Liver Transplant & HPB Surgery

 

Evaluation and preparation for liver transplant

The preparation starts with recipient's evaluation. Once the patient is found suitable for transplantation, any potential donors in the family should have their blood group checked and one who is compatible should undergo donor evaluation. If the donor is suitable, authorisation committee clearance is obtained and transplant scheduled. Patients planned for a living donor liver transplant can generally undergo the same in about 2-3 weeks.

 

Once ESLD is diagnosed and need for a transplant is perceived, patients undergo a formal evaluation, which involves blood tests, CT and other scans, tests for heart, lungs and other organ systems and assessment by various specialists. Evaluation is performed with the following goals:

To establish the diagnosis and find the cause of cirrhosis / ESLD

To determine the severity of liver disease and its effects on other organ systems such as kidneys, lungs, etc. and thus determine urgency of transplant

To actively look for liver tumour

To evaluate the condition of other organ systems such as heart, lungs, kidneys, etc. and determine patients' ability to tolerate this major operation

To evaluate difficulty, technical feasibility and risk of surgery (previous abdominal infections, surgery, thrombosis of liver blood vessels)

Evaluation generally takes about 7-10 days and is done on outpatient basis.

 

A living donor should meet the following criteria:

• Compatible blood group with the recipient
• A family member (wife, husband, mother, father, brother, sister, son, daughter, grandfather, grandmother, grandson, granddaughter) or close relative of the patient
• We do not accept family friends, well-wishers, staff or neighbours as donors
• Age group 18-55 years
• Should not be overweight, because people who are overweight may have fatty liver
• The donor liver should be large enough to provide adequate volume for the recipient (patient) as well as for the donor
• Donor should be in good overall physical and mental health and undergo a thorough medical and psychological evaluation and volunteer for donation after fully understanding the risks of surgery
• The decision to donate can be changed at any stage of the evaluation, before or after the tests are done or any time before the surgery.

Evaluation

Donor evaluation takes about 7-10 days and are done on an outpatient basis, commonly along with the recipient evaluation. Donors usually undergo liver function tests, liver volumes, tests to evaluate other organ in first phase. Few donors might need a biopsy to study liver quality in more details, where a tiny piece of liver is examined under a microscope.

When potential donors are rejected, it can be stressful for the family, but this is done for the safety of the donor and success of transplant, an alternative donor should then be identified. Both the patients and donors emotional health and willingness for transplant is important for the operation and they would be counselled by a psychologist during Evaluation.

Authorisation committee clearance

All patients planned for living donor transplant need clearance by the government appointed authorization committee. Our administrative staff will help patients and their families understand and prepare various legal forms, affidavits and supporting documents. The transplant team is independent of the authorisation committee and cannot influence its decision. All cases who have completed both patient and donor evaluations are reviewed by the multi-disciplinary transplant team, where their suitability for transplant is discussed and tentative date for transplant decided. The transplant is scheduled only after clearance by the authorisation committee

• Financial arrangement

  Liver transplant is offered as a package at our institute. It includes pre-transplant workup fee, operation charges and life-long consultation charges for both patient and the donor. The pre-transplant coordinators will explain expected expenses at various phases, mode of payment, inclusions and exclusions of the package. Patients with additional risk factors such as kidney or cardio-respiratory problems, those expected to undergo a complex operation, need prolonged ICU care or hospitalisation might be offered the high-risk package. Patients undergoing combined liver-kidney transplant, dual lobe transplant, ABO incompatible transplant or have hepatitis B or other diseases require use of additional expensive medicines, they should discuss the package applicable to them with the pre-transplant coordinator.

  Patients whose expenses for transplant and post-operative medical care will be borne by insurance company, employer or embassy should discuss the same with the patient financial liaison or TPA helpdesk, who will guide patients with required paperwork. Some insurance companies only pay part of the package and the remaining amount has to be arranged by the patients' family.

  What if a patient does not have a suitable living donor?

  Patients who do not have a suitable living donor or are unlikely to get a deceased donor transplant in time for their disease severity might benefit from one of the following innovative procedures.
  
  

  Swap transplant

  When one of patient's family members is suitable and willing for donation, but is not a good match for the patient, a paired donation or swap transplant may be considered. In this type of transplant, two families with suitable living donors exchange their donors because they are not a good match for their own patient, but are appropriate for each other's patients. Both transplants are performed simultaneously and therefore can only be done by a large experienced transplant team after careful planning.

  Dual lobe liver transplant

  When a potential living donor's liver volume is found inadequate for the recipient on pre-operative CT scan, they may be rejected and another donor evaluated. It is common that in one family two or more people might have been rejected for donation each because of low liver volumes, who were otherwise suitable. If partial livers from both donors are combined; it is often adequate for the patient. In such a transplant, three operations (one recipient and two donors) are performed simultaneously.

  ABO incompatible (ABM) transplant

  Generally, liver transplant is performed with blood group compatible donor livers, because ABO (blood group) incompatible transplantation triggers production of antibodies against the transplanted liver causing organ rejection. However, if some special immunosuppressive medicines and measures are used, antibody levels can be reduced before transplant and organ rejection prevented.

  Deceased donor transplant

  Once recipient evaluation is completed and patient is found medically fit for transplant, the prescribed forms have to be completed and submitted through the hospital to the state-wide appropriate authority for registering their names on the waiting list for a deceased donor transplant.

  When a potential deceased donor liver is available, patients are alerted immediately and called to the hospital. While one team prepares the patient for transplant, another team retrieves the donor liver. The liver is carefully checked for its suitability for transplantation. Livers from donors may be considered high risk if they had previous hepatitis B or hepatitis C infection, had risk factors for HIV infection, had active infection or cancer. Patients should discuss the quality of liver and associated risks with the transplant team before accepting or rejecting it. If the transplant team finds the liver unsuitable, the donor family withdraws their consent to donate or for any other reason the transplant is cancelled; patients will have to return home and continue waiting for the next offer. While such "false alarms" could be stressful, these decisions are always taken in the interest of patient safety and to optimize chances of a successful transplant.