Radisson Blue Summit 3 presentation..

1. LIVER transplantation
Present SCENARIO
in India…
Dr. PARVIDER S. LUBANA
MS; D.N.B. FAMAS; FICS (USA)
Fellow Liver Transplant Surgery Memorial Sloan Ketterin Cancer Center Newyork
Fellow Liver surgery Singapore General Hospital, SINGAPORE.
Consultant & Asst. Professor
Hepato-Pan-Biliary & Colo-Rectal Services
M.G.M. Medical College & M.Y.Hospital

2. ANATOMY……
 Eight segments, based on arterial
and portal venous inflow.
 Segment 1 -caudate lobe.
Independent lobe.
 Segments 2-4 segments of the left
lobe
 Segments 5-8 are segments of the
right lobe

3. Couinad’s segmental division
of the liver..

4. Structures in the Hilum of the Liver: HDL : Common Bile duct, Hepatic artery, portal vein
.

5. Functions of the liver…
Detoxification
Storage of iron, Production of chemicals
vitamins,
of bile
minerals
Manufacture
Storage of energy Production of proteins and
blood clotting factors

6.  Physiology of liver …
 Maintaining core body temprature
 ph balance and corection of lactic acidosis
 Synthesis of clotting factors.
 Glucose metabolism, glycolysis and gluconeogenesis.
 Urea formation from protien catabolism.
 Bilirubin formation from Hb degradaion
 Drug and hormone metabolism
 Removal of gut endotoxins and foreign antigen

7. HOWEVER……IF….
The functioning of the liver is
inadequate to meet the
requirements of the body
liver failure

8. CAUSES OF LIVER FAILURE…
o
o 1. Inflammation of the liver over a prolonged time period.
o
2. Chronic alcohol intake, eventually leading to
cirrhosis and liver failure.
o 3. Autoimmune disorder -primary biliary cirrhosis.
o 4. Biliary atresia Structural abnormality with absence or a closure of the
bile duct opening.
o 6. Congenital disorders of copper metabolism, leading to excess
deposition of copper. (Wilson's disease, Menke's disease).
o 7. Liver (HCC) & Bile D cancer (CC).

9. Treatment….
Liver
Transplantation

10. LIVER TRANSPLANTATION
“The only option for people whose liver can no
longer function”

11. In the last 40 years, Liver transplantation
has evolved from an experimental procedure
confined to laboratory to a clinically
therapeutic intervention that is applied
world wide to virtually all form of end stage
liver disease.
• In 2010 alone 9040 Liver Transplants were
done in 157 Transplant centers world wide.
• In India the rate is 120-125 Transplants a
year at various centers.

12. Since early times, the idea of tissue and
organ Transplantation has captured the
imagination of the successive generation and
over the centuries numerous fanciful
descriptions of successful transplants have
been recorded.
One of most widely cited early example is
that of Christian Arab Saints Cosmos and
Damian performing a miraculous
transplantation of the leg.

14. MILESTONES IN ORGAN TRANSPLANTATION…..
1954 Joe Murray performed successful kidney Transplant
between identical twins.
1962 Roy Calne demonstrated the efficacy of azathioprine
in preventing rejection of Kidney allografts.
1963 Tom Starzl performed the first human liver
transplant.
1966 Lilehei & Kelly-Human Pancreas Transplant.
1967 Sir Christiaan Bernard performed first human heart
Transplant(Cape Town S.A.).
1968 Fritz Derom performed first successful human lung
Transplant(Ghent Belgium).

15. 1978 - Roy Calne introduced cyclosporin into clinical practice.
1981- Bruce Reitz & Normann Shumway performed first
successful Heart-Lung Transplant (Stanford U.S.A. )
1987- Fokert Belzer developed university of wisconsin ( UW)
Solution – a new Liver & Pancreas preservation solution.
1989- Tom Starzl demonstrated clinical efficacy of
FK506 (Tacrolimus).

17.  Chronic Liver Disease is 10th leading cause of death
in India.. 25000 deaths annually.
(3rd National Health & Nutrition examination Survey)
 ALD is the most common indication for LTx in India.
(67%)
 World wide HCV is most common indication for
LTx(40%)

18. INDICATIONS FOR LTx:
Fulminant Hepatic Failure :
o Alcoholic Liver Disease
o Chronic Hepatitis C & Hepatitis B infection.
o Non-alcoholic steatohepatitis
o Autoimmune Hepatitis
o Primary Biliary Cirrhosis
o Primary Sclerosing Cholangitis
o Hepatic tumors
o Metabolic and genetic disorders

19. 27000 patients need LTX in India

20. Ideal Candidate FOR LIVER TRANSPLANTATION …
o Presence of irreversible liver disease and a life
expectancy of less than 12 months with no effective
medical or surgical alternatives to transplantation.
o Chronic liver disease that has progressed to the point
of significant interference with the patient's ability
to work or with his quality of life.
o Progression of liver ds that will predictably results in
mortality exceeding that of transplantation.

21. CROSS SECTION OF A NORMAL LIVER.
The Holes Are Bile Ducts.

22. “FATTY LIVER” –ALCOHOLIC LIVER DISEASE.
NOTICE THE YELLOW COLOUR AND SWOLLEN
APPEARANCE

23. LIVER WITH CIRRHOSIS DUE TO ALCOHOL
CONSUMPTION . NOTICE THE SMALL NODULES.

24. A LIVER WITH METASTATIC
ADENOCARCINOMA.

25. CLOSE UP OF AN
ALCOHOLIC HYALINE LIVER.

26. AN EXAMPLE OF HAEMOSIDEROSIS.

27. HEPATIC CELL CARCINOMA.

28. HCC

29. CONTRAINDICATIONS TO LTX
o Presence of a malignancy in any other part of the
body.
o Presence of an active infection.
o Presence of advanced cancer of the liver.
o Presence of severe heart, lung or kidney
disease.
o Presence of advanced HIV disease.

30. DEFINITIONS OF COMMON TERMS
 ALLOGRAFT – an Organ or Tissue Transplanted from one
individual to another.
 SYNGENEIC GRAFT (Isograft) - a Transplant between two
identical twins.
 ORTHOTOPIC GRAFT - a graft placed in its normal anatomical
position .
 HETEROTOPIC GRAFT - a graft placed in a site different from
that where the organ is normally located.
 XENOGRAFT - a graft performed between different species.

31. Where does a Liver for a transplant come from ?
There are two types of LTX options:
Living donor transplantation
This involves removing a segment of liver from a healthy
living donor & implanting it into a recipient. Both the donor and
recipient liver segment will grow to normal size in a few weeks.
Cadaveric transplantation
The ideal donor is a
Young, previously healthy,
Brain dead,
Heart beating victim of an
Road traffic accident.

33. LIVER TRANSPLANTATION- DONORS
 Live related donors:
The patient’s blood relative. Rate of success is better if the liver is
obtained from a first degree relative (father, mother, brother or
sister)
 Living unrelated donors:
This can be done only after an approval by the hospital appointed
committee members.
 Cadaveric (deceased) donors:
Usually seen following a road traffic accident or an irreversible
injury to the brain. In these individuals, a part of the brain known
as the brain stem fails to function and the patient is brain dead.

34. DONOR EXCLUSION CRITERIA
 Age > 60
 Dopamine >10 mcg/kg/min
 Cardiac arrest > 15 min.
 Hospitalization > 3 days
 Transaminases > 3 x normal
 Malignancy
 Systemic infection
 HIV, HTLV III, HbsAg

35. RECIPIENT PROCEDURES
 Most difficult part of LTX.
 Hepatectomy with removal of corresponding abd.
Aorta & IVC.
 During ANHEPATIC PHASE venovenous bypass is
used to return blood from IVC & portal vein to SVC.
 Donor liver size can be reduced or split grafts can
be made.

36. PRE Opr. INVESTIGATIONS….
o Computed tomography.
o Ultrasound to determine blood flow to the liver.
o Echocardiogram to evaluate cardiac function.
o
Pulmonary function studies (PFT) to determine the functioning of
the lungs.
o
Blood tests. (LFT, coagulation profile)
o Test for HIV and hepatitis

37. PRE OPERATIVE VOLUMETRIC DETERMINATION
OF LIVER
 Helical CT
 Used to directly measure liver volumes

Formula for association with BSA
TOTAL LIVER VOLUME = 706.2 X BSA (in m2) + 2.4

38. SELECTION CRITERIA FOR ORGAN ALLOCATION…
o United Network for Organ Sharing (UNOS) governing
body for organ allocation utilizes MELD score.
o Model for End Stage Liver Disease (MELD) Score
 0.957 x loge (creatinine) + 0.378 x loge (bilirubin
mg/dL) + 1.12 x loge (INR) + 0.643 x 10
[Range from 10 to 40]

39. PROCEDURE….
In liver transplant surgery the diseased liver
is removed through an incision made in the
upper abdomen. The new liver is put in place
and attached to the patient's blood vessels
and bile ducts.

40. Normal
anatomical
location
Right upper quadrant of the
of the abdomen
Liver…

41. UPPER ABDOMINAL INCISION…

42. No… Not the Entire Liver-
just a portion of the normal live donor Liver is required .
( Liver has an amazing regenerative capacity)
* Prometheus
A fit patient with a healthy Liver will regenerate a 75 %
resection within three months.
Diseased
Healthy Liver
Liver Of
Segment the
From receipient
donor

43. LIVER RESECTION MODES…
o Finger fracture, kelly clamps.
o Cavitron Ultrasonic Surgical Aspirator (CUSA)
ultrasonic dissector
o Harmonic scalpel
o Radiofrequency dissecting sealer
o Argon laser

44. Donor Graft

45. Donor graft

48. Hepatic
Portal artery
vein Common
bile
duct
ivc
Anastomoses done between the
Portal vein,Hepatic artery, IVC and Bile duct
of the donor liver and the recipient

49. Anastomosis of Full size cadaver Liver

50. Living donor graft

51. Comparison –
before and after transplantation

52. POST OPERATIVE COMPLICATIONS…
 Right pleural effusion
 Hepatic edema secondary to aggressive resuscitation &
increased intravascular volume.
o Electrolyte Derangements
o Thrombocytopenia
o Biliary leak
o Hepatic artery thrombosis
o Allograft rejection

53. OUTCOME
LTx improves the quality and duration of life
in most recipients.
 Overall LTX outcome has improved progressively
over the last two decades.
 Improved outcome after LTX is due to better
immunosuppression, organ preservation,
chemoprophylaxis ,technical advances & wonderful
Pre-Postoperative care of the patient.
 Graft survival after LTX is around 85% at 1 year
and 70% at 5 years.

54. Dr.Tom Starzl
1st orthotopic Liver
Transplant
(1963) Denver

56. Overall the future of LTX remains
promising.
The potential future
obstacles in India includes:
 Organ shortage
 Expanding recipient pool
 Financial constraints
 Religious myths.
 Rigid govt. policies*
 *Chinese model

57. TYPES OF GRAFT REJECTION
HYPERACUTE:
 Immediate graft destruction due to pre
formed anti HLA/ABO anti bodies.
 Characterized by intravascular thrombosis.
 Very rare in LTX.

58. ACUTE /CELLULAR REJECTION
 Occurs during first 6 mths, mediated by T cell
dependent immune response.
 Reversible in majority by increasing
immunosuppression.
 Characterized by mononuclear cell infiltration.
 Enlarged tender liver, pyrexia, deranged LFTs.

59. CHRONIC ALLOGRAFT REJECTION ..
 Occurs after first 6 months.
 Most common cause of graft failure.
 Non immune factors may contribute to pathogenesis.
 Myointimal proliferation of hep. arteries-bile duct
destruction.
 Inflammation is usually absent.
 Retransplantation is the only treatment.

60. HLA ANTIGENS
 Are the most common cause of graft
rejection
 Their physiological function is as antigen
recognition units.
 Are highly polymorphic (amino acids sequence
differs between individuals).
 HLA – A , - B (class 1) & - DR (class 2) are most
important in organ transplantation.
 Anti – HLA antibodies may cause hyperacute
rejection.

61. IMMUNOSUPPRESSIVE THERAPY
Most immunosuppressive protocol use a combination
of immunosuppressive drugs.
Individual drugs can be classified according to their
principle mode of action in preventing the T – cell
dependent rejection response.
Azathioprine, Cyclosporin,
Tacrolimus(FK506),
Rapamycin, OKT3 & Anti – CD25 are
commonly used combination.

62. Thus …..remember…….
LIVER IS PRICELESS

63. • Watch those drugs !
• All drugs are chemicals,
and when you mix them up
without a doctor's advice you
could create something
poisonous that could damage
me badly.
 I scar easily.. and those scars, called "cirrhosis"
are permanent.
Medicine is sometimes necessary. But taking pills
when they aren't necessary is a bad habit. All
those chemicals can really hurt a liver.

64. • Don't eat too much fatty food…
I make the cholesterol your body needs, and I
try to make the right amount.
Give me a break….
Eat a good, well balanced nourishing diet. If you
eat the right stuff for me, I'll really do my
stuff for you!

65. • Don't drown me in beer, alcohol or
wine!
Even one drink is too much for some
people and could scar me for life.

66. • Be careful with aerosol sprays!
•
Remember, I have to detoxify what
you breathe in, too. So when you are
cleaning with aerosol cleaners, make
sure the room is ventilated, or wear
a mask.
• That goes double for bug sprays, mildew sprays, paint sprays
and all those other chemical sprays you use.
• Be careful what you breathe!

67. WARNING:
I can't and won't tell you I'm in trouble until
I'm almost at the end of my rope... and yours.
Remember: I am a non-complainer. Overloading
me with drugs, alcohol and other junk can
destroy me! This may be the only warning you
will ever get.
Your….. Liver

68. ?

70. Thanx a
Bunch