A liver transplant is a life-preserving operation that replaces a diseased and poorly functioning liver with either a whole or portion of a healthy donated liver. Liver transplantation has become a well-recognized treatment option for people with organ failure.
In Canada, over 400 such operations are performed every year. Livers are donated either from individuals who have been declared brain dead and with the consent of their next of kin, or from a living donor such as a relative or friend. Liver transplant centres match donors with recipients based on compatible liver size and blood type.
A liver transplant is a surgical procedure to remove a diseased liver and replace it with a healthy liver from a donor. Most liver transplant operations use livers from deceased donors, though a liver may also come from a living donor.
The number of people waiting for new livers is much larger than the number of available livers, so liver transplant is reserved for people who are critically ill. Some people receive a liver transplant right away, while others spend many months waiting for a liver transplant.
Your liver is the largest organ inside your body. It helps your body digest food, store energy, and remove poisons. You cannot live without a liver that works. If your liver fails, your doctor may put you on a waiting list for a liver transplant. Doctors do liver transplants when other treatment cannot keep a damaged liver working.
During a liver transplantation, the surgeon removes the diseased liver and replaces it with a healthy one. Most transplant livers come from a donor who has died. Sometimes there is a living donor. This is when a healthy person donates part of his or her liver for a specific patient.
The most common reason for a transplant in adults is cirrhosis. This is scarring of the liver, caused by injury or long-term disease. The most common reason in children is biliary atresia, a disease of the bile ducts.
If you have a transplant, you must take drugs the rest of your life to help keep your body from rejecting the new liver.
LIVER TRANSPLANTATION PROCEDURE
What is a liver transplant?
A liver transplant is a surgical procedure performed to replace a diseased liver with a healthy liver from another person. The liver may come from a deceased organ donor or from a living donor. Family members or individuals who are unrelated but make a good match may be able to donate a portion of their liver. This type of transplant is called a living transplant. Individuals who donate a portion of their liver can live healthy lives with the remaining liver.
An entire liver may be transplanted, or just a section. Because the liver is the only organ in the body able to regenerate, a transplanted portion of a liver can rebuild to normal capacity within weeks.
Anatomy of the liver
The liver is the largest organ in the body. It is located in the upper right side of the abdomen, beneath the diaphragm, and on top of the stomach, right kidney, and intestines. Shaped like a cone, the liver is a dark reddish-brown organ that weighs about three pounds.
The liver holds about one pint (13 percent) of the body’s blood supply at any given moment. The liver consists of two main lobes, each made up of thousands of lobules. These lobules are connected to small ducts that connect with larger ducts to ultimately form the hepatic duct. The hepatic duct transports the bile (fluid that helps break down fats and gets rid of wastes in the body) produced by the liver cells to the gallbladder and duodenum (the first part of the small intestine).
The liver carries out many important functions, such as:
- Making bile and producing certain proteins for blood plasma
- Changing food into energy
- Clearing the blood of drugs and other poisonous substances
- Regulating blood clotting
REASONS FOR THE PROCEDURE
A liver transplant may be recommended for people who have end-stage liver disease (ESLD), a serious, life-threatening liver dysfunction. ESLD may result from various conditions of the liver.
The most common liver disease for which transplants are done is cirrhosis. Cirrhosis is a long-term disease of the liver in which a fiber-like tissue covers the organ and prevents toxins and poisonous substances from being removed. Other diseases that may progress to ESLD include, but are not limited to, the following:
- Acute hepatic necrosis. This is the death of tissue in the liver.
- Biliary atresia. A condition in which the bile ducts are absent or have developed abnormally.
- Metabolic disease. Conditions that affect the chemical activity in cells that are affected by the liver.
- Liver cancers. These are primary tumors (that start in the liver) that have not spread outside the liver.
- Autoimmune hepatitis. A chronic inflammation of the liver, resulting in liver cell damage and destruction.
There may be other reasons for your doctor to recommend a liver transplant.
RISKS OF THE PROCEDURE
As with any surgery, complications can occur. Some complications from liver transplantation may include, but are not limited to, the following:
- Blockage of the blood vessels to the new liver
- Leakage of bile or blockage of bile ducts
- Initial lack of function of new liver
The new liver may not function for a brief time after the transplant. The new liver may also be rejected. Rejection is a normal reaction of the body to a foreign object or tissue. When a new liver is transplanted into a recipient’s body, the immune system reacts to what it perceives as a threat and attacks the new organ, not realizing that the transplanted liver is beneficial. To allow the organ to survive in a new body, medications must be taken to trick the immune system into accepting the transplant and not attacking it as a foreign object.
Contraindications for liver transplantation include, but are not limited to, the following:
- Current or recurring infection that cannot be treated effectively
- Metastatic cancer. This is cancer that has spread from its primary location to one or more additional locations in the body.
- Severe cardiac or other medical problems preventing the ability to tolerate the surgical procedure
- Serious conditions other than liver disease that would not improve after transplantation
- Noncompliance with treatment regimen
- Alcohol consumption
There may be other risks depending on your specific medical condition. Be sure to discuss any concerns with your doctor prior to the procedure.
BEFORE THE PROCEDURE
In order to receive a liver from an organ donor who has died (cadaver), a recipient must be placed on a waiting list of the United Network for Organ Sharing (UNOS). Extensive testing must be done before an individual can be placed on the transplant list.
Because of the wide range of information necessary to determine eligibility for transplant, the evaluation process is carried out by a transplant team. The team includes a transplant surgeon, a transplant hepatologist (doctor specializing in the treatment of the liver), one or more transplant nurses, a social worker, and a psychiatrist or psychologist. Additional team members may include a dietitian, a chaplain, and/or an anesthesiologist.
Components of the transplant evaluation process include, but are not limited to, the following:
- Psychological and social evaluation. Psychological and social issues involved in organ transplantation, such as stress, financial issues, and support by family and/or significant others are assessed. These issues can significantly impact the outcome of a transplant.
- Blood tests. Blood tests are performed to help determine a good donor match, to assess your priority on the donor list, and to help improve the chances that the donor organ will not be rejected.
- Diagnostic tests. Diagnostic tests may be performed to assess your liver as well as your overall health status. These tests may include X-rays, ultrasound procedures, liver biopsy, and dental examinations. Women may receive a Pap test, gynecology evaluation, and a mammogram.
The transplant team will consider all information from interviews, your medical history, physical examination, and diagnostic tests in determining your eligibility for liver transplantation.
Once you have been accepted as a transplant candidate, you will be placed on the UNOS list. Candidates in most urgent need of a transplant are given highest priority when a donor liver becomes available based on UNOS guidelines. When a donor organ becomes available, you will be notified and told to come to the hospital immediately.
If you are to receive a section of liver from a living family member (living-related transplant), the transplant may be performed at a planned time. The potential donor must have a compatible blood type and be in good health. A psychological test will be conducted to ensure the donor is comfortable with the decision.
The following steps will precede the transplant:
- Your doctor will explain the procedure to you and offer you the opportunity to ask any questions about the procedure.
- You will be asked to sign a consent form that gives your permission to do the surgery. Read the form carefully and ask questions if something is not clear.
- For a planned living transplant, you should fast for eight hours before the operation, generally after midnight. In the case of a cadaver organ transplant, you should begin to fast once you are notified that a liver has become available.
- You may receive a sedative prior to the procedure to help you relax.
- Based on your medical condition, your doctor may request other specific preparation.
DURING THE PROCEDURE
Liver transplantation requires a stay in a hospital. Procedures may vary depending on your condition and your doctor’s practices.
Generally, a liver transplant follows this process:
- You will be asked to remove your clothing and given a gown to wear.
- An intravenous (IV) line will be started in your arm or hand. Additional catheters will be inserted in your neck and wrist to monitor the status of your heart and blood pressure, as well as for obtaining blood samples. Alternate sites for the additional catheters include the subclavian (under the collarbone) area and the groin.
- You will be positioned on the operating table, lying on your back.
- If there is excessive hair at the surgical site, it may be clipped off.
- A catheter will be inserted into your bladder to drain urine.
- After you are sedated, the anesthesiologist will insert a tube into your lungs so that your breathing can be controlled with a ventilator. The anesthesiologist will continuously monitor your heart rate, blood pressure, breathing, and blood oxygen level during the surgery.
- The skin over the surgical site will be cleansed with an antiseptic solution.
- The doctor will make a slanting incision just under the ribs on both sides of the abdomen. The incision will extend straight up for a short distance over the breast bone.
- The doctor will carefully separate the diseased liver from the surrounding organs and structures.
- The attached arteries and veins will be clamped to stop blood flow into the diseased liver.
- Depending on several factors, including the type of transplant being performed (whole liver versus a portion of liver), different surgical techniques may be used to remove the diseased liver and implant the donor liver or portion of the liver.
- The diseased liver will be removed after it has been cut off from the blood vessels.
- The doctor will visually inspect the donor liver or portion of liver prior to implanting it.
- The donor liver will be attached to the blood vessels. Blood flow to the new liver will be established and then checked for bleeding at the suture lines.
- The new liver will be connected to the bile ducts.
- The incision will be closed with stitches or surgical staples.
- A drain may be placed in the incision site to reduce swelling.
- A sterile bandage or dressing will be applied.