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Transplant Surgeries


Liver Transplant

Liver is the largest internal organ weighing about 3 pounds and acts as a storage house by removing toxic byproducts of certain medications. Liver Transplant is an operation that replaces a diseased liver with a healthy liver or a segment of a liver from another person called the donor. The most common technique is Orthotopic Transplantation in which the liver is removed and is replaced by the donor organ in the same anatomic location as the original liver. Liver failure can occur suddenly or as a result of complications from certain medications. Liver transplants are the most accepted treatment for end stage liver disease and acute liver failure. After a transplant, the patient will be free from the disease and lead a fairly normal life. Liver Transplants are classified as

  • Deceased Donor Liver Transplant (DDLT) : The full liver is used when the donor organ comes from a brain dead but heart beating donor.
  • Living Donor Liver Transplant (LDLT) : A half (or hemi) liver is used when the donor organ comes from a living donor.
  • Auxiliary Transplantation : In this a part of the liver of a healthy adult donor (living or cadaver) is transplanted into the recipient. The patients’ diseased liver remains intact until the auxiliary piece regenerates and assumes function and then the diseased liver may then be removed.

What does the liver do?

The body’s largest internal organ, the liver has many important functions including

  • preventing infections
  • removing bacteria and toxins from the blood
  • controlling immune responses
  • processing nutrients, medications, and hormones
  • making proteins that help the blood clot
  • producing bile, which helps the body absorb fats—including cholesterol—and fat-soluble vitamins
  • storing vitamins, minerals, fats, and sugars for use by the body

A healthy liver is necessary for survival. A healthy liver can regenerate most of its own cells when they become damaged.

Criteria for Liver Transplant

When the liver is so diseased that is not able to maintain the normal body functions, then liver transplant is required. There are various conditions that can lead to a liver failure. They are :

  • Chronic Hepatitis with Cirrhosis
  • Alcoholism
  • Biliary Artresia (malfunction of the bile ducts)
  • Wilson’s Disease ( a rare inherited disease with abnormal deposition of copper throughout the body and liver)
  • Alpha 1 Antitrypsin Deficiency (abnormal accumulation of alpha-1 antitrypsin protein in the liver resulting in cirrhosis)
  • Liver Cancer
  • Primary Biliary Cirrhosis ( a condition where the immune system inappropriately attacks and destroys the bile ducts)
  • Sclerosing Cholangitis (scarring and narrowing of the bile ducts causing the backup of bile in the liver)
  • Hemochromatosis ( a common inherited disease where the body is overwhelmed with iron)

What are the signs and symptoms of liver failure?

The signs and symptoms of liver failure may include

  • jaundice, a condition that causes yellowing of the skin and the whites of the eyes
  • fatigue
  • weakness
  • loss of appetite
  • nausea
  • weight loss
  • muscle loss
  • itching
  • bruising or bleeding easily because blood does not clot
  • bleeding in the stomach
  • vomiting blood
  • passing black stools
  • ascites, the buildup of fluid in the abdomen
  • forgetfulness or confusion

Tests Required Before Getting a Liver Transplant

To update previous tests, some of the diagnostic studies are performed during an evaluation. They are

  • Doppler ultrasound to determine if the blood vessels to and from the liver are open.
  • Pulmonary function studies to determine the lungs' ability to exchange oxygen and carbon dioxide.
  • Echocardiogram to help evaluate the patient’s heart.
  • Computed tomography which uses X-rays and a computer to generate pictures of the liver and showing its shape and size.
  • Blood tests examine blood type, biochemical status of blood, clotting ability and to gauge liver function. AIDS and Hepatitis tests are also included.

Donor for Liver Transplant

  • Living-Donor : This process involves removing a segment of liver from a healthy living donor and implanting it into a recipient. Both the donor and recipient liver segments will grow to a normal size in a few weeks.
  • The donor must be a blood relative or spouse. Blood type and body size are critical factors in determining an appropriate donor.

When a suitable liver from a deceased donor is matched to a person who is ready to receive it, the surgery is scheduled as quickly as possible. The recipient completes presurgical testing and is prepared for surgery while the donor liver is obtained, transported to the hospital, and carefully checked to ensure it is suitable for transplantation.

Liver transplant surgery is complex and can take up to 12 hours. The patient receiving the liver requires general anesthesia given through a breathing tube inserted into the windpipe, intravenous lines to provide medicine and fluids, and a catheter to drain urine.

An incision is made in the upper abdomen, and the surgical team detaches the diseased or injured liver from blood vessels and the common bile duct, clamps the vessels and duct, and removes the liver. The team then attaches the recipient’s blood vessels and common bile duct to those in the donor liver. The donor liver is typically placed in the same location where the diseased or injured liver was. Tubes are sometimes placed around the transplanted liver to allow blood and fluids to drain out of the abdomen. A tube may be used to temporarily drain bile from the new liver into an external pouch so the bile can be measured to determine whether the liver is producing bile as it should. In cases where the recipient’s common bile duct cannot be connected to the donor’s bile duct, the donor bile duct is drained into a loop of small intestine.

After surgery, the patient goes to an anesthesia recovery area and then to an intensive care unit. After the patient is stabilized, the breathing tube used for anesthesia is removed and the patient moves out of intensive care and into a regular hospital room. Patients usually stay in the hospital from 1 to 2 weeks after a liver transplant.

Living donor transplants involve two surgeries performed in the same hospital. In one operating room, a surgical team removes the transplant recipient’s diseased or injured liver. In another operating room, another surgical team removes a segment of the donor’s healthy liver. Then the segment of donor liver is transplanted into the recipient. Otherwise, the surgery and recovery for the recipient is similar to that for a recipient of a liver from a deceased donor. The living donor typically remains hospitalized for about 1 week after surgery.

What are the complications of liver transplantation?

Possible complications of liver transplant surgery include

  • bleeding
  • damage to the bile ducts
  • blood clots in the liver’s blood vessels
  • infection
  • rejection of the new liver by the body’s immune system
  • side effects from the immunosuppressive medications liver transplant recipients must take to prevent rejection

In addition, liver diseases can recur in transplanted livers. The transplanted liver can be damaged if, for example, a person who had cirrhosis caused by long-term alcohol abuse resumes drinking after the transplant. Recurrence of certain liver diseases such as hepatitis C can also damage the transplanted liver. Recurrence of hepatitis B in the transplanted liver can now be prevented. Finally, autoimmune diseases, such as autoimmune hepatitis, primary biliary cirrhosis, and primary sclerosing cholangitis, may also recur.

If a person’s transplanted liver fails as a result of rejection or recurrent disease, the doctors on the transplant team must decide whether another transplant is possible.

What is liver transplant rejection and how is it treated?

Rejection occurs when a person’s immune system recognizes the transplanted liver as “foreign” and tries to destroy it. Rejection commonly occurs a week or two after a transplant, although rejection can occur at any time that immunosuppressive medications fail to control the patient’s immune reaction. Rejection does not always cause noticeable symptoms. Elevated liver enzyme levels in the blood may be the first sign that rejection is occurring. Other signs and symptoms of rejection may include fatigue, loss of appetite, nausea, abdominal tenderness or pain, fever, jaundice, dark-colored urine, or lightcolored stools.

A liver biopsy is usually needed to verify that rejection is occurring in the transplanted liver and exclude other causes of symptoms or abnormal liver enzyme levels. A biopsy involves using a needle to remove a small piece of liver tissue to be examined with a microscope.

Immunosuppressive medications are used to decrease the activity of the recipient’s immune response to prevent and treat rejection. Transplant recipients must take immunosuppressive medications for the rest of their life to prevent rejection.

Immunosuppressive medications commonly given after a transplant include

  • intravenous methylprednisolone (Depo- Medrol, Solu-Medrol), which is given during and immediately after surgery, and prednisone (Deltasone, Sterapred), once oral medications can be given
  • tacrolimus (Prograf) or cyclosporine (Neoral, Sandimmune)
  • sirolimus (Rapamune), which cannot be used for several months after a liver transplant because it can cause blood clots in the major artery providing blood to the transplanted liver and prevents the surgical wounds from healing; however, sirolimus is safe once the artery and wounds have completely healed
  • mycophenolate mofetil (CellCept), mycophenolic acid (Myfortic), and azathioprine (Azasan, Imuran), which may be given along with cyclosporine or tacrolimus

In general, a transplant recipient needs to take more medications during the first several months after a transplant, and later some medications may be eliminated or doses may be lowered to minimize side effects. One year after transplantation, many patients require only tacrolimus, cyclosporine, or sirolimus.

Immunosuppressive medications can have significant side effects. By suppressing the immune system, the medications can make patients more susceptible to infections. Other possible side effects include

  • weight gain—prednisone
  • diabetes—tacrolimus, cyclosporine
  • high blood pressure—prednisone, tacrolimus, cyclosporine, sirolimus
  • high blood cholesterol or triglycerides—cyclosporine, sirolimus
  • osteoporosis—prednisone
  • kidney damage—tacrolimus, cyclosporine, sirolimus

Long-term use of immunosuppressive medications can also increase a person’s risk of developing cancers of the skin and other sites. Yearly monitoring is required to detect any cancers at an early, treatable stage.


A number of medications, as well as grapefruit and grapefruit juice, can increase or decrease the levels of tacrolimus, cyclosporine, and sirolimus in the body. To prevent complications caused by the levels of these immunosuppressive medications becoming either too high or too low, people taking these medications should avoid grapefruit and discuss any new medications—prescribed or over-the-counter—with their transplant team.

 What is the outlook for people who have a liver transplant?

Most liver transplants are successful. About 80 to 85 percent of transplanted livers are functioning after 1 year. People who have a liver transplant are usually able to return to normal activities after recovering for several months.

Liver transplant recipients receive intensive medical follow-up during the first year after a transplant. They have regular blood tests to check whether the liver is being damaged by rejection, infections, or problems with blood vessels or bile ducts.

To help achieve a good outcome after a liver transplant, recipients need to

  • follow instructions for taking medications
  • keep all medical appointments
  • avoid people who are ill and let their doctor know when they are ill
  • learn to recognize the signs of rejection and infection and report them promptly to their doctor
  • maintain a healthy lifestyle by making healthy food choices, exercising, not smoking, and not drinking alcohol

Guidelines for Liver Transplant:

1. The Donor should be a relative of the patient and should be happy to donate his liver on selfless basis.

2. It is preferable that the donor must be between the age group of 18 and 45 years. He/she should be fit, strong and have a matching or compatible blood group:

Patient blood group

Matching donor groups

A+ or A-

A+/ A- /O+ / O-

B+ or B-

B+ / B- / O+ / O-

AB+ or AB -

Any blood group acceptable

O+ or O-

O+ / O

3. Though liver looks like a single organ but in reality it consists of 8 different lobes and thus can be separated into these lobes. Generally the donor’s right half of the liver is donated during an adult – to – adult liver transplant. Liver’s bloodless division into right and left has now become possible because of latest techniques and gadgets. A living donor can now easy donate his liver safely as the remaining left side grows back to around 80 percent of liver’s original size in few weeks and quite close to the original size within few months. The ratio of risk in liver donation is even lower than 1:200.

4. It is mandatory that the donor should be a psychologically-sound adult who is well aware to take any sort of decision.

Specialists


Dr. Arvinder Singh Soin
Dr. Kancherla Ravindranath
Dr. Neelam Mohan
Dr. R. V. Raghavendra Rao
Dr. Sanjay Singh Negi
Dr Shamsudin Mohamed Rela
Dr. Subash Gupta
Dr. Vinay Kumaran
Dr. Vivek Vij
Dr. Geeta Billa
Dr. Rajasekhar Perumalla


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