Liver Transplant - Procedure, Surgery, Problems and Recovery

Liver Transplant is a surgical procedure to replace a diseased liver with a healthy liver. A hepatologist and gastrointestinal surgeon along with other professional medical staff performs a liver transplant surgery. It usually takes about 8 to 14 hours to complete.

It has a high success rate. According to the National Institutes of Health, currently, over 1,800 liver transplants are performed in India annually.

A liver transplant is a surgical procedure performed to replace a diseased liver with a healthy one from another person. There are several types of liver transplant procedures. However, the most common types vary based on the person who has donated the liver. These include:

1. Living donor liver transplantation: The procedure replaces a diseased or damaged liver with a portion of a healthy one from a living donor. Anyone can be a living donor, be it the spouse, parents, siblings, grandparents, children, or friend of the recipient. 
2. Deceased donor liver transplantation: It is also known as cadaver liver transplantation. It involves removing a healthy liver from a recently deceased person and transplanting it into a patient with a damaged liver. 
   

Anatomy and Physiology of Liver

The liver is the largest organ of the human body and is reddish-brown in appearance. It weighs about 3 pounds (1.4 kg). It is the only organ in our body that can regenerate.

It 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

Liver transplant surgery is generally recommended for patients who are at end-stage liver disease. Additionally, it helps treat the following conditions:

1. Liver hepatitis
2. Autoimmune hepatitis
3. Biliary Atresia
4. Alcoholic liver disease
5. Liver cirrhosis (Cryptogenic Cirrhosis and Graft Cirrhosis)
6. Liver cancer
7. Bile duct cancer
8. Metabolic diseases such as Hemochromatosis, Tyrosinemia, and Wilson’s Disease

A doctor generally recommends liver transplants to patients who have significant complications due to end-stage chronic liver disease. A liver transplant procedure is needed in the case of:

1. Alcoholic cirrhosis (alcohol-induced liver disease)
2. Primary biliary cirrhosis
3. Liver cancers, such as hepatocellular carcinoma and hepatoblastoma
4. Chronic infections like hepatitis B or C
5. Thrombosis (blood clots in veins or arteries)
6. Metabolic disorders related to liver failure like Wilson’s disease
7. Biliary atresia (a congenital disability that blocks the bile ducts)

Liver transplantation is a rigorous procedure that involves the following steps: -

1. Registration of the liver donor and the recipient
2. Shortlisting of the recipient based on the emergency, health condition and availability of the donor's liver
3. Undergoing the liver transplant procedure

The procedure is done under general anaesthesia to keep the patient comfortable. A gastrointestinal surgeon and other professional medical staff perform this procedure. The procedure steps involved in liver transplants in adults and paediatrics liver transplants are different.

However, the following are the general steps involved during liver transplant surgery:

1. Firstly, an anaesthesiologist induces general anaesthesia. 
2. The surgeon will then check the vital measures of the patient, such as the heart rate, oxygen concentration, and blood pressure throughout the procedure.
3. A thin tube called a Foley catheter will also be inserted into the urethra. It helps in urine excretion during surgery.
4. Once the patient is stable after administering the anaesthesia, the surgeon conducts the liver transplant procedure.
5. The surgeon will make a long incision across the stomach to access the liver. The location and the size of the incision will vary according to the surgeon's approach and the anatomy of the recipient.
6. The surgeon will then remove the liver and place the donor's liver. 
7. Then the surgeon will connect the blood vessels and the bile ducts to the donor's liver.
8. Once the new liver is in place, the surgeon will then close up the incision through stitches or staples.

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 Liver Transplant

The doctor will recommend tests. It is for evaluating the suitability and getting clearance for a liver transplant. Some of the tests that include the transplant evaluation process are: 

1. Blood tests
2. Imaging studies (X-rays, ultrasound, MRI) 
3. Pulmonary fitness test
4. Cardiac test
5. Multidisciplinary clearance
6. Social and psychological evaluation to determine if the patient is fit for surgery and can take the stress of surgery.
7. Dental exams, comprehensive heart and lung tests, and liver biopsy.
8. Women may undergo mammograms, Pap tests and general gynaecological examinations.

Once the patient is qualified, the doctor will explain the complete liver transplant procedure in detail to the patient and the donor. The doctor will ask the patient and the donor not to eat or drink anything after midnight before the surgery.

On the Day of the Liver Transplant

The patient may expect the following on the day of surgery:

1. The patient must reach the hospital before the scheduled time for surgery. 
2. The doctor will ask the patient to sign the consent form that allows the doctor to perform the liver transplant surgery. 
3. Once done, the patient must change into the hospital gown. 
4. The doctor or nurse will administer anaesthesia and sedatives to keep the patient calm and sleep during the surgery. 
5. Then, the patient will be shifted to the operation theatre, where doctors will perform the surgery.

The following things can be expected after the liver transplant procedure:

The Recovery Process at the Hospital

1. Post-surgery, both the donor and the recipient will spend the first night in intensive care under close observation and then be moved to the hospital ward so that they can recover.
2. Various tubes will be installed in the body after the surgery, which will be removed over time:
   1. IV lines (a soft, flexible tube placed inside a vein) in the arm or the neck to give the fluids and medications.
   2. Tubes in the stomach and the abdominal cavity drain fluids.
   3. A catheter in the bladder to drain urine.
3. The patient is prescribed anti-rejection medicine just after the surgery.
4. Antibiotics, painkillers and other medications are also prescribed during the recovery at the hospital.
5. The patient would have to stay in the intensive care unit for a few days to check for the recovery and functioning of the new liver.
6. The patient is usually discharged 7 to 10 days after the procedure depending on the patient's stability.

Recovery Process/Expectation After Hospital Discharge

1. All the instructions provided by the surgeon at the time of discharge need to be followed by the patient strictly.
2. The doctor prescribes antibiotics, painkillers, and immunosuppressants (to prevent the immune system from attacking the new liver) for the patient.
3. The doctor reduces the dose and frequency of medications once the patient starts recovering.
4. The patient is advised to take a healthy diet and practice a healthy lifestyle.
5. Avoid intake of alcohol to reduce the risk of liver disease recurrence.
6. The patient will be able to join work three months after the surgery.
7. Several patients experience a lack of sexual desire before the transplant. Such patients may require time to get their libido (desire for sex), returned after the surgery.
8. The patient should start exercising a few days a week during recovery.
9. The patient should visit the doctor for regular checkups.

First Follow-up Appointment

The follow-up appointments may be as follows:

1. The patient will have his/her first follow-up with the doctor after a day of discharge.
2. The liver transplant team will design a regular check-up schedule for the patient with the doctor.
3. The patient will have his/her second follow-up after a week of discharge. The doctor may perform blood tests to assess the recovery on a follow-up visit. 
4. The patient can return to the normal routine and work after a few months of liver transplant surgery. However, the recovery duration will vary from person to person and depends on how ill the patient was before the surgery for a liver transplant.

A liver transplant is a life-saving procedure that saves the lives of several people around the world. The success rate of the liver transplant is high and offers positive hope to patients with liver disease. Below mentioned are some of the benefits of liver transplantation.

1. Most liver transplant patients live longer
2. Better quality of life
3. Less chance of dying from liver disease
4. Development of extra energy
5. More likely to return to normal activities such as work and travel

Like any other surgery, a liver transplant is not free of risks. The common risks and complications of liver transplant are mentioned below:

1. Bleeding from the surgical area
2. Blocked bile ducts or leakage of bile
3. Blocked blood vessels to the new liver
4. Non-functioning of the new liver for a short time immediately after the surgery
5. Breathing difficulty
6. Side effects of immunity – suppressing medicines
7. Stroke or heart attack
8. Liver transplant rejection

When is Consultation with the Doctor Needed?

The patient must contact their surgeon if he/she experiences the following:

1. Fever (a sign of infection or rejection)
2. Vomiting 
3. Diarrhoea
4. Bleeding from the surgical area
5. Swelling, redness or drainage from the surgical site
6. Jaundice
7. Drainage from the surgical site

Delayed liver transplant surgery can worsen the underlying liver disease. It will accelerate the condition, leading to more severe symptoms and complications. If a liver transplant procedure gets delayed, it can lead to the following:

1. Damaged to the point where it cannot perform its normal functions properly.
2. End-stage liver damage or failure. The stages of liver failure include inflammation, fibrosis, and cirrhosis.
3. Cancer in the liver may also spread to other organs, which can eventually lead to death. 

The cost of a liver transplant ranges from ₹15,00,000 to ₹35,00,000. The cost varies based on the following factors:

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