A few decades ago, the idea of organ transplants was merely an idea. Medical science has advanced to the point where organs, like the heart, kidney, and liver can be removed and replaced for the healthy survival of a person. A liver transplant is a unique yet complex surgery where a diseased liver is replaced with a healthy one. But it is not as simple as it sounds.
To understand what liver transplant is all about, we spoke to Dr. Arvinder Singh Soin. Dr. Soin is the Chairman of the Institute of Liver Transplantation and Regenerative Medicine at Medanta Hospital Gurgaon. Read our interaction here.
Ques. Does the type of transplant (Live Donor LT and Deceased Donor LT) impact the survival rate of a patient? What is the difference in the health effects of both?
A liver transplant means replacing a person’s bad liver with a good one. So when the liver fails, either in acute liver failure or chronic liver disease, we remove the entire bad liver and replace it with a healthy liver. This healthy liver can come from two sources –
One is a deceased donor or a dead donor. The so-called cadaveric donor is a brain dead person in ICU, whose brain is dead but the other organs are working. And the other kind of donor is a living person, from whom we take half a liver. This person has to be a blood relative of the patient. In this case, we take a part of the donor’s liver and transplant it into the patient. The good thing about the liver is that when you divide it or remove a part of it, the rest of it regenerates to normal size. So the remaining part of the donor’s liver and the half liver donated to the patient will regenerate to normal liver’s size in a matter of 2-3 months.
Now, people often ask, is there a difference in survival of patients after deceased donor transplant, compared to live donor transplant. The answer is that survival after a live donor liver transplant is 95% and when a person receives a liver from a dead donor, it is 90%. That’s because there is a slight difference in liver quality. The liver that is taken from a living person is tested over many days. We make sure that it is safe for the donor to donate and for the recipient to accept it. In the case of a dead person’s liver, we don’t get that many days to investigate the donor. Livers that come from dead people are slightly inferior in quality and therefore give a slightly inferior survival to the patient compared to live donor’s livers.
Ques. There have been many technological innovations in the field of Liver transplant. Surgeons can now provide certain treatments using only a part of the liver. Can you describe this process?
Over the last 21 years that I have practiced liver transplant in India, we have innovated extensively to increase the safety of liver transplantation, as well as, improve the access of this procedure for patients who are dying of liver failure or liver cancer.
So one of the innovations that are key to patients who do not have blood group matched donor in their family is the SWAP liver transplant. This means that a patient has a blood group B and the donor (who is medically fit in their family) has a blood group A, then A cannot donate to B. So, in this case, we match up this family with another family that has the opposite problem. That family has A group patient and a B group donor. So we exchange the donor livers in both these families. And both patients can be saved. We do all these four operations, two donors and two patient operations, all at the same time on the same day. We have large teams that can handle this SWAP liver transplant.
In the last 5 years, we have also started ABO-incompatible transplantation, which means that we can put a different blood group into the patient. If the patient blood group is O, you can transplant them with a liver that has a blood group B or A. This is possible by doing certain modifications with the patients’ immune system before the transplant. We do plasma exchange 2-3 times and give some special medicines to the patients before the transplant, which removes the antibodies (the substances that would normally reject a different blood group liver). So after this kind of pre-treatment, we can successfully transplant patients with a mismatched liver. These techniques are a boon for patients who do not have blood group matched donors in their families.
One of the prime concerns of live donors before they decide to donate half their liver for their loved one is how big the scar will be, how much pain will they have, and how long will it take for them to recover. The standard liver surgery that we do leaves a big scar but is very safe. The donor surgery is completely safe, but there is some scarring. To ease the patient’s pain and to give them relatively small scars (so-called scar less surgery) and to improve the comfort of the donor, we have innovated and started robotic live donor surgery. Hopefully in the next few years, every liver donor will be able to have robotic surgery.
Ques. What measures are taken to maintain a patient’s health in case he/she is on the waiting list for a liver match?
Many patients have to wait for weeks and months before they get a transplant, even after we suggest that they have it. This happens because there are times when a family member is unable to donate a liver and the cadaver liver is on the waiting. So during the waiting period, because they have liver failure, they may get infections. The infections can be recurrent. So we do liver and kidney tests on these patients repeatedly, because liver failure also impacts the kidney. The patient has to see their liver team every 1-2 weeks during their waiting period. They need to have regular liver tests, kidney tests, tests for infections, etc. They may face problems like dizziness, mental confusion, collection of water in the stomach, or bleeding. For these issues, they should see their liver specialist as soon as possible, so that, their stability can be maintained until the time they do not get a transplant.
Ques. How does the live liver transplant affect a donor? Is there any risk involved for the donor as well?
Donation of a part of one’s liver is a big operation, no doubt, but it is only done by experts who have spent 15-20 years practicing it. It is very standardized. In large-volume centers, surgeons have extensive experience in this procedure. My team and I at Medanta Hospital Gurgaon have done over 3,300 live donor liver transplants. Therefore, we have done that many donor surgeries. When one is that experienced, one takes care of every minute detail to make sure that it is safe for the donor. The typical thing we tell a donor is the 0.1 % risk which everything in life has. You cross the road, you have a 0.1% risk, probably more than that. So that is the risk to life, otherwise, it is completely safe.
There are minor problems that can affect a donor in the first 2-3 weeks. They may need redressing or getting cough or chest infections. But all these problems are easily treatable. They generally get discharged in about a week after surgery, they can get back to normal life in a month. If they are in the army or do lots of physical activity, then they can get back to their life, in 3-4 months. There is no risk to donors later in life. They have a normal life and normal longevity. Only thing is that they have a scar which never vanishes, but it is something that a person gets used to.
Ques. What is liver regeneration? How is it beneficial for a patient with end-stage liver disease?
The liver is an amazing organ. It is the only internal organ that regenerates, which means that if you remove a part of it or if a part of it is damaged, then it can grow its cells, both in number and in size. It can restore the volume of the liver as it was before the injury or before removal. So liver regeneration is a very unique quality of the liver.
You can imagine that just like hair and nails grow, skin cells are shed and new ones are acquired, similarly liver grows. The liver grows back within weeks.
When the liver gets deceased, like in hepatitis or cirrhosis, then this process of liver regeneration is retarded. So if the liver is badly deceased, like in those patients who have liver failure, or need a transplant, in such patients, the regenerative ability of the liver is just not there. But in normal patients, you could take out a portion of the liver, and it will grow back. If a patient has hepatitis or early cirrhosis, there is still some regeneration possible. Whether the liver would fully or partially regenerate or not at all, depends upon how healthy a liver is.
About The Doctor
Dr Arvinder Singh Soin is the Chairman of Institute of Liver Transplantation and Regenerative Medicine at Medanta -The Medicity, Gurgaon. He has a rich experience of 31 years in this field.
He has performed more than 2500 liver transplant in India. Earlier he was associated with Sir Ganga Ram Hospital. He was honoured by the President of India, by bestowing on him the Padmashri, for Liver Transplantation program in India.
For a priority appointment or more information, contact us at +91 8010994994 or book an appointment with Dr. Arvinder Singh Soin here