Living Donor Liver Transplant - Surgery, Requirements, Risks, Success Rate

A Living Donor Liver Transplantation is a surgical procedure in which a portion of the liver is removed from a healthy live donor and then transplanted into someone whose liver is no longer properly working. The living donor liver transplant is done because several people are waiting for their turn for liver transplantation. But, the numbers of diseased livers are often not available enough to fulfil the requirement of the livers. The living donor liver transplant offers an alternative to waiting in such conditions. Most living liver donors are close family members or friends of the liver transplant candidates.

Anatomy and Physiology of the Liver

The liver is the largest internal organ in the upper right quadrant of the abdominal cavity, above the stomach and beneath the diaphragm. The weight of the liver is about 1.4 kg and is reddish-brown in appearance. The liver 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

Living donor liver transplantation is considered as it have a high success rate and also decreases the time the patient waits for the liver transplant on the national transplant waiting list. Living donor liver transplantation helps treat the following conditions:

1. Acute liver failure
2. Chronic liver disease
3. Cirrhosis
4. Primary liver cancer 

Patients with acute liver failure or chronic liver diseases who are waiting for a liver transplant greatly exceed the number of available livers from a deceased donor. The living donor liver transplant offers an alternative to waiting in such conditions. Living-donor liver transplants are more common among children who need transplants than among adults. 

Living donor 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 12 to 16 hours as it takes 4 to 6 hours to remove the donor liver and another 6 to 12 hours to implant the liver in the recipient. 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. At first, 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 through open or laparoscopic techniques.
   1. In open surgery, a large incision is made to expose and remove the diseased liver and place a healthy liver.
   2. In laparoscopic surgery, the surgeon makes small holes to insert the camera and instruments for surgery. It is a minimally invasive technique.
5. The surgeon will remove a portion of the donor's liver depending on the size and the need of the recipient.
6. Next, the surgeon selects the section of the recipient's liver that the surgeon has predetermined to remove. 
7. The liver obtained from the donor is then placed. The blood vessels and the bile duct are connected to the new liver.
8. They will then close the incision of both the donor and recipient and finish the operation.

Living donor 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 Living Donor Liver Transplantation

1. Donor and recipient preparation:
   1. The transplant team will discuss with the donor and the recipient to schedule the surgery
   2. Both the donor and the recipient have to undergo a thorough health check-up.
2. Surgical preparation:
   1. The surgeon may recommend some tests to check the compatibility of the donor with the recipient. These may include blood tests for finding blood group and Rh factor and the organ's size.
   2. Both the donor and the recipient must inform the doctor/surgeon about all the medicines, including herbal medications and health supplements that they consume.
   3. The doctor may advise both the donor and recipient to stop taking medicines like aspirin, warfarin, and other medications that make the blood thinner and make it hard to clot. 
   4. The donor and the recipient will be advised not to eat anything before the surgery post midnight on the day of the surgery.
   5. If any medicines are prescribed, the donor and the recipient may take them with a small sip of water.

On the day of Living Donor Liver Transplantation

1. The donor and the recipient should:
   1. Follow all the instructions provided by the doctor. 
   2. Leave all the valuables at home.
   3. Try to reach the hospital before the time of the surgery.
   4. Fill out a consent form before the surgery on reaching the hospital.
   5. Wear loose-fitting, comfortable clothes.
   6. Change into a surgical gown and cap before surgery.
2. The doctor will insert an IV in the arm of the patient, and the donor and the recipient will be taken to the surgery room.
3. All the vital signs of the donor and the recipient will be checked before shifting to the operation theatre.
4. Once the surgery starts, the family of the patient is informed, and the healthcare providers update them at regular intervals about the patient’s condition. 
5. Once the surgery is performed, both the donor and the recipient will be taken to a recovery room. Here the donor and the recipient will be monitored until their health condition becomes stable. 

The following things can be expected after the living donor liver transplantation 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:
   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. Over time, these tubes will be removed.
4. The donor and the recipient will be kept in observation until the after-effect of anaesthesia wears off.
5. The donor and the recipient will monitor and check for any signs of complications and provide medicines to control the pain.
6. Depending on the recovery condition, the doctor will discharge the patient.

Recovery process/expectation after hospital discharge

1. Instructions provided by the doctor must follow at home.
2. Proper hygiene should be maintained always. Hand washing after meeting strangers should be practised, and a separate towel should be available for the patient.
3. The patient should wear a mask in the first three months following the surgery while going to the crowded area. 
4. A normal diet can be started as soon as the doctor recommends. Diet rich in protein should be consumed.
5. Plenty of water should be consumed by the donor and the recipient.
6. The dressing on the surgical area must be kept in place till the follow-up visit. It may get wet while taking a bath, but it is best to keep it dry if possible. 
7. The doctor may also recommend some regular exercise to the patients. 
8. Lifting anything heavier than five lbs. for the first six weeks after the surgery is unsafe.
9. All the medications prescribed by the doctor must be consumed regularly as per the dosage.
10. The donor and the recipient should visit the doctor for regular checkups.

First follow-up appointment

The follow-up appointments may be as follows:

1. After one month: At the appointment, after completion of 1 month, the doctor will remove the staples from the incision area. The doctor may decrease the dose of the pain killer. If needed, they may also eliminate the need for pain-relieving medicines.
2. After one and half months: During the second follow-up, the doctor will remove bile and drainage tubes from the body. The doctor will also check for the healing progress of the wound. 
3. After six months: The doctor will call the patient to check the healing process. After six months, the incision should heal completely.

Living donor liver transplantation is a life-saving procedure that saves the lives of several people around the world. Below mentioned are some of the benefits of living donor liver transplantation.

1. Increase the number of available livers for people on the waiting list.
2. This type of surgery also helps minimise the chances of developing complications arising from waiting for the transplant, including complete liver damage and death.
3. The liver of the donor recovers within 2 to 4 weeks after the surgery. Within two months, it regains its original size.
4. A higher short-term survival rate.
5. The relatively shorter hospital stay after surgery than deceased donor liver transplant.

Like any other surgery, the living donor liver transplantation also has some potential risks and complications, such as:

1. Pain and discomfort
2. Nausea
3. Bleeding that may require a blood transfusion
4. Infection
5. Formation of scar tissue
6. Leakage of bile
7. Hernia
8. Pneumonia
9. Rejection of the transplanted liver

When is consultation with the doctor needed?

The patient must consult the doctor immediately if he or she experiences:

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.

Research has found that delaying a living donor liver transplantation can lead to:

1. Complications of liver failure include fluid accumulation in the brain, accumulation of toxins and bleeding disorders that can worsen the complications.
2. Progression of chronic liver failure leading to increased risk of death or permanent debility.
3. Can be life-threatening for the patient.

The cost of living donor liver transplantation ranges from ₹15,00,000 to ₹30,00,000. The cost varies based on the following factors:

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