Orthotopic Liver Transplant in Delhi, India

Orthotopic Liver Transplant is indicated in people with acute or chronic liver disease that cannot be treated with non-surgical treatment or alternative forms of surgery. It can be done in both adults and children. The most common indications are:

• Liver cirrhosis          
• Cryptogenic 
• Alcohol-related
• Hepatitis B and Hepatitis C
• Cholestatic liver disease
• Primary biliary cirrhosis (PBC) or Primary sclerosing cholangitis (PSC)
• Non-cholestatic liver disorders
• Chronic HBV infection, autoimmune hepatitis, or cryptogenic
• Metabolic liver disease
• Alpha-1-antitrypsin deficiency, Wilson's disease, hereditary hemochromatosis, or Crigler–Najjar syndrome
• Acute liver failure
• Primary malignancies of the liver
• Hepatocellular carcinoma, hepatoblastoma, or hilar cholangiocarcinoma
• Budd-Chiari syndrome

Ideal candidates are those with a confirmed diagnosis of end-stage liver failure. Any other mode cannot treat it. Some other factors that influence patient selection are:

• The patient should be less than 65 years of age.
• May have a history of alcoholism deformed

Have been diagnosed with:

• Liver cirrhosis
• Cryptogenic
• Alcohol-related liver disease
• Viral
• Cholestatic liver disease
• Metabolic liver disease
• Acute liver failure
• Liver tumours

 Certain donor requirements include:

• A family member of the recipient (not necessarily)
• Good health (General)
• Blood type must match the recipient. However, with immunosuppressants, blood group incompatible transplants can be performed.
• The donor should be willingly donating their liver.
• The age of the donor should be between 18 and 55 years.
• The donor should be willing to undergo a complete body checkup and scans to ensure a healthy body and organs.
• Should not have any current communicable disease or cancer.

The contraindications to liver transplant can be divided into absolute and relative contraindications:

1. Absolute contraindications

• AIDS
• HIV positivity (for urgent transplants)
• Age >70 years
• Active non-hepatobiliary infections
• Active drug addiction (abstinence of <6 months)
• Active alcohol abuse 
• Severe psychiatric disease
• Extrahepatic neoplastic disease
• Metastases from a primary tumour
• Documented decerebration

1. Relative contraindications

• The age of the recipient is between 60 and 70 years
• HIV positivity
• Portal vein thrombosis
• Cardiological and/or anesthesiological risk
• Probability of poor compliance (reflected by logistic, family-related, psychological, and/or reliability issues)

Firstly, eligibility tests of the donor and recipient are carried out by performing several full-body checkups. A complete body assessment helps doctors identify any pre-existing medical conditions that may play a significant role during or after the transplant procedure. All the risks and complications, along with the benefits of the operation, are explained to the patient, and consent for the same is obtained. 

The goals of the assessment process are to determine that the recipient is:

• Healthy enough to tolerate the procedure medications
• to assess any systemic conditions that might interfere with the success of the transplant.
• The donor should be willing to take medications as directed and follow the suggestions of the transplant team.

Specific tests, procedures, and consultations that may be advised are:

• Lab blood and urine tests
• Imaging tests
• Tests of the heart to determine the health of the cardiovascular system
• A general health exam, such as routine cancer screening tests, to evaluate the overall health. Also, to check for any other illnesses that may impact the success of the transplant.

The evaluation may also include the following:

• Nutrition counselling: To discuss pre-and postoperative meals
• Psychological evaluation: To assess the patient's mental health.
• Meetings with social workers: Meet with friends and relatives to ensure that the transplant is not forced upon and is solely happening at the individual's discretion.
• Addiction counselling: To evaluate any unhealthy habits and eliminate or control them. Also, its effects on transplant treatment shall be discussed.
• Financial counselling: To be prepared for the expenses involved in the entire procedure before and after the transplant.

After the tests and evaluation are completed, a meeting with the transplant and ethics committee of the transplant hospital is scheduled, where the donor and recipient families are questioned to prevent any forceful and criminal acts. Once the committee is satisfied, the patient is placed on the transplant waiting list.

• Pre-surgical Phase

Before the transplant surgery, liver-support therapy might be indicated. Virtually all liver transplants are done using the orthotopic technique. 

• Anaesthesia 

Patients are anaesthetized to provide excellent pain control in the immediate postoperative period and permit the minimization of general anaesthetic during the procedure. The anesthesiologist administers general anaesthesia for the entire duration of the surgical procedure.

• Surgical Phase - 

The transplant operation can be divided based on the presence of the liver in the body: 

1. Hepatectomy phase: removal of the liver
2. Anhepatic phase: No liver phase
3. Postimplantation phase: After the transplant 

The operation is done through a cut in the upper abdomen. The hepatectomy requires dividing all the ligamentous attachments to the liver, common bile duct, hepatic artery, vein, and portal vein. Most of the time, the retrohepatic portion of the inferior vena cava is taken out along with the liver. An alternative technique, however, preserves the recipient's vena cava.

An ice-cold organ preservation solution replaces the donor's blood in the liver until the allograft liver is implanted. Implantation includes the connection of the inferior vena cava, hepatic artery and portal vein. The bile duct is formed after the blood flow is restored to the new liver; it is done by joining it to the recipient's bile duct or the small intestine. 

The surgery would require at least eight to ten hours. Sometimes it may be longer or shorter depending on the difficulty of the procedure.

Most liver transplants utilise the entire liver from a non-living donor for the transplant, specifically for adult recipients. However, in India, due to low decreased donations, LDLT is common in which a part of the liver is taken from a healthy liver. A major advancement in paediatric liver transplantation is the development of reduced-size liver transplants. A portion of an adult liver is transplanted in an infant or young child.

Cooling

Between the removal of the liver from the donor to its placement in the recipient, the liver is stored in a temperature-cooled preservation solution. The reduced temperature delays the process of deterioration from normal metabolic processes. The storage solution is specifically designed to counteract the unwanted effects of cold ischemia. 

Closure 

The skin is finally closed with absorbable sutures.

Pain management 

Pain medication is prescribed at the surgeon's discretion and depending on the patient's pain level and ability to tolerate it. It is suggested that weaning the patient from the pain medication should begin a few days after the operation.

Some of the complications associated with liver transplant surgery are:

• Acute or chronic rejection of the liver
• Intraoperative death (due to massive haemorrhage, hemodynamic imbalance, arrhythmias, cardiac arrest, stroke, graft dysfunction)
• Extrahepatic infections: bacterial, viral, fungal, parasitic
• Gastrointestinal complications: gastrointestinal bleeding, pancreatitis, intestinal perforation
• Cardiovascular complications: myocardial infarction, and arrhythmias
• Cerebrovascular complications: intracranial haemorrhage, ischemic stroke, cerebral oedema encephalitis
• Tumours: De novo hepatic or non-hepatic tumours, tumours transmitted by the donor, lymphoproliferative disease
• Urinary-tract complications: renal failure (acute and chronic), urinary tract infection
• Pulmonary complications: pulmonary embolism, acute respiratory distress syndrome, pneumonia 
• Social complications: Non-compliance with the immunosuppressant regimen, psychosocial adaptation difficulties, suicide
• Bone-marrow depression
• Multi-organ failure

Orthotopic Liver Transplant is a major procedure and requires immense postoperative care. Some of the points that may help are as follows:

• Joining liver transplant support groups on social media or those in the same locality may help share experiences and the do's and don'ts before or after the surgery.
• Connecting with rehabilitation services 
• Setting realistic goals for nutrition and exercise management. Unfollowing unhealthy habits may be the first step towards a better tomorrow.
• Regular intake of immunosuppressant drugs as advised by the doctor.
• Regular follow-up with the liver transplant team to ensure timely investigations and good compliance with immunosuppressive drugs.

•  you need to know about liver transplantation
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• Can Hepatitis C Be Cured by a Liver Transplant?
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• Tips To Take Care of Your Liver
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