Orthotopic Liver Transplant - Procedure Types & Indications

According to a study by Mondal et al., 2022, the prevalence of nonalcoholic fatty liver disease (NAFLD) in India is up to 20%. Orthotopic liver transplant is a vital treatment option for those facing severe liver conditions. 

The orthotopic liver transplant procedure requires careful postoperative management for optimal functioning of the transplanted liver. Read on to learn more about the procedure, risks, and benefits of this type of liver transplant surgery. 

An orthotopic liver transplant (OLT) is a surgical procedure where a damaged liver is replaced with a healthy liver from a donor. In this procedure, the recipient’s liver is removed, and the donor’s liver is placed in the same anatomical position as the original. This type of transplant is the most common method used for liver transplants. 

The primary difference between orthotopic liver transplant vs heterotopic liver transplant is the positioning and functioning of the native and donor liver. In the latter approach, the recipient’s original liver is kept in place as it continues to function alongside the donor’s. 

Anatomy and Physiology of the Liver

The liver is a dark reddish-brown organ in the upper right portion of the abdomen, located just below the diaphragm (a major muscle used in respiration). 

It has two main lobes, divided into eight segments composed of 1,000 smaller lobules forming the common hepatic duct. The duct carries bile produced by liver cells to the gallbladder and the duodenum through the common bile duct.

The liver gets its blood supply from two sources: 

1. The hepatic artery, which provides oxygen-rich blood

2. The hepatic portal vein, which brings in nutrient-rich blood

An orthotopic liver transplant is a treatment option for various acute and chronic liver conditions when other medical interventions have failed. The following are some of the diseases commonly treated with this procedure:

1. Cirrhosis: A late stage of liver fibrosis (scarring)

2. Primary Biliary Cholangitis: An autoimmune disease that slowly destroys the bile ducts within the liver

3. Biliary Atresia: A severe condition in infants where the bile ducts are blocked or absent

4. Metabolic Diseases: Inherited disorders affecting the liver like Wilson’s disease (copper metabolism dysfunction), alpha-1 antitrypsin deficiency (causes lung and liver damage), and haemochromatosis (excess iron storage)

5. Acute Liver Failure: Sudden loss of liver function in individuals without pre-existing liver disease

Other conditions like hepatitis B and C, primary sclerosing cholangitis, and Budd-Chiari syndrome may also require an orthotopic liver transplant.

OLT is a life-saving operation for patients with confirmed end-stage liver failure. Ideal candidates for this surgery are selected based on criteria that ensure optimal transplant outcomes. Factors influencing patient selection include: 

1. No other treatment options have worked. 

2. Patients should be less than 65 years of age. 

3. Individuals with comorbidities like cardiopulmonary dysfunction or active liver infection may have surgical or recovery complications.

4. Recipients must adhere strictly to post-transplant medication regimens and follow-up appointments.

An orthotopic liver transplant offers numerous life-saving benefits for patients with severe liver disease. The following are some of the key advantages:

1. Cure for Liver Disease: For many conditions, such as cirrhosis, end-stage liver disease, and specific metabolic disorders, a liver transplant is the only definitive cure. 

2. Increased Longevity: According to a study by Bhargava et al., the survival rates of primary liver transplant recipients were 87.7%, 79.9%, and 74.3% at 1, 3, and 5 years respectively.

3. Enhancement in Quality of Life: Patients often experience a significant improvement in standard of living post-transplant. They report increased energy levels and the ability to return to normal activities and work.

Preparing for an orthotopic liver transplant involves meticulous planning and careful coordination, both before and on the day of the surgery. This ensures the patient is physically and mentally prepared for the complex procedure.

Before an Orthotopic Liver Transplant 

Prior to the procedure, patients undergo a series of pre-operative tests to ensure they are fit for surgery. Based on the results of these tests, they are placed on the liver transplant waiting list. Individuals can expect the following before an orthotopic liver transplant: 

On the Day of the Orthotopic Liver Transplant 

Patients must be prepared to go to the hospital immediately once a donor’s liver becomes available, which can happen at any time of the day or night. Once at the medical centre, they can expect the following: 

The orthotopic liver transplant procedure is a complex operation that involves replacing a diseased or failing liver with a healthy one from a donor. The complete surgery takes about 5-8 hours and may include the following steps: 

1. Anaesthesia: The procedure is conducted under general anaesthesia, meaning the patient is asleep and pain-free throughout the surgery.

2. Dissection stage: The surgeon makes a large incision in the upper half of the abdomen to access the liver. They carefully dissect it from the surrounding tissues and structures. Two methods can do the removal of the native liver: 

1. Caval replacement, or the classic technique: The inferior vena cava (the main vein going up to the heart) is removed and replaced with the central vein from the donated liver. 

2. Piggy-back technique: The recipient’s central vein is left in place, and the new liver is attached. 

3. Anhepatic stage: The diseased liver is removed. The donor’s liver is placed in the vacated space in the same anatomical position. The surgeon connects the vessels of the donor liver (portal vein, hepatic artery, and inferior vena cava) to the recipient’s corresponding vessels.

4. Reperfusion stage: The clamps on the blood vessels are removed to restore blood flow to the liver. The function of the liver is closely monitored for any signs of immediate rejection or failure. The bile ducts are then connected to enable bile drainage.

5. Closure: The incision is closed with staples or sutures.  

Note: The treatment approach is selected based on the patient’s condition and the surgeon’s opinion. 

Complete recovery after an orthotopic liver transplant may take about six to twelve months. Most patients can resume routine activities and work within one to two months. 

Recovery in the Hospital

The duration of hospitalisation following the procedure spans 7 to 14 days. It can vary depending on the patient’s condition and recovery progress. Throughout this period, individuals can expect the following:  

1. Intensive Care Unit (ICU) Stay: Immediately following surgery, patients are transferred to the ICU. Here, they receive round-the-clock monitoring to manage vital signs.

2. Monitoring for Complications: The medical team closely watches for signs of bleeding, infection, or rejection of the new liver. Frequent blood tests are conducted to assess liver function and detect early signs of complications.

3. Pain Management: Postoperative pain is managed through medications. It helps in recovery and mobility. 

4. Physical Therapy: Mobilisation is encouraged within a day or two to prevent complications such as blood clots. Physical therapists may work with patients to help them regain strength and mobility.

5. Shifting to a General Ward: As the patient stabilises, generally after the first 2-3 days, they are moved from the ICU to a general ward. The drains and tubes are removed. 

At-home Recovery 

Recovery at home is a continuation of the care initiated in the hospital. It ensures the patient's long-term health and the success of the transplant. The following are the activities and guidelines during this vital phase:

1. Medication Management: Patients must adhere to a strict regimen of immunosuppressive drugs to prevent organ rejection. They are also prescribed medications to manage pain, prevent infections, and control other health conditions.

2. Diet and Nutrition: A healthy diet that supports liver health and overall recovery is important. This may include low salt, cholesterol, fat, and sugar. 

3. Psychological Support: Recovering from a liver transplant can be emotionally challenging. Comfort from family, friends, or professional counsellors can be beneficial. Joining a support group where experiences are shared can also be helpful.

First Follow-up Appointment

The recipient and donor’s first follow-up appointment will be scheduled one week after the procedure to remove stitches and evaluate recovery. 

Donors should have follow-up visits every 5-7 days for the first month, followed by evaluations at 3 months and 1 year. Recipients require lifelong follow-ups, initially frequent but gradually reducing in frequency over time. Once stable, they only need to visit the clinic every 3-6 months.

These appointments involve blood tests, liver function tests, and assessments to monitor recovery. Doctors also adjust medications as needed.

While an orthotopic liver transplant can offer several benefits, it also comes with significant risks. Understanding these potential complications is crucial for both patients and caregivers:

1. Acute or Chronic Rejection of the Liver: About 20-40% of patients undergo acute rejection within the first three months after OLT. Chronic rejections can occur in about 10-20% of patients more than six months after the procedure. 

2. Infection: Patients are more susceptible to infections after OLT, including bacterial, viral, and fungal. 

3. Urinary Tract Complications: These may include renal failure and urinary tract infections. The incidence of renal failure after OLT is 8.0%, 13.9%, and 18.1% at 1, 3, and 5 years respectively. 

4. Vascular Complications: Issues with the blood vessels connected to the liver, such as blockages or blood clots, can occur. 

5. Liver Dysfunction: The new liver can sometimes fail to function properly immediately after the transplant, a condition known as primary graft dysfunction. This requires urgent medical attention.

When to call a doctor?

After an orthotopic liver transplant, it is crucial to be aware of signs of complications that may require immediate medical attention. Mentioned below are specific instances when patients should contact their doctor:

1. Fever above 100.4℉

2. Jaundice 

3. Pain in the stomach 

4. Shortness of breath or chest pain 

5. Diarrhoea and vomiting 

6. Severe headache 

7. Fatigue or weakness 

Delaying OLT when it is medically recommended can result in the progression of liver disease and increase the risk of liver failure. This can significantly impact a patient’s quality of life and cause various complications, including: 

1. Cerebral oedema (fluid buildup in the belly and brain) 

2. Issues with blood clotting 

3. Infections, such as UTIs and pneumonia 

4. Kidney failure 

Cost of Orthotopic Liver Transplant 

The price of an orthotopic liver transplant in India starts from ₹ 15,00,000 and can go up to ₹ 27,00,000. The average cost of the procedure is ₹ 20,00,000. This expense can vary based on multiple factors. 

Note: These prices are approximate. HexaHealth can help patients understand the up-to-date costs depending on their particular situation. 

The factors that can affect the cost of an orthotopic liver transplant include: 

1. Surgeon Expertise: Highly qualified and renowned surgeons and medical teams usually command higher fees.

2. Hospital and Location: The area of the hospital and its facilities can significantly impact expenses. Medical centres in metropolitan cities with higher medical care costs typically charge more.

3. Type of Donor: The cost of a liver transplant depends on whether it comes from a living or a deceased donor. Deceased donor transplants are often more expensive. 

4. Medical Tests and Pre-operative Care: Extensive evaluation is required before a liver transplant, including blood tests, imaging, and donor screening tests, which can be costly.

5. Insurance: The extent of insurance coverage can impact the out-of-pocket expenses for the patient.

An orthotopic liver transplant is crucial for patients with severe liver disease. This surgery is recommended for those who have not benefited from other treatments. It significantly improves an individual’s health and their overall quality of life.

HexaHealth helps patients by connecting them with experienced liver transplant specialists and reputable transplant centres. From facilitating the initial consultations to ensuring seamless post-operative care, we provide comprehensive guidance. So, if you need an orthotopic liver transplant procedure, contact us TODAY!

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