplant team is aware about any changes in telephone number, email ID or address.

How Long Does It Take to Get a Donor Liver?

 Liver is allocated based on waiting time; longest waiting time gets the organ. Exception to this rule is only in case of acute liver failure. The average waiting time for chronic liver diseases is around 3 –6 months. The waiting time is variable and depends on multiple factors including the patients blood group.

Patient with AB blood group will get organ early, patient with O blood group will take time. In our center average waiting time is 3 to 6 months. Our center is pioneer in organ donation in Pune city. It has done more than 100 multi organ donations till now which is largest in Maharashtra state

Living Donor Liver Transplantation  (LDLT)

LDLT is most commonly performed liver transplant in India. Donor is a family member preferably first degree relative. First-degree relative are father, mother, brother, sister, wife, children and grand parents. Other than them remaining family members are second-degree relatives.

Donor and recipient undergo evaluation as per protocol. Surgery is performed only when the donor is fit and healthy and donor evaluation does not show any concerns. In LDLT the liver quality is very good and it starts functioning immediately. The liver regenerates in both donor and recipient over period of 6 to 8 weeks.

The main advantage of LDLT is that it avoids prolonged waiting time. Transplant can be done as soon as all paperwork is done. This also avoids patient from falling sick while waiting for a cadaveric organ. This leads to timely transplant with good quality organ and better survival post transplant. Recovery of patients is quicker.

Suitable Living Liver Donor

Suitable donor is

• Family relative who should be willing for donation. First-degree relative is preferred as less paperwork is required plus in-house committee clearance is sufficient in larger center.
• Fit and healthy, age group 18 to 50 preferably. Donor more than 50 years can be considered on case basis.
• Donor should be blood group compatible

• Documentation as prescribed by governmental authorities to prove the existence of a blood relation is necessary to proceed with donation.

Liver Donor Assessment

Assessment is started with surgeons consultation followed by blood test, CT scan and investigations for fitness. Assessment is done in stepwise manner to avoid unnecessary investigation in case donor is not suitable for donation. Entire process may take 3-4 days. Aims of donor evaluation are

• Donor and recipient blood group are compatible.
• Donor has a healthy liver and excellent liver function.
• Assess volumes of both lobes. GRWR of 0.8 for recipient and minimum remnant volume of 30 % for donor. Donor having remnant less than 30 % cannot be taken up for donation.
• Assess the overall health of the donor in terms of his heart function, lungs, and kidneys. Psychiatry consultation is most important. All other consultations are done as per protocol.
• Diabetes is contraindication, hypertension well controlled, hypothyroidism can be considered after specialist consultation.

Documents necessary for LDLT

As per government guidelines list of documents is given to family. Donor dependent consent is must for all LDLT. The list of documents may vary according to state. Once documents are ready committee clearance is obtained. The documents are primarily to confirm the relationship and also make sure that both are aware about the procedure and risk involved.

Donor surgery

Donor surgery as started before recipient surgery. It takes about 6-7 hours. Plan regarding surgery is finalized before in pre transplant meeting. 99% plan remains the same. All vessels and duct for remnant liver are preserved. Donor is extubated in operation theater and than he is transferred to liver ICU. Family members can meet the donor in liver ICU.

The graft is flushed with preservation fluid and stored in icebox. Any vascular reconstructions are done on bench using PTFE or stored vessels.

Risks of Being a Living Liver Donor

Morbidity is about 5 to 10 %

Mortality is about 1 in 500.

There are no long-term side effects of liver donation. The liver regenerates within 4-6 weeks to its normal size. The operation should not impact the donor’s studies, career options, diet, exercise, pregnancy and family.

Liver Transplant Operation

The recipient operation is started once donor team is happy with the liver. Hepatectomy is first step, which means removal of recipient liver.

Second step is implanting the new donor liver, doing all vascular connections. Sequence of reconstruction is

• Hepatic vein to hepatic vein
• Portal vein to portal vein
• Reperfusion
• Artery to hepatic artery
• Bile duct to bile duct.

The wound is then closed after placement of one or two drains, to drain excess fluid.

Post Operative Care

Recipient is transferred to liver ICU after the surgery.

Extubated few hours later or next day morning after liver ultrasound.

ICU stay is 3 to 4 days, later shifted to ward. Ward stay about one week.

Main concerns are

• Vascular thrombosis
• Bile leak
• Renal dysfunction
• Sepsis
• Pleural effusion
• Prolonged ventilation in few cases
• Poor nutrition.

The transplant team keeps a detailed watch on the recipient recovery. Family is updated twice every day about the recovery.

Medications

Post-liver transplant medications are very important. During hospital stay they receive antibiotic as per protocol or culture report.

Most important medication is immunosuppressant that is added in sequential manner. The doses of these medication is changed based on liver function, renal function and trough levels of the drug. Immunosuppressant has to continue life long. One member of family is taught about medication, doses and precautions to be taken before discharge.

In addition to medications, additional medications to prevent viral and fungal infections, multivitamins and medications to prevent acidity are also given at the time of discharge.

Going home after a Liver Transplant

Patients are discharged once they are on their own, wound has healed well and taking medications on their own.