Liver Transplantation by Dr Harshal RajekarDr.Harshal Rajekar
Dr. Harshal Rajekar
Liver transplantation is the replacement of a diseased liver with a healthy liver allograft. The most commonly used technique is orthotopic transplantation, in which the native liver is removed and the donor organ is placed in the same anatomic location as the original liver.
The first human liver transplant was performed in 1963 by a surgical team led by Dr. Thomas Starzl of Denver, Colorado, United States. Dr. Starzl performed several additional transplants over the next few years before the first short-term success was achieved in 1967 with the first one-year survival post-transplantation.
The introduction of cyclosporine by Sir Roy Calne markedly improved patient outcomes, and the 1980s saw recognition of liver transplantation as a standard clinical treatment for both adult and pediatric patients with appropriate indications.
Francis Chan (born November 3, 1991) is believed to be the youngest liver transplant patient. He was 2 months old when he underwent two transplant operations 3 days apart in Sydney.
Presently one year patient survival is more than 90% and outcomes continue to improve, although liver transplantation remains a formidable procedure with frequent complications. Liver transplant outcomes remain plagued by recurrent viral disease, recurrence of cancer and immunological rejection.
Although the technique of LTX has been refined to a relatively standardized approach, the operation remains a formidable surgical challenge.
Liver transplantation may be cadaveric when the liver is retrieved from a brain dead patient; or may be living donor liver transplant, when a part of the liver is retrieved from a healthy adult.
Who needs a Liver Transplant?
Patients with end-stage liver disease in whom the projected survival at 1 year is predicted to be less than 90%; are considered candidates for receiving a liver transplant. Major liver disorders necessitating transplantation include cirrhosis, acute hepatitis A and E, chronic hepatitis B and C, liver cancer.
As a general rule, the following complications of end stage liver disease warrant transplantation:
* Recurrent variceal hemorrhage (upper GI bleeding)
* Intractable ascites (fluid in the abdomen)
* Spontaneous bacterial peritonitis (infection in the abdomen)
* Refractory encephalopathy (changes in mental status)
* Severe jaundice
* Exacerbated synthetic dysfunction
* Sudden deterioration
* Fulminant hepatic failure
The MELD (model for end stage liver disease) score is used to prioritize patients for liver transplantation.
In interpreting the MELD Score in hospitalized patients, the 3-month mortality is:
40 or more — 71.3% mortality
30–39 — 52.6% mortality
20–29 — 19.6% mortality
10–19 — 14.0% mortality
<9 — 1.6% mortality
The major constraint to meeting the demand for transplants is the availability of donated (cadaver) organs. Rising public awareness about organ transplantation should continue to reduce the organ shortage. Currently, any patient who has chronic or acute liver disease that leads to the inability to sustain a normal quality of life or that results in life-threatening complications should be considered a candidate for LT.
Living Donor Liver Transplantation:-
The concept of LDLT is based on the remarkable regenerative capacities of the human liver and the widespread shortage of cadaveric livers for patients awaiting transplant. In LDLT, a part of healthy liver is surgically removed from a living person and transplanted into a recipient, immediately after the recipient’s diseased liver has been entirely removed.
Historically, LDLT began as a means for parents of children with severe liver disease to donate a portion of their healthy liver to replace their child’s entire damaged liver. The first report of successful LDLT was by Dr. Silvano Raia at the Universidade de Sao Paulo (USP) Medical School in 1986. Now live donor liver transplant is commonly practiced. In various case series the risk of complications in the donor is around 5-10%, and very occasionally a second operation is needed. Death after donor hepatectomy has been reported at 0% (Japan), 0.3% (USA) and <1% (Europe), with risks likely to improve further as surgeons gain more experience in this procedure. In a typical adult recipient LDLT, 60% -65% of the liver (the right lobe) is removed from a healthy living donor. The donor’s liver will regenerate to 100% function within 4-6 weeks and will reach full volumetric size with recapitulation of the normal structure soon thereafter. The transplanted portion will reach full function and the appropriate size in the recipient as well, although it will take longer than for the donor.
According to conservative estimates, liver diseases affect more than one of every 10 Indians. Statistics obtained from birth and death registration department of Pune Municipal Corporation showed that an average of 35-40 people die every month of liver related problems in Pune alone. Statistics reveal that nearly 2.5 lakh people in India die of terminal liver disease of which 25,000 can be saved by transplants every year.
While non alcoholics too suffer from liver cirrhosis, the maximum risk is for alcoholics, even in those with hepatitis B and C. It takes 15 to 20 years for a hepatitis C infection to develop into cirrhosis, usually picked up during preventive health checks or when the patients are tested prior to other medical procedures.
Hepatitis B is one of the major diseases of mankind and is a serious global public health problem. Of the 2 billion people who have been infected with the hepatitis B virus (HBV) in the world, more than 350 million have chronic (lifelong) infections. In India, of the 25 million infants born every year, over one million run the lifetime risk of developing chronic HBV infection. Estimates indicate that annually over 100,000 Indians die due to illnesses related to HBV infection.
In India, about 250,000 people die of viral hepatitis annually. There is no other form of treatment for liver cirrhosis and failure at present apart from liver transplantation.
It is estimated that liver diseases are among the top ten killer diseases in India, causing lakhs of deaths every year. Besides, there are those who suffer from chronic liver problems, needing recurrent hospitalization and prolonged medical attention, which leaves them physically, mentally, emotionally and financially devastated.
On the other hand, there are millions of cases of hepatic diseases, which go unreported or are reported when the matters have gone out of hand. Poverty coupled with lack of education and awareness prevents people from seeking medical advice until it is too late. It is very important for people to realize that one can suffer liver damage without exhibiting obvious symptoms. The most common liver disease presents with jaundice. However, many people with end‐stage liver disease may not have marked jaundice.
In addition, high cost of treatment poses as major obstacle in convincing people about taking treatment.
Liver cancer is a fairly rare form of cancer in the western world but much more common in Africa and parts of Asia. Liver cancer is rapidly fatal and unfortunately, most of the cases are diagnosed at a later stage. Liver cancer accounted for nearly 7% of all cancer related deaths in India according to data published this year and was the 4th commonest cause of cancer death.
Liver Cancer is a common problem in this part of the country and is usually related to the infection with Hepatitis B Virus and Hepatitis C Virus, alcohol consumption and fatty liver disease related to overweight and diabetes mellitus. Liver Transplantation is the only hope for many patients with liver cancer in the presence of liver cirrhosis and this modality is more widely available than just a decade ago.
Liver cancer is emerging as one of the fastest spreading cancers in India. The good news, however, is that almost 50% see a specialist in a treatable condition as opposed to 10% about two decades ago.
Early detection always helps in better treatment outcome. It is recommended that high-risk category people get screened regularly, and see a liver specialist if cancer is diagnosed. Hepatitis B and C used to be the most common causes of liver disease in India that led to liver cancer later. Since the past few years, alcohol has also added to the list. For diabetics, who are over-weight and consume alcohol, the chances of getting liver cancer increases by eight fold. Diabetics have two-and-a-half times more chances of developing chronic liver disease.
Studies have indicated that some liver related diseases like Hepatitis B and Hepatitis C virus could burgeon into an epidemic much larger in scale than the dreaded HIV. However, these diseases being silent killers with long gestation periods do not attract the attention of the Government or the other influential bodies. The needs of patients with liver related disease have been grossly underestimated and largely ignored. Nearly 1 million people suffer from chronic liver disease because of alcohol. At least one in five Indians is living with some kind of liver problem. At most hospitals, patients with alcoholic liver disease (ALD) comprise a big chunk. Almost 70% of in-patients with liver disease and 15% with liver cancer have ALD. This is congruent to the data worldwide and says that ALD accounts for 40% deaths from cirrhosis and 30% from liver cancer. The problem, say experts, is only growing because of lack of awareness and few dedicated liver hospitals. With this, the incidence of liver cancer is probably going to increase.
Dr Harshal Rajekar
MBBS MS MRCS DNB
+91 992 307 8668