Deceased Donor Liver Transplant - Procedure and Recovery

A Deceased Donor Liver Transplantation involves surgically replacing an unhealthy or diseased liver (that no longer functions normally) with a healthy liver from the deceased donor. This is also medically referred to as Cadaver Liver Transplantation. The liver is donated from a deceased donor either after brain death or circulatory death.

1. Donation after Brain Death (DBD) donors: Approximately 75 out of 100 livers donated by deceased donors are from the donors whose brain stops working and are declared brain dead.
2. Donation after Circulatory Death (DCD) donors: Approximately 25 out of 100 livers donated by deceased donors are from the donors whose heart stops working and are declared circulatory dead. This type is a newer process of liver transplantation

Anatomy and Physiology of the Liver

The liver is the largest internal organ in the upper right quadrant of the abdominal cavity, above the stomach and beneath the diaphragm. The weight of the liver is about 1.4 kg and is reddish-brown in appearance. The liver comprises two lobes which are further subdivided into 1000 small lobes. These small lobes are associated with small ducts. Different small ducts connect with a large duct known as the common hepatic duct. The hepatic duct carries the bile synthesised by the liver to the gall bladder and intestine.

The liver performs over 500 vital functions. Some of the essential functions of the liver include:

1. Bile synthesis
2. Synthesis of plasma proteins and cholesterol
3. Storing of glycogen
4. Regulating serum amino acid levels
5. Helps in blood clotting

A deceased donor liver transplant is nowadays a routine procedure for the treatment of terminal liver failure and often represents the only chance of a cure. When a living donor is unavailable, a deceased donor liver transplant is the only option. Some of the medical conditions treated by deceased donor liver transplant are:

1. Acute liver failure
2. Chronic liver disease
3. Cirrhosis
4. Primary liver cancer 

An individual requires a liver transplant when his/her liver stops working properly. It is recommended when an individual has an end-stage liver disease that cannot be treated longer and need a replacement only. A deceased donor liver transplant is needed in the following cases:

1. Liver failure
2. Liver cirrhosis
3. Acute hepatitis necrosis ( cells in the liver die due to infection and reaction to chemicals or toxins)
4. Viral hepatitis (mainly caused by hepatitis B and C)
5. Metabolic diseases
6. Primary liver cancer
7. Autoimmune hepatitis (body immune system attacks the liver cells)
8. Biliary atresia (a rare disease of the liver and bile duct that occurs in newborns)

The deceased donor liver transplantation is a life-saving and successful procedure for patients with end-stage liver disease. The procedure takes about 5 to 6 hours to complete depending on the patient's age, his/her medical condition and other medical complications. The procedure is done under general anaesthesia to keep the patient comfortable. A hepatologist along with other professional medical staff performs this procedure. The following steps are involved in the procedure:

1. At first, the patient will be made to lie on the back on the operation table, and an anaesthesiologist induces a nerve block and/or general anaesthesia. 
2. Once the patient sedates due to the effect of the anaesthesia, the doctor will insert a tube into the lungs.
3. A thin tube called a Foley catheter will also be inserted into the urethra. It helps in urine excretion during surgery.
4. The skin at the operation site will be cleaned using a sterile antiseptic solution.
5. An incision will be made under the ribs on both sides of the abdomen. A laparoscope and other surgical instruments are administered through the incisions.
6. The surgeon carefully and precisely separates the donor liver from the nearby tissues and organs.
7. The surgeon removes the damaged liver, the doctor clamps the arteries and veins to stop the blood flow. 
8. Then, the deceased donor's liver is carefully attached to blood vessels to initiate blood flow.
9. The surgeon will then attach the bile ducts to the newly transplanted liver and check for any bleeding.
10. Later, the incisions are closed with the help of stitches and staples.
11. Finally, the sterile bandage will be applied to the incision site to prevent swelling and infection.

Deceased donor liver transplantation generally requires the patient to stay in the hospital for a few days, depending on his or her health condition. To prepare for the day of surgery, the patient must consider the following things:

Before Deceased Donor Liver Transplantation

1. The recipient will be notified about the availability of the liver from the deceased.
2. The patient will undergo various tests to determine eligibility for undergoing liver transplant surgery.
3. The recipient must inform the doctor/surgeon about all the medicines, including herbal medications and health supplements that they consume.
4. The doctor may advise the recipient to stop taking medicines like aspirin, warfarin, and other medications that make the blood thinner and make it hard to clot. 
5. The recipient will be advised not to eat anything before the surgery post midnight on the day of the surgery.
6. If any medicines are prescribed, the recipient may take them with a small sip of water.

On the day of Deceased Donor Liver Transplantation

1. The recipient should:
   1. Follow all the instructions provided by the doctor. 
   2. Leave all the valuables at home.
   3. Try to reach the hospital before the time of the surgery.
   4. Fill out a consent form before the surgery on reaching the hospital.
   5. Wear loose-fitting, comfortable clothes.
   6. Change into a surgical gown and cap before surgery.
2. The doctor will insert an IV in the arm of the patient and then he/she will be taken to the surgery room.
3. All the vital signs of the recipient will be checked before shifting to the operation theatre.
4. Once the surgery starts, the family of the patient will be informed, and the healthcare providers will update them at regular intervals about the patient’s condition. 
5. Once the surgery is performed, the recipient will be taken to a recovery room. Here the recipient will be monitored until their health condition becomes stable. 

The following things can be expected after the deceased donor liver transplantation procedure:

The recovery process at the hospital

1. After the transplant, the patient will be shifted to the intensive care unit, where medical staff will monitor the patient's vitals and recovery process.
2. Various tubes will be installed in the body after the surgery:
   1. IV lines in the arm or the neck to give the fluids and medications.
   2. Tubes in the stomach and the abdominal cavity to drain fluids.
   3. A catheter in the bladder to drain urine.
3. Over time, these tubes will be removed.
4. The doctor and nurse will monitor the condition to check for the signs of any complications.
5. Once the condition is stable, the patient will be discharged from the hospital. The doctor will prescribe medications on the day of discharge.

Recovery process/expectation after hospital discharge

1. Instructions provided by the doctor must follow at home.
2. Proper hygiene should be maintained always. Hand washing after meeting strangers should be practised, and a separate towel should be available for the patient.
3. The patient should wear a mask in the first three months following the surgery while going to the crowded area. 
4. A normal diet can be started as soon as the doctor recommends. Diet rich in protein should be consumed.
5. Plenty of water should be consumed by the donor and the recipient.
6. The dressing on the surgical area must be kept in place till the follow-up visit. It may get wet while taking a bath, but it is best to keep it dry if possible. 
7. The doctor may also recommend some regular exercise to the patients. 
8. Lifting anything heavier than five lbs. for the first six weeks after the surgery is unsafe.
9. All the medications prescribed by the doctor must be consumed regularly as per the dosage.
10. The recipient should visit the doctor for regular checkups.

First follow-up appointment

1. The first follow-up with the doctor will generally be scheduled about one or two weeks from the day of the discharge. 
2. The patient will have regular, frequent follow up with the doctor for the first six weeks after the liver transplant.
3. The doctor will monitor the condition and perform some exams, including blood tests, to monitor liver function. It is also to check for the rejection of the new liver transplant and infection.
4. The patient will be on a specific diet for the first few weeks. He/she should also avoid drinking alcohol and smoking after the transplant. 
5. The doctor might also change the medication or advise the patient to continue with the previous medication for some more time, depending on the condition and recovery of the surgical area.

Deceased donor liver transplantation is the most common type of liver transplant procedure. The benefits of this procedure include:

1. Better quality of life with a healthy liver.
2. It is a choice of treatment when living donors are not available.
3. Can transplant as a whole liver.

Like any other surgery, the deceased donor liver transplantation also has some potential risks and complications, such as:

1. High fever, chills, or flu-like symptoms
2. Rejection of the newly transplanted liver
3. Infection in the transplanted liver
4. Vomiting
5. Diarrhoea
6. Pale stool and dark-coloured urine
7. Yellow skin or eyes (jaundice-like symptoms)
8. Swelling in the tummy and toes
9. Redness and inflammation in the body
10. Reaction to anaesthesia
11. Leakage of the bile or blocked bile ducts
12. Bleeding 
13. Infection or pus at the site of operation
14. Itchy skin

When is consultation with the doctor needed?

A patient should contact the doctor as soon as possible if he/she observes any risks or complications. Risks and complications associated with the liver transplant are:

1. If there is any infection at the site of the incision.
2. Persistent high fever. This may be a sign of rejection.
3. Bleeding from the site of the incision.
4. Formation of blood clots.
5. Bile leakage: It is a rare complication. It occurs in very few cases; most of them resolve independently and do not require any treatment.

Research has found that delaying a deceased donor liver transplantation can lead to:

1. Complications of liver failure include fluid accumulation in the brain, accumulation of toxins and bleeding disorders that can worsen the complications.
2. Progression of chronic liver failure leads to an increased risk of death or permanent debility.
3. Can be life-threatening for the patient.

The cost of deceased donor liver transplantation ranges from ₹15,00,000 to ₹25,00,000. The cost varies based on the following factors:

1. Age of the patient
2. Type of the procedure done
3. Technique and equipment used
4. The medical condition of the patient
5. The type of hospital facility availed - individual room or shared.