Liver transplantation has evolved significantly over the past 50 years since the first successful transplant in 1967. It is now a standard treatment for end-stage liver disease and certain liver cancers. The document discusses the history and technical aspects of liver transplantation as well as current indications, controversies, and myths. Key points include that one-year survival rates are now 85-90% while five-year survival is around 75%. Liver transplantation offers patients with decompensated cirrhosis their only chance for long-term survival.

1. Liver Transplantation
Current status,
controversies & Myths
Dr. Abhishek Yadav
MS M.Ch
Consultant Liver Transplantation
& HPB Surgery

2. • History and Evolution
• Present status
• Current indications
• Controversies
• Myths
• Surgical aspects

3. The history of Liver Transplantation is a
complicated story to tell - it is a story of great
successes and tragic failures
Greg J McKeena

4. The first attempt at liver transplantation- 1963
The 3 year old boy bled to death on the OT table
The complexity and difficulty was so extreme, it took
the team several hours just to make the incision and
enter the abdomen.
Despite the fact that the team had performed over 200 such
procedures in animal models

5. First successful liver transplant 1967

6. 50 years and thousands of
transplants later!

7. Why is Liver transplantation
unique and challenging?
• Uniquely located - thoracic & abdominal
• Large size
• Dual blood supply, multiple veins
• Orthotopic positioning
• Multi system derangement
• High stakes at failure- Nothing to support a failing liver!
• Coagulopathy

8. Evolution of Liver
Transplantation in India
• THOA act was passed in 1994
• Initial attempts in 1995 failed
• First success DDLT and LDLT in 1998
• Only 130 transplants were done till 2004

9. 2000 transplants happen annually
Estimated need is 200,000

10. Prolong survival
Prevent complications
Improve quality of life
Liver Transplantation Who and When?
85-90% 1 year survival
75 % 5 year survival

11. Liver transplantation is an experimental
procedure
Most transplants end up with failure
1

12. Liver Transplantation
Who?
• Chronic Liver disease - cirrhosis
• Acute Liver failure
• Primary liver malignancies
• Congenital disorders
• Evolving (controversial indications)

13. Chronic liver disease
• Decompensation
• Variceal bleed
• Ascites
• Spontaneous bacterial peritonitis
• Hepatic encephalopathy
• Hepatorenal syndrome
H
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14. Why Liver Transplant in cirrhosis
Complication 1yr Survival
▪ Variceal bleeding 60%
▪ Uncontrolled Ascites 50%
▪ Hepatorenal Syndrome 0%
▪ Spontaneous Bacterial Peritonitis 40%
▪ Hepatic encephalopathy 35%
Post Transplant 1 yr survival 85-90%

15. Variceal Bleeding
• 15-20% 30 day mortality with each episode of
bleed
• 1 year survival only 52% in those who survive 2
weeks
The course of patients after variceal hemorrhage Graham DY, Smith JL Gastroenterology. 1981;80(4):800.
Upper digestive bleeding in cirrhosis. Post-therapeutic outcome and prognostic indicatorsD'Amico G, De Franchis R, Cooperative
Study GroupHepatology. 2003;38(3):599.

16. Ascites &Spontaneous
bacterial peritonitis
1 & 2 year mortality 70and 80% respectively after the development of
Bacterial peritonitis
Development of ascites in a patient with liver disease is an indication for
referral for liver transplantation
Gastroenterology. 1993 Apr;104(4):1133-8.Risk factors for spontaneous bacterial peritonitis in cirrhotic patients with ascites.Andreu M1, Sola R, Sitges-Serra A, Alia C,
Gallen M, Vila MC, Coll S, Oliver MI.
Hepatology. 1988 Jan-Feb;8(1):27-31.Recurrence of spontaneous bacterial peritonitis in cirrhosis: frequency and predictive factors.Titó L1, Rimola A, Ginès P, Llach J,
Arroyo V, Rodés J.

17. Hepato renal syndrome
• Development of HRS is a marker of severe liver
dysfunction
• Reversal of liver functions with a transplantation
is the only potential modality for recovery
Dig Dis Sci. 2003 Jan;48(1):179-86.Effects of orthotopic liver transplantation on vasoactive systems and
renal function in patients with advanced liver cirrhosis.Cassinello C1, Moreno E, Gozalo A, Ortuño B,
Cuenca B, Solís-Herruzo JA.

18. Scoring models
MELD >11
Benefits of transplant
outweigh the risks

19. Controversies
• MELD score
• Described to predict mortality after TIPS
• Allocation tool and not a listing tool
• For equitable organ allocation
• Does not consider quality of life issues
• Not validated for living donor transplants

20. Controversies
51 year old male
Dependent wife and 2 children
Refractory ascites impairing work
S. Bilirubin 1.9 ; INR- 1.29 ; Creatinine 1.0
MELD score - 9
Wife is willing to consider transplantation and be a
donor
Are we justified in not considering/offering a liver
transplant?

21. In an ideal world…
• All patients with cirrhosis are primed about the
possible future need for a transplant
• All patients with decompensation of cirrhosis are
referred to a transplant specialist
• Child score >B8 and MELD >12 are definite
indications for transplantation
• Liver transplantation is curative and not
palliative!

22. Any other form of therapy for decompensated
cirrhosis is curative…
2

23. Clichy criteria
King’s College criteria
MELD scoring
APACHE
Dhiman (PGI), 3 adverse CPI
Acharya, age > 50, INR> 3.5, Bil> 40 mg/dl
Acute Liver Failure- Prognostic Models

24. • CT scan Acute on Chronic from true ALF, Liver volume
• Discuss possibility of LT quite early on
• Select donor, ‘cooling off’ period not possible
• Monitor progress without FFP support
• Intervene if deterioration in 72 hrs, Grade III/IV HE
or cerebral edema
What We Do

25. • Attractive because it tackles the tumour and the
liver disease
• Transplantation and resection are the only
curative modalities for HCC
• Initially propagated for non resectable HCC-
Dismal survival
Transplantation for Liver Tumors

27. Philosophy behind Milan Criteria
• To achieve survival rates comparable to those for non
malignant indications
• Logical considering equitable organ distribution
• 75% 5 year survival for malignancy

28. Controversies
• 75 % 5 year survival for a malignancy- isn't it
asking for too much?
• The living donor scenario- when the organ is
directed towards a specific recipient

29. In an ideal world…
• Liver transplantation/resection should be
considered for every patient with an HCC
• Other treatment modalities like TACE/RFA
should be considered when the above are not
feasible
• Transplantation for HCC (LDLT) should be
individualised

30. HCC is a malignant condition hence
transplantation is not an option
4

31. Is age a criteria for
considering transplantation?

32. Transplantation should not be considered
beyond 65-70 years.
5

33. Too sick to transplant!
• They are sick therefore they need a transplant!
• They probably wouldn't be so sick if they had had
a transplant!
• The decision MUST be a multidisciplinary one.

34. Liver transplant is
unaffordable!
• Costs between 30-35,000 USD
• Only 10-15% patients pay more than the
package amount
• Economically more viable than dealing with
complications of liver disease

35. Liver transplantation is unaffordable for the
masses
6

36. Is he/she fit to undergo a
transplant ?
▪ All labs / Coagulation studies
▪ Echocardiography
▪ Stress Echocardiography
▪ P F T
▪ USG Liver Doppler / C T Liver Angio

37. Recipient Evaluation

38. Who can be a donor ?
▪ 1st / 2nd degree relative
▪ Compatible Blood Group
▪ Approval from independent Ethics Committee

39. Who can be a donor ?
▪ Healthy / Fit / Young ( 18 to 55 yrs )
▪ All labs normal
▪ CXR / ECG / Echo / PFT normal
▪ Psychiatry / Physician / Gynae evaluation

40. Donor evaluation
▪ Size of graft
▪ Quality of graft
▪ Type of graft
▪ Anatomy of graft

41. Size : CT Volumetry

42. Size : CT Volumetry
▪ GRWR = Graft volume X 100 = > 0.8
Recipient weight
• i.e. > 600 cc R lobe for a 75 kg recipient
▪ Remnant liver > 30 % of Total Liver Volume

43. Quality : CT for L A I

44. Graft Quality : CT for
LAI
▪ L A I = Mean Liver Attenuation – Mean Splenic attenuation
▪ If LAI > + 5 : steatosis is low
▪ Low LAI may have significant Fat : Liver Biopsy
▪ Fatty Liver : Bad graft for recipient
▪ Bad remnant for donor

45. Anatomy : CT angio for
Veins

46. Anatomy : CT angio for
Veins

47. Anatomy : CT angio for Portal Vein

48. Anatomy : CT angio for Portal Vein

49. Anatomy : CT angio for arteries

50. Anatomy : CT angio for arteries

51. Anatomy : MRCP for bile ducts

52. Anatomy : MRCP for bile ducts

53. The operation(s)
▪ Donor hepatectomy ( R lobe resection )

54. The operation(s)
▪ Donor hepatectomy ( R lobe resection )
▪ Explantation of Recipient Liver

55. The operation(s)
▪ Donor hepatectomy ( R lobe resection )
▪ Explantation of Recipient Liver
▪ Backtable preparation

56. The operation(s)
▪ Donor hepatectomy ( R lobe resection )
▪ Explantation of Recipient Liver
▪ Backtable preparation
▪ Implantation of the graft liver

57. The operation(s)
▪ Donor hepatectomy ( R lobe resection )

60. Porta dissection in donor

61. RHA & RPV clamped
temporarily

62. Parenchymal division : CUSA

64. Parenchymal transection done

68. Leaving Donor Stumps as short as possible

69. Separated lobes

70. Donor safety
▪ Top priority in any LRLT program
▪ Only healthy young donors
▪ Informed consent
▪ Exclude fatty livers : CT / Liver biopsy
▪ Adequate Volume ( > 30 % Remnant )
▪ High quality imaging to look for any anomalies
CT liver angiography / MRCP

71. Donor safety
▪ Intraoperative cholangiogram before bile duct
transection
▪ Ensure no duct narrowing / leak : Saline test
Methylene blue test
Cholangiography
▪ HIDA scan before drain removal

72. The operation(s)
▪ Recipient explantation

73. Diaphragm
Falciform
ligament
Adhesions over
Suprahepatic IVC

74. Diaphragm
RHVRt Inferior
phrenic vein
Rt Lobe

75. Diaphragm
RHV
IVC
Hepatic Artery
Clip on Bile
duct
Clamp on
Portal Vein

76. Diaphragm
RHV Cuff
IVC
Clip on bile duct

78. Diaphragm
RHV Cuff
Sutured
LHV Cuff
IVC

79. The operation(s)
▪ Backtable preparation of graft

80. Backtable : Grafts on Seg 5 , 8 veins
V 8
V 5

81. The operation(s)
▪ Graft implantation

82. Implantation ( plumbing ! )
▪ IVC cross clamped
• RHV / MHV / neo-MHV to IVC
• Graft RPV to recipient RPV
▪ Cross clamp released
• Graft RHA to recipient RHA / LHA
▪ Graft RHD ( or 2 / 3 ducts ) to bile duct / jejunum

83. RHV Cuff
Graft Liver

84. Donor RHV Cuff
Recipient RHV Cuff / IVC

85. Extension graft for MHV

86. R H V & M H V to I V
C

87. R lobe graft after reperfusion

88. Graft RHA to RHA : 8 – 0 / Loupe

90. Graft R H D to bile duct /
jejunum

91. L lobe graft after reperfusion

92. Intra-op Doppler : inflow & outflow

93. Post Operative
• Extubation- Morning after surgery
• ICU- 5-8 days
• Discharge- 15-25 days

94. Follow up
• Weekly visits- 2 months
• Biweekly ( lab tests)- 2 months
• Monthly (lab tests) - 6 months
• 3-6 monthly- For life

95. • Cost
• Nephrotoxicity
• Cardiovascular complications
• Risk of infection
• Risk of malignancy
Complications of immunosuppression

96. Teamwork!

97. Our patients who incite and inspire us
everyday
Thank You!
abhishek.hpb@gmail.com
www.drabhishekyadav.com