#CrediTalk: Getting Into The Details of Liver Transplant

Liver transplantation is a process of replacing a healthy liver in place of a diseased one. However, it is not as simple as Doctor Google makes it sound. To have our doubts cleared, we interacted with Dr. Amit Nath Rastogi (Senior Consultant, Institute of Liver Transplantation and Regenerative Medicine) at Medanta Hospital Gurgaon. Read our discussion on Liver Transplants facts in India. Ques 1: India has become the regional transplant centre in South East Asia and most of these surgeries are Live donor Liver transplants. While most of the surgeries have been successful, why is there a setback in the Deceased donor LTs?Ans: The general trend of liver transplant in the world is divisive. In most western countries, these transplants are deceased pre-dominant, while in most eastern countries (Southeast Asia, Korea, Japan and most of China) these cases are living related. There is no clear cut reason behind this. However, it is probably because of the kind of societies we are in. Maybe, in the East, we have more family-oriented units where members are ready to donate. There is a lack of awareness about the deceased donor transplant in the eastern part of the world, especially in India. There are some social beliefs and government support that might be lagging in this concept, as compared to the west. So predominantly, more than 90% of the surgeries in the west would be deceased donor transplants and more than 90% surgeries in our country would be living donor transplants. Apart from these things, maybe we need to have a more firm understanding, awareness, as well as laws from the government to make deceased donors more suitable. From a patient perspective, I would say that a deceased donor is better than a living transplant because nobody has to donate a liver. As surgeons, we would be more than happy if we have a bigger deceased donor program. Ques 2: Medanta Hospital, Gurgaon has noted 100% safety in 17 robotic liver resections and 3 robotic-assisted donor hepatectomies. Does the use of robotic assistance impact the success rates of the transplants? What are the chief benefits of this technology?Ans: Robotic surgery is coming up in a big way, not only in the liver but in many surgical fields. The robotic surgery is an enhancement of the laparoscopic procedures that are being done. Robotic surgery is more surgeon friendly and probably more patient-friendly also. Robotic liver surgery is a new branch to develop, not only in Medanta Hospital Gurgaon but in the whole world. So robotic liver surgery, I would say, is still in the developmental stage. We have not reached a stage where we can routinely give it to most of the patients. We are developing our robotic program. We have run a few cases of hepatectomy and few cases of donor assisted robotic resections. We are not routinely doing it, but we are on a path towards it. The robot would have the advantages of laparoscopy in terms of a smaller incision (thus smaller scar), less pain, less trauma, and faster recovery for the recipients and donors. Apart from the usual advantages of laparoscopic surgery, robots are more surgeon friendly. It is more ergonomic because the way to operate is almost a replication of open surgeries. So maybe robotic surgery will ultimately take up a large part of the open surgeries that we do today. Ques 3: Medanta Hospital Gurgaon was the first institution to report a successful Swap Liver Transplant. Since then nearly 28 such surgeries have been done. What is Swap LT all about? What would you like to say about it in terms of patient education?Ans: Swap is a general English word. Swap means that you exchange and interchange. The same concept was applied to the liver. There are two common scenarios where a swap liver transplant can be done: The patient has an X blood group and the family is ready to donate. But there is no member of the family with a matching blood group, hence they are stuck. A similar situation happens with another family that has a reverse combination. For example, Imagine a patient has A blood group but the donor is B group. In another situation, there is a patient with B blood group and the family member has A donor. So, between these two families, the donors will be exchanged. This is known as swap liver transplant. It is where the donor of one family donates to the compatible recipient of the other family and vice versa. Legally, both the recipients and donors have to be close relatives so that this law is not misused. We match both recipients in terms of both donor weight and the other usual matching points. If everything is found suitable, the swap liver transplant is done. Almost 90% of the swap LTs are done for ABO incompatibility between the groups. Another small subset of patients ar the ones where they have compatible blood groups, but the volumes do not match. For example, in a situation where the patient's weight is more and the donor weight is very less, the amount of liver to be donated is not enough. In that situation, he can swap with another family where the other donor is of a higher weight and has quite a larger chunk of liver. Here also swap can be done for volume but this is very uncommon. So these are the two types of transplants that happen. Ques 4: Besides Swap LT, what other innovations or measures are being taken by the Indian healthcare sector to combat the universal organ shortage problem?Ans: We should go ahead with the possibility of exploring and getting more cadaveric liver transplants because that is the area where we are lacking. The donation rates are almost 20-30 per million population to almost 45 per million population in Spain. If you compare it to India, it would be 0.2-0.3%. If you look at it, the per million population donation rate in India is almost 30-40 times or maybe 50-60 times lesser than other parts of the world. In such a large country like India, there is a huge potential for deceased liver donation. We need to create awareness among the societies about this concept. We need to have better care of patients and also build better infrastructure. Most importantly, some form of law that would allow hospitals to declare brain death should be introduced so the organs can increase, first and foremost, in the deceased donor transplantation. Till the time, it happens or even if that happens, the other possibilities are splitting the cadaveric liver. Here, the liver can be divided into two parts. A better situation is where you have to give a small part to a child and a bigger part to the adult. Sometimes you can even split the liver into two halves for two adult patients. The other way to increase the donation would be something which is known as ABO-incompatible transplants. All the swaps cannot materialize because sometimes, you have a patient who is waiting with an unmatched blood group but you do not have the other pair. In this type, a transplant can be done across the blood group barriers. There are special preparations for it that include some medicines and special dialysis. But that is another way of increasing the donor pool. Another important thing is the use of upcoming technology like the use of normothermic machine perfusion. The machine takes up the liver and infuses it with the preservative solution. This is a new technology which is coming up. It is not completely established but various types of machines are available. The advantage of these machines is that the livers that are usually rejected for disease donor transplants can be put up on the machine and used. So these are 3-4 possibilities where you can increase the donor pool. Ques 5: The largest numbers of pediatric liver transplants are done here in Medanta. The smallest child weighed only 2.1 kgs at the time of the transplant. What challenges do you face in such cases and what is your approach in managing them?Ans:Liver transplants in children are a different scenario compared to adults. Many challenges happen in LT for children. Most of the challenges are the pre-operative management of these small children. We, at Medanta Hospital, have a big liver unit. We have strong surgical and medical backups which are our advantage here. In pediatric LT, the most important thing is a multidisciplinary setup, which takes care of these children better, both in pre-op and post-op. The smallest child that we operated on was only 2.1 kgs (one of the smallest in the world). There are two other important challenges in children - One, because these children are so sick, they become malnourished. They have low weight and they are more prone to infections. They may have many complications that happen with the liver. So pre-operatively, we have to bring them to a level where transplant can be done. Similar postoperatively challenges also remain. Second, most of the donors are adults. The amount of liver we get for children is higher in weight than it should be for them. So we have to reduce this weight. Various surgical interventions need to be done. The small children have small portal veins and smaller blood flows. So those are the technical challenges that we face. All these challenges can be circumvented. We are proud to say that we have an active and large pediatric transplant program at Medanta Hospital Gurgaon. We have done more than 300 Liver transplants in children. Ques 6: ABO-incompatible liver transplantation is a key procedure performed at this hospital. Could you please briefly explain the basics and benefits of this LT?Ans: Normally, the principles of blood transfusion are incorporated in the principles of liver donation. The way you give blood to somebody, a similar way the organ can be given. So O becomes the universal donor and AB becomes the universal recipient. A can donate to A, B can donate to B. Sometimes, you have a family who has a donor but the blood group is not matching. They cannot go ahead with the transplant because of a lack of blood group compatibility. So for such cases, ABO-incompatible came up. This type of transplant came up for patients of acute liver failure because in this case, you cannot immediately plan the transplant. But subsequently, this liver transplant type is being adopted for chronic liver failure patients. Somebody who has a different blood group can donate to somebody who has an incompatible blood group. Special preparations are needed in such donors and recipients. Recipients have antibodies against the different blood groups so they would have antibodies against the liver too. You need to suppress those antibodies and suppress immunity. There are special medicines that are given to suppress the immunity to remove the immune cells from the system. There is a preparation window to do this. It should be done between 2-3 weeks. After this time, they can undergo transplant with ABO-incompatible livers. With success rates almost similar or maybe slightly inferior to the normal LTs. There are few warnings in this technique -

1. One is that because of preparation time there is an additional cost involved.
2. Another important thing is that such a recipient should not be extremely sick. The patient should be relatively stable. Because if they are too sick, they would not tolerate this procedure well. Such patients are more prone to infections.

Check out all the article in #CrediTalk series here.

About The Doctor

Dr. Amit Nath Rastogi is the Senior Consultant of the Institute of Liver Transplantation and Regenerative Medicine at Medanta -The Medicity, Gurgaon. He has a rich experience of 20 years in this field. His area of expertises lies in living donor liver transplantation, robotic & minimally invasive hepatobiliary surgery and complex hepatobiliary procedures. For a priority appointment or more information, contact us at +91 8010994994 or book an appointment with Dr. Amit Nath Rastogi here

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