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Summary

The liver is often called "the seat of life", which is an important organ performing vital functions of the body. When this organ is not able to function properly, it affects the body in various ways, such as digestion problems, excessive bleeding, reduced immunity and what not. Liver transplantation is a procedure where the non-functional liver is removed and a new functional liver is transplanted. The new liver can be taken from a dead or living donor. Many assessment tests are performed to see how severely your liver is diseased and whether you are medically fit to receive a new liver or not. Once you clear all the tests, your name is put up on the waiting list. You will be called by the transplant team once they find a suitable match for you. Important medical tests like blood tests, X-rays, urine tests and others will be done on the day of surgery.

A few days hospital stay is important after which proper dressing of the wound is to be done along with other measures, such as adequate rest, healthy diet, going for short walks, and so on. Medication has to be taken regularly and timely visits to the hospital are also very important to ensure the success of the transplant. A few complications may arise after the transplant, such as fever, indigestion, bleeding and in severe cases, rejection of the new liver. In such cases, another transplant surgery is required.

  1. What is a liver transplant suregry
  2. Why is liver transplant surgery done
  3. Types of liver transplant
  4. Preparations before liver transplant
  5. How is liver transplant done
  6. Post surgical care
  7. Precautions to take after liver transplant surgery
  8. Risks and complications of liver transplant surgery
  9. Follow-up after surgery
  10. Outcomes of liver transplant surgery

A liver transplant surgery is done when a person's liver gets damaged to an extent that it cannot continue and support normal functions of the body. This surgery involves the removal of the diseased liver and its replacement with a healthy one, which is taken from another person (called a donor). It is a life-saving procedure in case your liver fails or stops working properly.

Liver transplantation is done when the liver is not able to perform its functions like storage of sugar, vitamins, iron; removing harmful bacteria and lethal substances from the blood; producing enzymes, which breakdown fats; making proteins that help in the clotting of blood and so on. 

In the absence of a healthy liver, the person's health deteriorates and he/she also gets susceptible to various other infections and diseases. To avoid such a scenario, the diseased liver has to be replaced with a new one taken either from a living or dead donor. A liver transplant is also done in various medical conditions, which are discussed in this section below. 

  • The most common reason for the liver transplant surgery is the formation of scar in the cells and tissues of the liver, which is also known as cirrhosis of the liver. This scar tissue keeps building in the liver and replaces the normal tissue is replaced by the scar tissue. Cirrhosis of the affects the normal functioning of your liver and it may occur after many long-standing liver diseases.
  • Biliary atresia, a condition where scar tissue is formed in the bile ducts (ducts carrying digestive enzymes from the liver to the gut) is the most common reason for liver transplantation in children.
  • Acute hepatic necrosis, a condition of severe injury of the liver cells due to some medicines or an elevation of certain enzyme levels in the liver.
  • A liver transplant can also be used as a treatment option in cases of liver cancer.

Liver transplantation surgery is not done in certain cases, such as:

There are two types of liver transplant surgery based on the donor:

Deceased donor transplants

In a deceased donor transplant, your damaged liver is replaced with the liver of a person who has just died. In adults, the whole of the liver from the donor is transplanted whereas, in the case of children, only a portion of the healthy liver tissue is transplanted. The rest of the liver regrows in their body.

Living donor transplant

In a living donor transplant, the liver is taken from a living person and is transplanted in place of your diseased liver. Only a portion of the living person’s liver is taken because the liver is an organ, which grows itself and attains its normal size.

If your family member or spouse wants to be your living donor then the transplant team will make sure of certain things, such as taking the medical history of the donor, addictions, allergies, and so on, and to rule out the present medical problems, some medical tests will be done.

The following steps are followed before surgery is done:

  • Assessment of your body before a liver transplant
  • Waiting list period
  • Staying healthy while on the waiting list

Assessment before a liver transplant

The transplant team will carry out certain medical tests to make sure that you are fit to receive a new liver, such as:

  • Blood test
  • Urine test.
  • Tissue and blood matching to make sure that your body does not reject the new liver.
  • X-ray to get pictures of the organs inside your body.
  • Heart activity tests, such as electrocardiogram to rule out any heart diseases.
  • Evaluation of your overall health, including cancer screening.

Waiting list period

After your health is assessed by the transplant team, a decision will be made about whether you will receive a transplant or not. The transplant team will place your name on the waiting list after approval has been given. The waiting period ranges from 30 days to 5 years.

There are many factors that decide the place that you will get on the waiting list, such as:

  • How well your body will be able to cope up with the surgery?
  • How severe is the liver disease?
  • What is the cause of your liver disease?
  • Are you having any other disease or medical condition?
  • MELD score (Model for end-stage liver disease) is used for liver allocation. This score is calculated on the basis of the laboratory tests that measure the level of certain enzymes in the liver.

The preparations for your surgery will depend on the type of liver transplant you are going to have.

If you are going to receive a transplant from a deceased donor then you will be placed on the waiting list and the transplant team will call you when they find the matching liver for you. In case you are receiving a liver from a living donor then the surgery will be planned by your surgeon accordingly.

What you should do while you are on the waiting list?

As you are waiting for the new liver, you should do some simple yet important things and follow these healthy rules:

  • Eat healthy food.
  • Exercise regularly.
  • Do not smoke or consume alcohol.
  • Keep a check on your weight.
  • If you are taking medications, take them regularly.
  • Tell your doctor if you face any health problem.
  • Stay in touch with your transplant team. Your transplant team will call you when they find a suitable donor.
  • Always keep your hospital bag ready and transportation arrangements made because you will have to leave as early as possible if you get a call from the transplant team.

On the day of surgery

On the day of your surgery, the doctor may repeat certain medical tests, which were done before. These tests are done to rule out complications and make sure that you are healthy for the surgery.

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Liver transplantation is a long procedure and it may take 8 hours or longer for the whole procedure to be done. The cost of this surgery is around 35 lakhs and it is mostly done in private health care facilities. The transplant procedure is explained below:

  • Before starting the surgery, you will be given general anaesthesia (a numbing method) where you will fall asleep and won’t feel pain during the procedure.
  • If you are receiving a liver from a deceased donor then surgery will be started after the liver is made available at the transplant centre. 
  • After removal, the donor's liver is transferred into a cold saline solution (a germ-free salt solution) to preserve it. It can be kept in this solution for up to 8 hours.
  • A large cut is made across your belly going upwards towards in your chest.
  • The damaged liver will be removed and a new liver will be placed and connected to the blood vessels and bile ducts.
  • The surgeon will close the cut by giving stitches and covering it with a dressing.
  • In case you are receiving a liver from a living donor, then you and your donor will be operated at the same time. A portion of the liver will be taken from the donor and will be transplanted. The liver will grow itself and with the time, you and your donor both will be having a normal working liver.

After the surgery, you will have to stay in the ICU (Intensive care unit)  for two days. You will wake up in the ICU after the effect of anaesthesia wears off. Tubes will be attached to your nose to feed you with fluids, your mouth to help you breathe, and the operated area to drain excess fluids. These tubes will be removed after a few days. A hospital stay of at least 2 weeks duration is important.

Some other things that are advised after transplant surgery are as follows:

  • Anti-rejection medicines (Immunosuppressants).
  • After you get a new liver, you have to take some medicines throughout your life. These medicines are given so that your body does not reject the new liver.

Some side effects of these medicines are:

Since you will be on anti-rejection medicines that suppress your immune system so that your new liver doesn't get rejected, you become prone to infections. Thus, it is important that you take certain precautions and measures to ensure your body, as well as the new liver, are healthy. These include:

Maintaining hygiene

Since you will be prone to infections, it is crucial to maintain hygiene to avoid getting any infections. To ensure this, you should follow these things:

  • Always wash your hands as soon as you think they are dirty.
  • Bathe every day.
  • Wear clean clothes.
  • Avoid sexual activity with unknown partners.
  • Avoid going to crowded places. In case you have to, wear a protective mask.
  • Do not eat from outside. Wash fruits and vegetables before consumption. 
  • Do not use someone else's things, such as towels, razor, comb, clothes, utensils, and so on. 

Eating healthy

  • To keep yourself healthy while recovering, it is very important to take a healthy diet.
  • You should consume a diet which is low in salt, fat, cholesterol and sugar.
  • Consume fresh fruits and vegetables. Eat eggs, beans, legumes, fish. Take a high fibre diet and drink lots of water.
  • Avoid processed foods.

Exercising regularly  

You need to take rest once you come back home after surgery. Start gradually with simple activities like walking.

  • See your physiotherapist and do exercise as advised.
  • Sports and swimming should be avoided for some months as you might end up injuring yourself or getting an infection.

Avoiding alcohol

Alcohol should not be consumed if it was the reason for damaging the health of your liver previously. Even if the main reason was not alcohol, you should still avoid its consumption because it will damage the new liver. Doctors advice should always be taken on how much and how frequently you can consume alcohol.

Problems which can arise during the surgery:

Problems which can arise after the surgery:

During the early phase after surgery, the following complications may arise:

  • Non-functioning of the graft.
  • Rejection of the new liver.
  • Bleeding.
  • Infections.
  • Persistent jaundice.
  • High fever
  • Leakage in the bile duct

Long-term risks and complications:

  • Raised cholesterol level.
  • Risk of hepatitis B
  • Stone formation in the bile duct leading to impaired flow of bile (cholestasis).

Regular follow up visits are very important after the surgery. During these visits, the doctor may prescribe certain tests like blood tests, X-rays, ultrasound, urine tests among others to make sure that the new liver is working normally.

Contact your doctor immediately in case you get any of these:

  • High fever.
  • Vomiting.
  • Diarrhoea.
  • Pale skin or eyes.
  • Swelling in the belly.
  • Swelling in the ankles.
  • Swelling and redness around the wound.
  • Fluid coming out of the wound.

The outcome of liver transplant surgery varies from person to person and depends upon the following factors:

  • Immunity status 
    It is a very important factor, which varies from person to person. The new liver is foreign to the body and so, the immune system tends to reject or destroy it. The chances of rejection of the new liver are highest during the first 3 to 6 months of the surgery. Your doctor will prescribe you anti-rejection medicines for this. 
  • MELD Score 
    The severity of the liver disease you have also affects the outcome of the surgery.
  • General health
    If you are healthy, your body will be able to take the stress of the surgery in a better way. However, in the case of additional medical conditions, such as diabetes and high BP, the risks of rejection and infections are even more.
  • Age
    The outcome of surgery is less favourable in people of old age as compared to those who are young.

References

  1. U.S. Department of Health and Human Services. Definition & Facts of Liver Transplant. 2017 Mar. National Institute of Diabetes and Digestive and Kidney Diseases.
  2. Centre for Disease Control and prevention. The Liver. National Centre for HIV/AIDS. Division of Viral Hepatitis. 2017 Aug 18.
  3. National Health Services. Liver Transplant: Overview. NHS-UK. Health A to Z. 2018 Jan 5.
  4. U.S. Department of Health & Human Services. Definition & Facts for Cirrhosis. 2018 Mar. National Institute of Diabetes and Digestive and Kidney Diseases.
  5. U.S. Department of Health & Human Services. Biliary Atresia. 2017 Sept. National Institute of Diabetes and Digestive and Kidney Diseases.
  6. National Institute of Health. Acute Hepatic Necrosis. 2019 Jul 1. LiverTox. Clinical and Research Information on Drug-Induced Liver Injury.
  7. U.S. Department of Health and Human Services. Liver. Organ Procurement and Transplantation Network.
  8. U.S. National Library of Medicine. Liver Transplant. 2018 April 9. NIH. MedlinePlus.
  9. U.S. Department of Health & Human Services. The Liver Transplant Process. 2017 Mar. National Institute of Diabetes and Digestive and Kidney Diseases.
  10. U.S. Department of Health & Human Services. About MELD and PELD. Organ Procurement and Transplantation Network
  11. National Health Services. Liver transplant: Waiting list. 2018 Jan 5. NHS-UK. Health A to Z.
  12. U.S. Department of Health & Human Services. Liver Transplant Surgery. 2017 Mar. National Institute of Diabetes and Digestive and Kidney Diseases.
  13. Narasimhan G. Living donor liver transplantation in India. 2016 Apr. Hepatobiliary Surgery and Nutrition; 5(2):127-32. PubMed PMID: 27115006
  14. National Health Services. Liver transplant: The operation . NHS-UK. Health A to Z. 2018 Jan 5.
  15. Sauer M, Bechstein WO, Neuhaus P. Liver transplantation. 2001. Surgical Treatment: Evidence-Based and Problem-Oriented.
  16. Shah R, Savio John S. Cholestatic Jaundice (Cholestasis, Cholestatic Hepatitis). 2019 Jun 4. StatPearls.
  17. Moini M, Schilsky ML, Tichy EM. Review on immunosuppression in liver transplantation. 2015 Jun 8. World Journal of Hepatology; 7(10):1355-68. PubMed PMID: 26052381
  18. U.S. Department of Health & Human Services. Living with a Liver Transplant. 2017 Mar. NIH. National Institute of Diabetes and Digestive and Kidney Diseases.
  19. National Health Services. Liver transplant: Afterwards . NHS-UK. Health A to Z. 2018 Jan 5.
  20. American Society of Transplantation. Liver: Annual Data Report 2012. 2012. American Journal of Transplantation.
  21. Moon DB, Lee SG. Liver Transplantation. Epub 2009 Sep 30. Gut and Liver;3(3):145-65. PubMed PMID: 20431740.
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