Liver Transplant in Adults - Procedure, Benefits and Recovery

A liver transplant is considered the last resort for liver disease treatment when other non-invasive and invasive methods fail to reduce the symptoms and revive the liver to function adequately. The liver can be donated by a living donor or a deceased donor.

Anatomy and Physiology of Liver

The liver is the largest organ of the human body and is reddish-brown in appearance. The liver 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

A healthy liver is required to maintain life. A severely diseased liver may result in life-threatening complications. Liver transplantation helps treat the following conditions:

1. Alcoholic liver disease is when liver damage due to excessive alcohol.
2. Primary Sclerosing Cholangitis in which bile ducts are scarred and inflamed, resulting in bile flow obstruction.
3. Biliary atresia causes bile to accumulate in the liver and causes liver damage.
4. Non-alcoholic steatohepatitis results in fat accumulation in the liver, which does not allow the cells of the liver to function properly.
5. Metabolic diseases include Wilson’s disease, Alpha1-antitrypsin deficiency, Maple Syrup Urine Disease, and urea cycle deficiency.
6. Autoimmune hepatitis is when the body's immune system attacks the healthy liver cells and damages them.
7. Acute hepatic necrosis
8. Chronic liver failure caused due to liver cirrhosis.
9. Liver cancer

Adult patients who have the following conditions need liver transplantation.

1. Alcoholic liver disease
2. Chronic liver failure
3. Biliary atresia
4. Acute hepatic necrosis
5. Primary liver cancer

Liver transplantation is an effective life-saving treatment method and standard of care for many forms of end-stage liver disease. The procedure takes about 6 to 7 hours to complete depending on the patient's age, comorbidities of the patient and complexity of the condition. 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. Firstly, an anaesthesiologist induces a nerve block and/or 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 procedure.
5. The surgeon will make an incision across the stomach to access the diseased liver. 
6. Then the surgeon will cut off the blood vessels near the diseased or unhealthy liver. 
7. The diseased liver is carefully separated by the surgeon from the nearby organs and structures. 
8. Once done, the surgeon will either remove the part of the liver or the complete liver. 
9. Then, the surgeon will replace the removed liver with the donated liver portion (from the living donor) or the entire liver (from the deceased donor).
10. Finally, the bile ducts and blood vessels are reattached to the replaced operated liver.
11. The doctor then closes up the incision through stitches or surgical tapes.

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 in Adults

The minimum requirements for a patient to qualify for a liver transplant are:

1. Advanced liver disease/liver cancer that cannot be treated through treatment other than a liver transplant.
2. The patient is healthy enough to bear the mental and physical burden of surgery.
3. The patient ensures to abstain from future drug abuse and alcohol use.
4. There is no other life-threatening disorder that limits the life expectancy of the patient.

The doctor will recommend tests on the recipient and living donor. 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 and the donor are 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 Liver Transplant in Adults

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

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

The following things can be expected after the liver transplant in adults 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 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. 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 is usually discharged 7 to 10 days after the procedure. 

Recovery process/expectation after hospital discharge

1. The patient is prescribed antibiotics, painkillers, and immunosuppressants (to prevent the immune system from attacking the new liver).
2. The doctor reduces the dose and frequency of medications once the patient starts recovering.
3. The patient is advised to take a healthy diet and practice a healthy lifestyle.
4. Avoid intake of alcohol to reduce the risk of liver disease recurrence.
5. The patient will be able to join work three months after the surgery.
6. Several patients experience a lack of sexual desire before the transplant. Such patients may require time to get their libido returned after the surgery.
7. Start exercising a few days a week during recovery.
8. The donor and 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 in adults is a life-saving procedure that saves the lives of several people around the world. Below mentioned are some of the benefits of liver transplant in adults.

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, the liver transplant in adults also has some potential risks and complications, such as:

1. Rejection of the transplanted liver by your immune system.
2. Infection at the site of the surgery
3. Weakening of the immune system due to immunosuppressant drugs leads to infection.
4. Liver function problems 
5. Narrowing of the bile ducts
6. Clots in the hepatic artery (that carries blood from the heart to the liver)
7. Bleeding
8. Leakage of the bile
9. Reaction to anaesthesia
10. Return of liver diseases such as (hepatitis C, fatty liver, and primary sclerosing cholangitis)
11. Risk of getting a cancer

When is consultation with the doctor needed?

A patient should contact the doctor immediately in case of any complications. Some of the risks or complications associated with liver transplants in adults 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.

If a liver transplant gets delayed, it can lead to the following:

1. It will get damaged to the point where it cannot perform its normal functions properly.
2. It will lead to end-stage liver damage or failure. The stages of liver failure include inflammation, fibrosis, cirrhosis, and end-stage liver failure. 
3. Cancer in the liver may also spread to other organs if the cancerous liver is not replaced with a healthy liver. Once the liver fails, it will eventually lead to the person's death. 

The cost of a liver transplant in adults ranges from ₹15,00,000 to ₹30,00,000. 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