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Living donor liver transplant: Not mere a dream away

TAREQ SALAHUDDIN
With the increasing incident of liver diseases, there is a pressing need for liver donors. However, there is a critical shortage of cadaveric donor livers for transplantation in the world. For today’s patients in need of liver transplantation, the hope lies in living donor liver transplantation (LDLT). It is not mere a dream now-a-days.
With the rapid advance of medical technology and the increasing clinical confidence and skills of today’s surgeons, the highly complicated LDLT procedure has produced excellent results. Today, patients with endstage liver disease have more choices than to wait, sometimes indefinitely, for cadaveric donors.
The shortage of cadaveric livers for transplant
There is an extreme shortage of living donors for liver transplantation. However, the demand may be sometimes meet up by near and dear ones with a good match of blood and other considerable factors.
The need for LDLT
Initially, segments of livers from living adults (in most cases the donors were the parents) were transplanted into children with terminal liver disease. With the expertise and experience gained by doctors, this procedure has been expanded to include adult recipients.
Milestones achieved by our team
1991: The first split liver transplant in UK
1992: The first auxiliary liver transplant for liver failure in UK 1993: The second auxiliary liver transplant for metabolic disease in the world
1993: The first living donor liver transplant in UK
1995: The first living donor liver transplant in Southeast Asia
1997: The second split liver transplant in Asia
2002: The first adult-to-adult living donor liver transplant in Southeast Asia.
The procedure
How it is done: The human liver comprises eight segments, each with its individual blood supply and bile drainage. Individual segments or a combination of segments (the right or left lobe) are retrieved from the living donor and transplanted into the patient. The remaining liver in the donor will regenerate and replace its size and function within four to six weeks. Similarly, the transplanted liver segments in the patient will regenerate rapidly.
Two team members of doctors will perform the donor and recipient operations almost simultaneously. About half the donor liver will be removed; the gallbladder will be removed as part of the surgery.
Once the diseased liver is removed from the recipient, the liver graft which had been retrieved earlier from the donor is implanted. Both halves of the liver will regenerate and grow to full size in four to six weeks. The
donor operation usually takes six to eight hours and the recipient operation eight to ten hours.
The donor is nursed in the intensive care unit for 24 hours and should be out of bed with assistance after two to three days.
The donor is hospitalised for six to eight days and should be able to resume most light home and work activities within one month, depending on the recovery.
The donor is expected to be closely reviewed by the surgeons over the next several weeks and then as required. There is no
dietary restriction but the donor will be prescribed vitamins for the next few months.
The recipient is expected to stay in hospital for a longer periods (usually three to four weeks), initially in the intensive care unit and later in the surgical ward. During this period, the recipient will be closely monitored for infection, rejection and regeneration of the transplanted liver.
Patient education
Basic facts for the recipient: Patients considered for living donor liver transplantation are those with end-stage liver disease who would be listed for a cadaveric donor liver (those from a brain-dead individual). They usually suffer from conditions like jaundice, recurrent encephalopathy, bleeding esophageal varices, intractable ascities, unacceptable quality of life like severe weakness, itch etc., certain unrescectable cancers of the liver.
Basic facts for the donor: The donor should be a close relative or emotionally related to the recipient. The donor must be older than 18 years and in good mental and physical health. In addition the donor must be of the same of the compatible blood group to the recipient. The donor must be free from HIV infection, chronic viral hepatitis B and C, significant medical illness, active alcoholism and pregnancy.
What are the risks to the donor?
The most common complications are pain, bleeding and infection. Others would include pneumonia, bile leakage, deep vein thrombosis and embolism to the lungs. The risk of death has been estimated to be between 0.1% to 0.5%.
The donor evaluation process: Who is suitable to be a donor
The prime purpose for the extensive donor evaluation process is to minimise the risk to both the donor and the recipient. It ascertains that the donor is in good mental and physical health, and that the portion of the liver to be retrieved is suitable for the recipient. The process comprises the following steps and each must be completed before proceeding to the next.
During the period, the donor will be commenced on iron medication and injected with Epogen, a red blood cell stimulant. Blood will be obtained for autologous transfusion in the peri-operative period.
Where to seek the LDLT programme
Conveniently located in Singapore, Gleneagles Hospital is a leading private hospital that provides an extensive range of healthcare facilities for Singaporeans and overseas patients.
With the development of a LDLT programme in Gleneagles Hospital, both adult and paediatric patients with end-stage liver diseases, particularly foreigners, will have the opportunity of a liver transplant where there was little hope previously.