Liver Transplantation

Orthotopic liver transplantation (OLT) has evolved over the last 35 years, and has now become established as the only and highly successful therapy for acute and chronic end- stage-liver disease with five years survival rate approaching to nearly 85%. Liver Transplantation (LT) in India is now an established therapy for acute and chronic liver failure. In the developed world, the formulation and acceptance of brain death criteria, establishment of dedicated transplant centres and availability of cyclosporine immuno- suppression resulted in a phenomenal growth in this area in the eighties. The refinement in surgical techniques, improvement in anaesthesia, perioperative care and access to newer immuno-suppressant drugs has now resulted in 1 year acturial survival rate of 90% and 5-8 year survival rate of 75%-80%. Shortage of donor organs continues to remain a significant problem and innovative surgical techniques of segmental transplantation, split liver transplantation and living related transplantation have been developed to address this problem.The success of paediatric LT in developed countries has increased the awareness and need for such procedures in the developing world.

Liver Transplantation expertise at Wockhardt Hospitals

The Wockhardt Hospitals,Mulund,Mumbai has been running Liver Transplantation programme which is recognised by the Govt. of Maharashtra under “The Transplantation of Human Organs Act,1994” of Govt of India. In September 2006 the 1st successful Live donor adult to adult liver transplantation was performed at wockhardt hospitals, Mumbai. This was the first adult to adult LT using Right liver graft in the entire western and central India

Facilities

• Dedicated Liver Transplantation ICU of International Standards managed by Nurses specially trained for managing LT patients.

• Well planned Operation rooms equipped with: CUSA, Argon Beam Coagulator, Tissue link,Ligasure, Intraoperative USG with colour doppler. patient warmers, Rapid fluid Infusor system(level-1), Online fluid warmers etc. Anaesthesia machine and Multi channel Monitors and special monitors for Cardiac output and SVR

• TEG machine for intraoperative monitoring of coagulation • Traineed OR nurses for Liver Transplantation

Supportive Departments:

• Blood bank with facilities for preparing blood components

• Laboratory for Hematology,biochemistry and Microbiology

Radiology:

• Advanced CT and MRI for evaluation of Live donor Dr Rajat Bhargava head of Mri and CT is an expert in calculating Liver volume and providing the proper Vascular and biliary images Sonologist ( Dr Sonali) an expert in performing Intraoperative post Liver Transplant doppler USG Interventional Radiology: for vascular and biliary interventions

Liver Transplantation Team:

The LIVER Transplant team at Wockhardt Hospitals is Headed by Prof Dr S K Mathur MS,FACS and consists of:

• two fully trained Liver transplant Surgeons • a Microvascular surgeon • and 4 assistant surgeons. • 3 well trained anaesthetists with experience in liver cases and liver transplantation • Team of trained Intensivists • Hepatologists • Social workers cum transplant coordinators

Medical Breakthroughs in Successful Liver transplantations done at Wockhardt Hospitals:

The team has done successful Cadaver as well as Live donor Partial(LDLT) liver Transplantations.

Case 1: Mr Jogilkar LDLT from son to father (2yrs 6 months)

Case2:Mr Chaturvedi Cadaver Transplantation(1yr 5months)

Case3: Jitin 11 yrs LDLT Father to son (1yr 4months)

Case4: Mr Kathuria Cadaver Transplantation (3months)

Liver Surgery :

Dr S.K Mathur has experience of more than 20 years in performing all types of liver resections for benign ( hemangioma, adenoma) as well as malignant tumors ( Primary & Metastatic). Following major resectional surgery of the liver; most of the patients make uneventful recovery and require one or two day stay in the intensive care and are discharged by fifth-7th day of the surgery. Resections for large liver tumours are performed using advanced resectional techniques like hanging maneuvour, piggy-back technique, total anterior approach etc. Benign tumours of

the liver like Hemangiomas, are treated either by resection or enucleation.

Liver Tumors:

Major or complex resections of the liver are performed mainly for malignant tumors of the liver which can be either primary i.e., arising from the liver itself like Hepatocellular carcinoma (HCC) or metastatic i.e., they originate in some other organ and then seed the liver; like metastasis from colorectal carcinoma.

Resections for large liver tumours are performed using advanced resectional techniques like hanging maneuvour, piggy-back technique, total anterior approach etc.

Case Report -1 : Right Hepatectomy for large HCC with total anterior approach

Case Report- 2 : Left hepatectomy for Hepatoblastomea in a 18 months old baby Benign tumours of the liver like Hemangiomas, are treated either by resection or enucleation.

Case Report – 3 : Enucleation of large symptomatic left lobe hemangioma

Case Report - 4 : Resection of large Right liver Hemangioma

Liver Cysts:

• The symptomatic Cystic lesions in the liver ( congenital,cysts, Hydatid cysts) are treated using Minimally invasive surgical techniques for suitable cases.

Case Report- 5: Laproscopic evacuation and deroofing of Hydatid cyst in the liver.

Liver Trauma:

• The department has a vast experience in managing all types of liver trauma,both conservatively or when indicated Surgically. Any residual collections,biliomas or bleeding are effectively managed by interventional radiologist.

Case- 6: Liver Trauma treated without Surgery

Indications for liver transplantation

Children :

• Extra Hepatic Biliary Atresia • Biliary Hypoplasia • Hepatoblastoma • Metabolic disorders such as alpha-1antitrypsin deficiency, Wilson's disease

Adults :

• Cirrhosis • PBC • Sclerosing cholangitis • Liver cancer (selected cases)

Common to Paediatric and Adult patients :

• Fulminant Liver Failure • Cryptogenic cirrhosis • Hepatitis B & C associated end stage liver disease

Absolute contraindications :

• HIV • Disseminated cancer (primary or metastatic) • Unfit for Major Surgery

Selection of recipients and timing of transplant :

Selection of patients for transplantation requires consideration of not only medical criteria (see above), but also the socioeconomic and educational background of the family. This is of paramount importance because in addition to the initial expenditure, receiving a transplant also involves a lifelong commitment on the part of the family to spend an average of Rs.12000/month on immunosuppression and to adhere strictly to the postoperative care protocol including anti-infection precautions and long-term medication.

Pre Transplant assesment in Liver Transplantation

This involves assessment of :

• Liver disease • liver function tests • Doppler Ultrasonography/ CT scan/MRI

• Esophago - Gastro - Duodenoscopy • Liver Biopsy (selected cases ) • Infection/cancer markers • Infection screening • Nutritional and electrolyte status • Cardiac, Respiratory and Renal function • Surgical & Anaesthetic risks • Social, Psychological and Economic issues • Patient and family counseling

This is a very important aspect of the pre-transplant process. The aim of this phase is three pronged

• To identify the cause of liver failure • To rule out contraindications for the transplant • To assess the fitness of the patient for the procedure.

Living related liver transplant

There is high-incidence of deaths on liver transplant waiting lists due to a shortage of cadaver donors all over the world. This problem is especially grim in Asian countries where donation rates are very low due to social and cultural reasons and also lack of awareness among public. Live donation though a major operation, can be undertaken safely. The donors can be discharged from the hospital within 10 days, and majority of them do not even require blood transfusion. In addition, liver has a large reserve functional volume and one can safely remove as much as 70% of the healthy liver without precipitating liver failure. Living donation only involves removal of 30% for paediatric recipients and 50-55% in the case of adult recipients. The advantages of LRLT are many. It almost guarantees an organ for each child with a suitable parent donor, and now with the right lobe transplants technology, many adults who can not wait for cadaver donor, can be safely transplanted.

Minimal Invasive Techniques for treating Non Resectable Liver Tumors

Local ablative therapies / Chemoembolisation:

Minimally invasive techniques are used at also used at Wockhardt Hospitals for the treatment of non-resectable tumours of the liver. These treatments are the options if surgery is not possible due to cirrhosis (or other conditions that cause poor liver function), the location of the tumor within the liver, or other health problems.Minimally Invasive Procedures for Non-Resectable Liver Tumors These techniques include

• RFA: Radio-frequency ablation of the tumour which can be either percutaneous under

Ultrasound or CT guidance or during open surgery. • PEI: Percutaneous Ethanol Injection of the tumour • TACE:Chemo-embolisation of the tumour using interventional radiological

techniques. • TACE for unresectable HCC

Portal Hypertension :

Portal hypertension and its complications (mainly bleeding from Varices) remain important clinical problems despite advances in treatment and understanding of the disease. Professor Mathur is recognised world over as an authority in the management of portal hypertension with huge experience of managing more than 600 patients of portal hypertension since 1982. Researched and developed an effective, safe and economical Sclerosant (3% Aqueous Phenol) for Esophageal variceal injection.It has been used more than 1000 patients since 1983.Developed inexpensive Injector indigenously for sclerotherapy. He has to his credit developed his own surgical technique for emergency rebleed - mathur’s modification of Sugiura’s procedure, which is recognized world over with rebleed rate of < 5%. Wockhardt Hospitals,Liver Center also performs all types of porto-systemic shunts including the selective shunts such as Distal Spleno-renal shunt. Portal biliopathy, a term used for clinical condition where patient develops obstructive jaundice due to compression of the bile duct by portal cavernoma , is well recoganised. Wockhardt Hospitals,Mumbai has a vast experience in treating such cases where portosystemic decompression by shunt surgery with or without biliary diversion that has resulted in permanent cure of the disease. This is one of the few units in the country with capability and experience of treating portal hypertension with all available treatment modalities namely – medical management, endoscopic therapy, TIPS and SurgeryThe unit has large experience in managing case of non-cirrhotic portal hypertension and Budd-Chiari Syndrome Dr Mathur has published about 30 research papers on Portal hypertension in International and Indian National journals and written chapters in books and regularly get invited to deliver guest lectures on surgical management of Portal hypertension at International and National conferences and CMEs. Quality of life after liver transplant The change in the quality of life of a patient after a transplant is truly amazing. Most people resume their normal activities including work within three months of the transplant. Apart from the fact that they need lifelong immunosuppressive medication (as is the case with any organ transplant) to prevent rejection of their new liver, they can expect a life which is

normal in all respects including longevity, reproductive function and physical activity. Most women have normal pregnancy after liver transplant. In the case of children, those with growth failure secondary to liver disease will resume growing and that there appears to be a general improvement in lifestyle.

Details about Doctor SK Mathur : Dr. Surendra Kumar Mathur is practicing surgeon-having passion for Hepato-Billiary Surgery. He is president of Indian Association of surgical Gastroenterology 2004-2005, Member of Scientific committee of international HPB Association 2004- 2005 and refree of British Journal of surgery. He has been invited faculty at 6th world congress of IHPBA, Washington, June 2004 & European HPB congress, Heidelberg, Germany, May 2005. He is also involved in teaching medical undergraduates at university hospital Aintree, Liverpool, UK. He is member of Editorial Board of Indian Journal of Gastroenterology, Surgery, Indian journal of clinical practice, Gastroenterology. He also has membership of many International and National Scientific Societies. He is invited speaker at many international and national conferences. He is recipient of Senior Level Post doctoral Fellowship of French Government.

Dr Mathur has special clinical experience in managing Liver tumors, Liver cysts, Biliary tumours including Hilar cholangiocarcinoma, and Gall bladder carcinoma. He regularly performs Major Liver resections for these lesions with morbidity and Mortality (<5%) matching international results. He has a large experience in managing patients with obstructive Jaundice (endoscopic and Surgical), in planning the management of Post cholecystectomy bile duct injuries & strictures and performing Bilio-enteric anastomosis for the same including revision surgery. He specializes in management of Pancreatic diseases incuding Sugery for Acute Pancreatic necrosis and chronic Pancreatitis, Pancreatic pseudocyst and pancreatic tumors. He has accomplished himself with restorative surgery for Ulcerative colitis and polyposis coli i.e Total proctocolectomy with Ileal pouch -anal anastomosis (thus avoiding a permanent Ileostomy). He also specializes in management of complex Entero-cutaneous fistulae and revision surgery for recurrent intraperitoneal adhesions and Incisional hernias. He is accomplished in Endoscopic and Surgical management of Upper G.I. bleeding.

Scientific Presentations given: Total 70 (International Conferences: 15 & National Conferences: 55)

Publication (Invited Articles)

• Liver Transplantation in India – Are we ready? 1991

• Liver Transplantation – An overview in G.E. Surgery Annual 1995.

• Liver Transplantation- Gastroenterology Today 1997.

• Hepatatic Transplantation. Karnataka Medical Journal 1995.

• Liver Transplantation in A.P.I. Text book of Medicine.

Membership of NGOs:

• National Liver Foundation (NLF), Mumbai.

• National organ Donation Campaign (NODC), Mumbai.

Member of Organ Transplantation Programmes of Govt. of Maharashtra:

• Maharashtra Confederation for Organ transplantation (MCFOT)

• Zonal Transplantation Coordination Committee (ZTCC), Mumbai

• Member of Expert Committee for drawing Guide Lines for Liver Transplantation.