Meaning, Types, Procedure & Risk Factors Of Liver Transplant Surgery

A liver transplant is a surgical procedure that removes a failing liver and replaces it with a healthy liver from a deceased donor or a piece of a healthy liver from a living donor. The liver is the only organ in the human body that can regenerate itself. Following surgery, the donor’s liver will shortly regain its normal size. The portion that is donated to the patient will also reach its full size in a few weeks.

A liver transplant is a life-saving procedure that can help restore a person’s life. Individuals who need liver transplants are very ill and have no other options for treatment. They could be suffering from end-stage liver disease, acute liver failure, or liver cancer. There are a lot of patients on the liver transplant waiting list.

Types of liver transplant

There are three primary methods for doing a liver transplant:
Deceased organ donation: This entails transplanting a liver retrieved from a recently deceased person.

Living-donor liver transplant: The liver can regenerate; thus, both the transplanted segment and the remaining portion of the donor’s liver can regrow into a normal-sized liver.
Split donation: A recently deceased individual’s liver is split into two parts, each of which is transplanted into a different patient, where they will develop into normal-sized organs.

Who needs a liver transplant operation?

The liver is a vital organ of the human body, and it is not possible for one to live without it. There are many critical functions that this organ performs, like the metabolism of toxins, clearing out waste, and synthesising proteins and enzymes. If your liver fails to function properly, then you may need a transplant.

You might need liver transplant surgery if you have end-stage liver disease, which is a potentially fatal condition. Many liver diseases may be the cause of it.

Cirrhosis is a prevalent cause of liver failure. It is a type of chronic liver disease that occurs when normal liver tissue is replaced by scar tissue. This prevents the liver from functioning normally.

Hepatic transplantation is normally used as a last resort. Donor livers are in high demand, and even if you acquire one, the transplant may not necessarily cure the underlying condition. Certain chronic liver illnesses will simply continue to wreak havoc on the new liver. But, because these diseases advance slowly, beginning anew with a healthy liver can buy time.

Other serious medical conditions that may need a liver transplant include:

• Acute hepatic necrosis happens when the liver tissues die. This could be caused by drug toxicity, bad reactions to medicines, or other toxins.
• Primary liver cancer, or hepatocellular carcinoma.
• Metabolic liver disease is where fat within the liver cells causes inflammation and injures the organ.
• Hepatitis B or C are caused by viruses.
• Autoimmune hepatitis is a type of liver inflammation caused by your immune system mistakenly attacking your liver.
• Biliary atresia is the blockage of the ducts that carry bile. This is a rare condition that is usually observed in newborn babies.
  You may qualify for a liver transplant surgery under the following conditions:
• A liver transplant may help you live a better life.
• You don’t have any chronic diseases that are beyond treatment, and you aren’t too sick to survive the transplant procedure.
• All other medical or surgical options have either failed or are not appropriate for that patient.
• The risks associated with receiving a liver transplant are known to you and your support networks (family and friends).

Who is not a candidate for liver transplant surgery?

You may be disqualified for a liver transplant operation because of the following issues:

• Obesity
• Active alcohol or drug use problems
• Severe, uncontrolled, and irreversible medical condition or infection
• Cancer that has spread beyond the liver
• Severe pulmonary hypertension
• Other organ failure that will not improve with a transplant
• History of non-compliance or inability to follow through on a prescribed course of treatment
• Severe psychiatric disorder

Tests to determine candidature for a transplant

Psychological and social support evaluation: A wide range of concerns are evaluated. Stress, money worries, and the prospect of receiving support from loved ones or friends following surgery are a few of them.

Blood tests: These laboratory tests establish your blood type, clotting ability, and liver function, as well as screening for conditions that might exclude you from receiving a transplant. These tests are performed to aid in identifying a suitable donor match and determining your placement on the waiting list.

Diagnostic tests: These can include a wide-range of tests like a computed tomography (CT) scan, a liver biopsy, doppler ultrasound, echocardiogram, pulmonary function study, colonoscopy, and dental exams. For women, there may be additional tests like a pap smear, a mammogram, and a complete gynaecology exam.

How long does it take to get a new liver?
You will be added to the waiting list if you are a viable liver transplant candidate. People are classified based on their blood type, body size, and severity of their medical condition. Three simple blood tests are used to assign a priority score to each patient (creatinine, bilirubin, and INR). For adults, the score is referred to as the MELD score (model of end stage liver disease) and for children, the PELD score (paediatric end stage liver disease) is used.

The highest-scoring patients are transplanted first. The sickest patients can receive transplants first because as they get sicker, their scores will rise and their priority for transplants will rise as well. It is difficult to predict how long a liver will take to become available. Your transplant coordinator is always accessible to discuss your position on the waiting list. The best course of action would be for you to talk with your doctor about what you can do to prepare for the upcoming surgery while you await the new liver. You can also start learning about how to care for a new liver.

Choosing the right transplant centre
Because you will undergo a life-altering surgery, ensuring that you choose a verified and reliant healthcare provider for this surgery is essential. It is critical to learn about the various transplant centres in your area before deciding on one.

Here are some points to keep in mind:

• The repute of the centre/hospital, mortality rates, technical expertise, and medical team.
• Whether or not the centre/hospital accepts your insurance.
• The convenience of travelling to and from the patient’s residence.
• Whether or if the centre specialises on living donor transplants or deceased donor organ transplants.
• Talk with multiple doctors and patients who have had transplants at the centre to hear about their experiences.
• The extent to which the centre/hospital has dealt with transplant cases.

How long can one live without a transplant?

It is impossible to determine whether someone with acute liver failure will ever recover. Those who do not recover could pass away within days. Chronic liver failure or cirrhosis develops over time. Although it is possible for people to survive with cirrhosis while awaiting a liver transplant for months or even years, the necessity for one increases when problems like portal hypertension start to appear.

If you’re awaiting a liver transplant to treat primary liver cancer, the disease could still be in its early stages. Liver transplant surgery is also the only course of treatment for liver cancer if it has not spread beyond the organ. Nevertheless, chronic liver disease is also present in most persons with primary liver cancer. So, the chances of being alive depend on case to case.

What happens during the transplant surgery?

A hospital stay is required for liver transplant surgery. Certain protocols may differ depending on your situation and the procedures of your healthcare provider. The surgery can take anywhere from 6 to 12 hours.

A liver transplant entails removing and preparing the donor liver, removing the damaged liver, and implanting the new organ. The liver has numerous essential linkages that must be restored for the new organ to get blood flow and empty bile.

Throughout the surgery, you will be sleeping due to general anaesthesia. With this type of surgery, surgeons place several tubes in your body to perform specific activities while you are unconscious.

To access your liver, one lengthy incision will be made across your abdomen. The liver will be carefully detached, and any blood veins or bile ducts attached to it will be clipped. The new liver will then be implanted and connected to your bile ducts and blood vessels. Then the surgeon will stitch up your incision, and you will be taken to the critical care unit.

After surgery
Once you’re in the intensive care unit, you will be hooked up to monitors that will keep track of your vitals like heart rate, breathing rate, and blood pressure. You will most likely be in the hospital for a week to two weeks.

You will be breathing with the help of a ventilator, which will regulate the amount of oxygen you take in. The breathing tube will be attached until it’s evident that you can breathe independently again.

A tiny plastic tube may also be put via your nose into your stomach to expel any air that you swallow. As your bowels return to normal function, the tube will be removed. Once the tube is removed, you will be unable to eat or drink.

Your new liver will be regularly examined using blood samples. Your kidneys, lungs, and circulatory system will also be monitored to ensure that they are all functioning properly.
Your blood pressure, heart, any bleeding issues, and pain will all be managed with IV infusions. These drips will gradually be reduced and stopped as your condition improves.
Antibiotics will be administered to you to ward off infections, along with immunosuppressants (also known as anti-rejection drugs). The anti-rejection drugs are essential because they help the new liver acclimatise to your body.

Once your condition seems stable, the breathing and stomach tubes will be removed, and you can begin drinking liquids. You will also gradually resume eating solid foods under the doctor’s supervision

Depending on your recovery and how stable your condition is, you will be shifted to a regular ward. You will be encouraged to move and walk around because movement is also essential for quicker recovery. More solid foods will be introduced into your diet.

Eventually, you will be fit for discharge, and your doctor will give you a complete overview of how to care for yourself at home. It is best to have the help of a carer until you are completely fit and fine.

Surgical risks of a liver transplant operation

The following are the most serious risks associated with the procedure:
Blood clots: Liver transplantation is a more involved procedure, and the longer you are on the operating table, the more likely you are to develop blood clots. The danger remains below 5%.

Haemorrhaging: The liver can bleed profusely, particularly if you have a blood clotting condition caused by liver injury. Liver surgeons anticipate this and frequently employ automatic blood transfusion technologies.
Bile duct injury: Damage during surgery could cause poisonous bile to flow into the abdominal cavity. Scar tissue can form where your bile ducts were damaged after surgery, causing a stricture or obstruction. As a result, the bile backs up into your liver.
Infection: This is a risk with any surgery, not just with liver transplant.
Possible complications
The risks of a liver transplant include organ rejection, increased vulnerability of  infection, graft failure, biliary problems, and a higher chance of contracting certain diseases, such as some forms of cancer.
Organ rejection: The term “rejection” refers to organ malfunction induced by the immune system’s reaction to the transplanted organ. That usually happens in the weeks or months following a transplant. Most cases of rejection can be successfully treated by adjusting the immunosuppressant dosage.

Infections: Immunosuppressive medications can make you more susceptible to infection. Do everything you can to lower your chances of contracting any type of infection. As a precaution, you may be prescribed antiviral, antibiotic, and/or antifungal medicine for a few months following your transplant to lower your risk of infection.

Biliary problems: Most transplant patients will experience biliary tract problems, such as a bile leak or a blockage produced by scar tissue in the bile ducts. If you have a bile leak, it may be necessary to remove the bile from your abdomen with a drainage tube. Bile duct obstructions are frequently treated by endoscopy, which involves inserting a short tube called a stent to allow bile to flow more freely. In some cases, additional surgery is required.

Kidney failure: Kidney failure has been identified as a prevalent side effect of immunosuppressant use in liver transplant recipients. Kidney failure occurs when the kidneys cease to function and are unable to filter waste materials from the blood. There are physical indicators of kidney failure, but your doctor will monitor your kidney function in your post-surgery consultations.

Graft failure: Graft failure means the transplanted organ does not function properly. It’s one of the most severe side effects of a liver transplant. The most common reason is a clot in the blood flow to the transplanted liver (thrombosis). Graft failure can occur suddenly or gradually over time. The body can be temporarily stabilised with medication, but the only effective treatment is another immediate liver transplant.

Cancer: People who have undergone a liver transplant surgery are susceptible to developing cancers like cervical cancer, melanoma, and non-melanoma skin cancer. They can also be prone to post-transplant lymphoprolipherative disorder (PTLD), which is a rare kind of cancer that only affects transplant recipients.

Living with a liver transplant

Although recovering from a liver transplant can take time, most patients can ultimately resume most of their regular activities and enjoy a good quality of life. Recovery can take up to a year, but you should be able to reach there slowly and steadily.

Being there for your scheduled follow-up appointments and doing as your doctor has advised are the most important part of recovery.

Taking immunosuppressants is important and you will have to take them throughout your life. These drugs ensure that your immune system does not reject the new liver and attack it. The doses will be regulated and adjusted by your medical team.
Ensuring that you get enough exercise, and that your diet is a balanced one, is also crucial. Maintaining a healthy weight will keep your liver healthy too.
If your liver damage was a result of drinking an excess of alcohol, then abstaining from it is highly recommended. Your doctor is likely to advise you avoid alcohol for life in this case.
It’s also a good idea not to consume alcohol if your liver disease wasn’t caused by alcohol, however in some circumstances it’s okay to do so in moderation.

Liver transplant cost

Compared to other countries, a liver transplant surgery costs significantly low in India. Yet, there are no differences in the facilities, level of service provided by the medical staff, hospitality, surgical skill, or success rates.

The average cost of a liver transplant in India would fall between INR 20 lakh and INR 30 lakh. This encompasses the pre-transplant evaluation, the procedure, and the recuperation time following the surgery.

However, this comparison does not imply that undergoing the surgery, and undertaking additional costs will not be expensive for the patient and their family.

So, checking your health insurance coverage to ensure that liver transplantation and prescription medications are covered. This is since you will require numerous prescription medications following the surgery and for the rest of your life.

Several factors influence the cost of an organ transplant:

• Costs for organ recovery and transportation
• Infrastructure and technology at the hospital
• Surgical expertise and their team
• Availability of advanced tools and techniques
• Duration of hospital stay and the type of chosen room
• Any other medical issues
• Recuperation and rehabilitation time
• Medicine for post-transplantation

Patients who do not live near the hospital or have travelled from another city for the transplant must consider the expense of their commute and stay. Most patients and their families choose to find a short-term rental home near the hospital. These expenses can quickly build up over the course of a few months, and should also be taken into consideration while evaluating the total costs.