Liver transplantation has evolved significantly over the past 50 years since the first successful transplant in 1967. It is now a standard treatment for end-stage liver disease and certain liver cancers. The document discusses the history and technical aspects of liver transplantation as well as current indications, controversies, and myths. Key points include that one-year survival rates are now 85-90% while five-year survival is around 75%. Liver transplantation offers patients with decompensated cirrhosis their only chance for long-term survival.
2. • History and Evolution
• Present status
• Current indications
• Controversies
• Myths
• Surgical aspects
3. The history of Liver Transplantation is a
complicated story to tell - it is a story of great
successes and tragic failures
Greg J McKeena
4. The first attempt at liver transplantation- 1963
The 3 year old boy bled to death on the OT table
The complexity and difficulty was so extreme, it took
the team several hours just to make the incision and
enter the abdomen.
Despite the fact that the team had performed over 200 such
procedures in animal models
7. Why is Liver transplantation
unique and challenging?
• Uniquely located - thoracic & abdominal
• Large size
• Dual blood supply, multiple veins
• Orthotopic positioning
• Multi system derangement
• High stakes at failure- Nothing to support a failing liver!
• Coagulopathy
8. Evolution of Liver
Transplantation in India
• THOA act was passed in 1994
• Initial attempts in 1995 failed
• First success DDLT and LDLT in 1998
• Only 130 transplants were done till 2004
13. Chronic liver disease
• Decompensation
• Variceal bleed
• Ascites
• Spontaneous bacterial peritonitis
• Hepatic encephalopathy
• Hepatorenal syndrome
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15. Variceal Bleeding
• 15-20% 30 day mortality with each episode of
bleed
• 1 year survival only 52% in those who survive 2
weeks
The course of patients after variceal hemorrhage Graham DY, Smith JL Gastroenterology. 1981;80(4):800.
Upper digestive bleeding in cirrhosis. Post-therapeutic outcome and prognostic indicatorsD'Amico G, De Franchis R, Cooperative
Study GroupHepatology. 2003;38(3):599.
16. Ascites &Spontaneous
bacterial peritonitis
1 & 2 year mortality 70and 80% respectively after the development of
Bacterial peritonitis
Development of ascites in a patient with liver disease is an indication for
referral for liver transplantation
Gastroenterology. 1993 Apr;104(4):1133-8.Risk factors for spontaneous bacterial peritonitis in cirrhotic patients with ascites.Andreu M1, Sola R, Sitges-Serra A, Alia C,
Gallen M, Vila MC, Coll S, Oliver MI.
Hepatology. 1988 Jan-Feb;8(1):27-31.Recurrence of spontaneous bacterial peritonitis in cirrhosis: frequency and predictive factors.Titó L1, Rimola A, Ginès P, Llach J,
Arroyo V, Rodés J.
17. Hepato renal syndrome
• Development of HRS is a marker of severe liver
dysfunction
• Reversal of liver functions with a transplantation
is the only potential modality for recovery
Dig Dis Sci. 2003 Jan;48(1):179-86.Effects of orthotopic liver transplantation on vasoactive systems and
renal function in patients with advanced liver cirrhosis.Cassinello C1, Moreno E, Gozalo A, Ortuño B,
Cuenca B, Solís-Herruzo JA.
19. Controversies
• MELD score
• Described to predict mortality after TIPS
• Allocation tool and not a listing tool
• For equitable organ allocation
• Does not consider quality of life issues
• Not validated for living donor transplants
20. Controversies
51 year old male
Dependent wife and 2 children
Refractory ascites impairing work
S. Bilirubin 1.9 ; INR- 1.29 ; Creatinine 1.0
MELD score - 9
Wife is willing to consider transplantation and be a
donor
Are we justified in not considering/offering a liver
transplant?
21. In an ideal world…
• All patients with cirrhosis are primed about the
possible future need for a transplant
• All patients with decompensation of cirrhosis are
referred to a transplant specialist
• Child score >B8 and MELD >12 are definite
indications for transplantation
• Liver transplantation is curative and not
palliative!
22. Any other form of therapy for decompensated
cirrhosis is curative…
2
24. • CT scan Acute on Chronic from true ALF, Liver volume
• Discuss possibility of LT quite early on
• Select donor, ‘cooling off’ period not possible
• Monitor progress without FFP support
• Intervene if deterioration in 72 hrs, Grade III/IV HE
or cerebral edema
What We Do
25. • Attractive because it tackles the tumour and the
liver disease
• Transplantation and resection are the only
curative modalities for HCC
• Initially propagated for non resectable HCC-
Dismal survival
Transplantation for Liver Tumors
26.
27. Philosophy behind Milan Criteria
• To achieve survival rates comparable to those for non
malignant indications
• Logical considering equitable organ distribution
• 75% 5 year survival for malignancy
28. Controversies
• 75 % 5 year survival for a malignancy- isn't it
asking for too much?
• The living donor scenario- when the organ is
directed towards a specific recipient
29. In an ideal world…
• Liver transplantation/resection should be
considered for every patient with an HCC
• Other treatment modalities like TACE/RFA
should be considered when the above are not
feasible
• Transplantation for HCC (LDLT) should be
individualised
30. HCC is a malignant condition hence
transplantation is not an option
4
31. Is age a criteria for
considering transplantation?
33. Too sick to transplant!
• They are sick therefore they need a transplant!
• They probably wouldn't be so sick if they had had
a transplant!
• The decision MUST be a multidisciplinary one.
34. Liver transplant is
unaffordable!
• Costs between 30-35,000 USD
• Only 10-15% patients pay more than the
package amount
• Economically more viable than dealing with
complications of liver disease
36. Is he/she fit to undergo a
transplant ?
▪ All labs / Coagulation studies
▪ Echocardiography
▪ Stress Echocardiography
▪ P F T
▪ USG Liver Doppler / C T Liver Angio
38. Who can be a donor ?
▪ 1st / 2nd degree relative
▪ Compatible Blood Group
▪ Approval from independent Ethics Committee
39. Who can be a donor ?
▪ Healthy / Fit / Young ( 18 to 55 yrs )
▪ All labs normal
▪ CXR / ECG / Echo / PFT normal
▪ Psychiatry / Physician / Gynae evaluation
42. Size : CT Volumetry
▪ GRWR = Graft volume X 100 = > 0.8
Recipient weight
• i.e. > 600 cc R lobe for a 75 kg recipient
▪ Remnant liver > 30 % of Total Liver Volume
44. Graft Quality : CT for
LAI
▪ L A I = Mean Liver Attenuation – Mean Splenic attenuation
▪ If LAI > + 5 : steatosis is low
▪ Low LAI may have significant Fat : Liver Biopsy
▪ Fatty Liver : Bad graft for recipient
▪ Bad remnant for donor
55. The operation(s)
▪ Donor hepatectomy ( R lobe resection )
▪ Explantation of Recipient Liver
▪ Backtable preparation
56. The operation(s)
▪ Donor hepatectomy ( R lobe resection )
▪ Explantation of Recipient Liver
▪ Backtable preparation
▪ Implantation of the graft liver
70. Donor safety
▪ Top priority in any LRLT program
▪ Only healthy young donors
▪ Informed consent
▪ Exclude fatty livers : CT / Liver biopsy
▪ Adequate Volume ( > 30 % Remnant )
▪ High quality imaging to look for any anomalies
CT liver angiography / MRCP
71. Donor safety
▪ Intraoperative cholangiogram before bile duct
transection
▪ Ensure no duct narrowing / leak : Saline test
Methylene blue test
Cholangiography
▪ HIDA scan before drain removal
