Liver Transplantation

1 Liver Transplantation

Resources on Liver Transplant Surgery

Treatment Locations for Liver Transplants

Liver transplantation is a major surgical procedure whereby a diseased or failing liver is replaced by a healthy liver from a donor. This can be done in 2 ways.

1. Cadaveric Liver Transplantation: this is where a liver is harvested from a cadaver (a deceased individual). Please also read the page entitled Cadaveric Liver Transplantation for further details.

2. Living Donor Liver Transplantation: this is also sometimes known as Split-liver transplantation and is where a portion of a healthy liver is taken from a live donor and transplanted into the recipient. Please also read the page entitled “Live Donor Liver Transplantation” for further details.

The recovery time varies but generally takes around 3 months. Thereafter, most recipients can lead a normal and active life, though most will require drugs for the remainder of their life to prevent the body's immune system from rejecting the new liver.

What Does the Liver Do?

The liver is a large organ located in the upper abdomen, mainly on the right side. It has many hundreds of functions which are essential for our survival and well being. Some of its major roles are summarised below;

storing fuel for the body in the form of glycogen which is made from sugars such as glucose. When glucose is required by body cells, the liver breaks down glycogen, releasing glucose into the bloodstream.
processing fats and proteins obtained from food.
the production of clotting factors. These are proteins which enable blood to clot.
the safe processing and removal of alcohol.
the safe processing of many poisons and toxins from the body.
the processing of many medicines.
the production of bile which is used to aid fat digestion in the gut.
the production of plasma proteins (mainly albumin) which are essential for fluid regulation within blood and the circulatory system.
the storage of elements and vitamins such as Vitamins A, D, E, K and iron.
the production of some antibodies to aid natural immunity.

A normal and healthy liver has a large reserve. It can recover and repair itself from many conditions such as infections, the effects of drugs, alcohol and other toxins and trauma. However, when this reserve is stretched too far from disease or exposure to toxins, the liver gradually starts to fail as normal liver cells are destroyed. The liver may go through stages of damage from a reversible fatty change, to hepatitis (inflammation of the liver), to cirrhosis (an irreversible scarring of the liver) to cancer.

When Would a Transplant be Required?

At most stages of the liver changes described above, other treatments are available and will generally be considered before transplantation. Therefore, a liver transplant will only be considered if these treatments are no longer effective or if liver damage is too advanced or irreversible and is a risk to life. The types of liver diseases which can lead to transplantation can generally be divided into 2 broad groups;

Acute Liver Diseases: these are conditions which are of short duration and liver failure occurs quickly. Examples include viral hepatitis,

Chronic Liver Diseases: these conditions are of longer duration, often taking years before causing enough liver damage to warrant a liver transplant. Examples include alcoholic liver disease, chronic hepatitis, autoimmune hepatitis, biliary cirrhosis, sclerosing cholangitis and metabolic disorders such as Wilson’s Disease. Some of these conditions are described in more detail elsewhere in this guide.

The exact timing and decision to undergo transplantation is a complex one, requiring the opinion of liver specialists and transplant surgeons. Some key factors which may influence a decision include;

the general health of the patient other than their liver disease,
the age, shape and size of the patient,
the patient’s mental and emotional state,
the presence of cancer in other organs,
the presence of infections, especially infections such as HIV,
the availability of organs for transplant.

The assessment of the patient involves many tests such as blood tests, including blood type, infection screens (for hepatitis, HIV and others), x-rays, ultrasound scans, other types of scans such as CT or MRI and liver biopsies. In addition, an ECG and echocardiogram are used to assess the heart and a chest X-ray and pulmonary function tests are used to test how well the lungs are working. These investigations are crucial in trying to minimise the risk of complications during and after surgery. This assessment will usually necessitate a hospital stay. In the UK and other EC countries, if a transplant is deemed necessary the patient is placed on a waiting list for a suitable donor. This wait may be as little as a few hours but may last several years. A suitable liver will be one which is matched to the recipient by blood grouping and by the shape and size of the donor. For cadaveric liver transplantation, the recipient must be available to receive the donor liver within only a few hours since generally organs can only be kept for approximately 20 hours after their removal from the donor.

Furthermore, in some countries, before being entered onto the waiting list, a priority score is given to each patient. This score will determine how quickly the transplant needs to be done. Patients with low scores tend to wait longer while those with higher scores are moved up the list so that they receive donor livers more quickly. These scores are calculated in adult patients by using a scoring system known as MELD (Model of End stage Liver Disease) and in children by using a similar scoring system known as PELD (Paediatric End stage Liver Disease). To create a score, three different biochemical parameters are measured by a blood test. These are;

creatine,
bilirubin,
INR: this is a marker of how effectively blood can clot.

The score thus obtained is however dynamic, i.e. patients may start off with low scores but if they become more unwell as their liver fails further, their MELD/PELD scores increase and they are moved up the waiting list. Consequently, the most unwell patients are transplanted first. Those with rapid onset (acute) liver failure tend to have the highest scores and are therefore given priority.

The Transplant Operation

On the day of hospital admission, it is vital that the patient (and donor if the procedure entails a live liver donation) is completely well. He/she must specifically be free from infections. If the patient is found to have any evidence of illness, transplantation will be postponed.

Patients will usually be given an enema to clear out their intestines before surgery. This may also help to prevent constipation after surgery. Men may also have their chests and abdomen shaved to reduce the risks from infection. Intravenous (IV) lines and most likely an intra-arterial line are inserted into the arms. Alternatively, a "central line" may be inserted into the upper chest wall, just under the right clavicle (collarbone). These lines give easy access to the patient’s circulation in order to give medication, fluids and blood transfusions, should these be necessary. Patients are also given a sedative to help them to relax and feel sleepy before going to the operating theatre.

Because liver transplantation surgery is a major procedure, the patient may need a blood transfusion. Today, blood available at all major hospitals and transplant centres across the world is screened for various infections; the likelihood of contracting such an infection is therefore very small. Most hospitals offer the option of "autotransfusion" - this is when the patient donates his own blood before surgery which is stored and subsequently used during transplantation.

The actual process of having a liver transplant is hugely complex and requires a major operation. A large team of dedicated transplant specialists will be involved from the surgeons themselves to other doctors such as anaesthetists and nurses. The surgery itself is done under general anaesthetic and can last between 6 and 12 hours. Once the patient is asleep, some drainage tubes (usually 2 or 3) are inserted around the liver to drain excess blood and fluid during the operation. An incision along the patient's upper abdomen, just below the ribs, is made through which the diseased liver is removed. The new donor liver is then placed in the upper abdomen and "plumbed in" by connecting the arteries and veins that take blood to and from the liver. The bile ducts are also connected. The incision is then stitched together and a protective dressing applied over the wound.

Patients will generally have several tubes and lines inserted all over the body. It may be useful to know what they are and why they’re there.

Intubation tube: this curved, clear, plastic tube is inserted into the mouth and down into the top of the trachea (windpipe). This tube is used by anaesthetists to access the lungs during an operation. A ventilator can be attached to the intubation tube to maintain breathing artificially during the transplantation procedure and for 1-2 days after surgery until the patient can breathe by him/herself. Most patients tend not to remember this phase of the recovery.

Nasogastric tube (NG tube): this long, thin tube is inserted through the nose and down past the throat and into the stomach. Its purpose is to drain stomach secretions and fluid. It is kept in place for several days after the operation until the bowels start to function normally.

Drainage tubes: 2-3 long tubes are inserted into the upper abdomen around the liver to drain blood and fluid from the operation site during and after the operation. These are left in-situ for approximately 1 week.

Urine Catheter: this is another long, thin plastic tube which is inserted through the urethra and into the urinary bladder. Urine then flows from the bladder, down the catheter and into a bag for collection and measurement of volume.

Intravenous lines: these are discussed above.

T-tube: in most patients, a special tube is inserted into the bile duct. This is used to collect bile from the duct for measurement. The T-tube remains in place for approximately 5 months. However, it causes no pain and should not affect daily life.

The Recovery

The recipient will spend approximately 2 days in an intensive care ward immediately following surgery. Here, doctors and nurses can provide extremely close supervision and monitoring of the patient. Vital signs are constantly assessed. Providing all is well the recipient will then be moved to a less intensive ward with a total stay in hospital of approximately 2-3 weeks. However, during this time the patient is closely monitored for signs of infection or rejection by the immune system. The wound itself usually takes around 6-8 weeks to heal fully.

The results of this procedure have been improving with time. Most problems arise within the first 3 months of transplantation from either infection or rejection of the new liver by the body's immune system. Drugs called immunosuppressants are required for the rest of the patient's life to weaken the immune system and therefore to prevent possible rejection. However, as an effect of weakening the immune system the recipient is at higher risk of developing infections. Re-admission to hospital is relatively common in the first one year after transplantation. Rejection and infection tend to be the 2 main reasons for this. It is possible to reduce the dose of these immunosuppressants over time.

Commonly, other medicines are also routinely given to transplant patients for a period of approximately 3 months. These include;

antibiotics: to reduce the risk of bacterial infections,
antifungal drugs: to reduce the risk of fungal infection, especially in the mouth,
antacids: to reduce the risk of heartburn type symptoms and stomach ulcers.

Unfortunately, despite the use of immunosuppressant drugs, chronic rejection of the liver may occur. In this instance other drugs may be required but often a second transplant is the only solution. Very occasionally the transplanted liver fails to function completely. A second transplant is again the only solution.

Arrangements for Follow-Up after Surgery

It is not possible to give specific details about follow-up arrangements here as the policy and when follow ups occur varies from unit to unit and from country to country. But a realistic schedule can look like this:

1. 2 weeks post-operation: during this visit, patients are assessed by the transplant surgeon and transplant co-ordinator (if there is one). Other members of the team may also be present.

2. 5 months post-operation: patients are once again assessed. If a T-tube is present, this will be removed now.

3. 1 year post-operation: this is the next routine assessment.

4. Every 1 year thereafter.

However, for international patients traveling back home after surgery, clearly more local arrangements for follow up need to be arranged.

What are the Risks of Transplant Surgery?

As with all major operations, having a liver transplant comes with risks which must be considered. Some of these risks are minor and easily controlled but others are serious and can cause major problems in themselves. Therefore, it is vital that a full assessment of the recipient is carried out to assess general fitness, the heart, lungs and state of the circulation. This in itself will help to reduce the major risks. Risks can be classified as follows;

1. Risks during the operation itself, including;

heart attack,
stroke,
haemorrhage (bleeding)
death (fortunately, this is rare)

2. Risks immediately after the operation, including;

haemorrhage: bleeding may occur at the junctions of the major blood vessels after the vessels from the donor liver are connected to the recipient’s.
bile leakage: bile may leak from the connected bile ducts causing irritation and infection around the operation site and abdomen.
kidney damage: this can be short term but needs to be closely monitored.
infection: as recipients will be taking drugs to reduce the efficiency of their immune systems to prevent “rejection”, infections are far more common in transplant patients.
thrombosis: a blood clot may develop in the hepatic artery. This large blood vessel passes through the liver. If obstructed by a clot, the liver will be compromised and eventually fail.
liver failure: after transplantation, the liver may fail to function. Often, the reasons for this are unclear but the only solution then is another transplant as an emergency.

3. Risks later on after the operation, including;

rejection: the body’s own immune system rejects the new liver as foreign tissue and mounts an immunological attack against it. To some extent, the chances of this are greatly reduced by immunosuppressant drugs.
diabetes: this can develop after transplantation.
hypertension: this means high blood pressure.
hypercholesterolaemia: this means a high circulating cholesterol level in the blood.

Liver transplantation for UK Citizens

For UK citizens a referral to a dedicated liver unit is usually made when a serious liver condition is diagnosed. A decision on transplantation is then taken in the way described above. If a transplant is deemed necessary the patient is entered onto the liver transplant waiting list which is held by the National Health Service ("NHS") at certain centres in the UK. Although the actual transplantation procedure is therefore not done privately, the process of assessment may be done by the NHS or by the private sector. The actual surgery and recovery is as described above.

Liver transplantation for non-UK Citizens

In the UK most whole livers from deceased donors are transplanted into those patients on the NHS waiting list. Therefore recipients are generally UK or EC citizens. However, if a donor liver becomes available but no suitable patient from the waiting list is found then it may be offered to non-UK or non-EC citizens.

In the case of donation by a living donor, the donor is usually a healthy family member who has the same blood group as the patient. The donor must be aged 21 years or more and should have no liver disease or any other chronic medical problems. The living donor has a portion of their healthy liver removed for transplantation to the recipient. Clearly this entails a surgical procedure for the donor also and the risks of this need to be discussed with the donor in person by the transplant team. The advantage of having a transplant from a living donor is that providing the donor is otherwise suitable, a date for surgery can be agreed at a time that is convenient to all parties. This is done in the UK in the private sector. Generally at the initial consultation as many results from any assessments done in the patient's home country as possible should be brought to the UK. Specifically, results of blood grouping tests for both donor and recipient should be available.

Liver Transplantation in Other Countries

Each country in which liver transplants are carried out has its own set of rules and regulations. This governs who can carry out these complex procedures and who can obtain them. Clearly, it is not possible to outline these complexities here.

At Globe Health Tours, we commonly send patients to India for Living Donor Liver Transplantation. In India, all patients are assessed and reviewed by an independent panel before the “go ahead” is given to proceed with surgery.

The Outcome

Liver Transplants are major operations that require dedication from patients and families and great skill from the clinical staff. The surgical team must care for both recipient and living donor and provide both medical support as well as emotional and psychological understanding to ensure long term success of the procedure.

Currently, the one year survival rate is around 90% with a five year survival rate of approximately 75-80%. This is slightly lower in those aged over 65 years.

Most individuals can enjoy a normal life after transplantation and can look forward to returning back to work, driving and exercising once the recovery phase is complete.