LIVER transplantation   Present      SCENARIO                  in India…      Dr. PARVIDER S. LUBANA          MS; D.N.B. F...
ANATOMY…… Eight segments, based on arterial  and portal venous inflow.   Segment 1 -caudate lobe.    Independent lobe. ...
Couinad’s segmental divisionof the liver..
Structures in the Hilum of the Liver: HDL :   Common Bile duct, Hepatic artery, portal vein.
Functions of the liver…                                     Detoxification Storage of iron,   Production       of chemical...
   Physiology of liver …   Maintaining core body temprature   ph balance and corection of lactic acidosis   Synthesis ...
HOWEVER……IF….  The functioning of the liver is   inadequate to meet the  requirements of the body         liver failure
CAUSES OF      LIVER FAILURE…oo   1. Inflammation of the liver over a prolonged time period.o     2. Chronic alcohol intak...
Treatment….              Liver              Transplantation
LIVER TRANSPLANTATION“The only option for people whose liver can   no   longer function”
In the last 40 years, Liver transplantationhas evolved from an experimental procedureconfined to laboratory to a clinicall...
Since early times, the idea of tissue andorgan Transplantation has captured theimagination of the successive generation an...
MILESTONES IN ORGAN TRANSPLANTATION…..1954 Joe Murray performed successful kidney Transplant     between identical twins.1...
1978 - Roy Calne introduced cyclosporin into clinical practice.1981-   Bruce Reitz & Normann Shumway performed first  succ...
   Chronic Liver Disease is 10th leading cause of death    in India.. 25000 deaths annually.        (3rd National Health ...
INDICATIONS FOR LTx:Fulminant Hepatic Failure :o Alcoholic Liver Diseaseo Chronic Hepatitis C & Hepatitis B infection.o No...
27000 patients need LTX in India
Ideal Candidate FOR LIVER TRANSPLANTATION …o   Presence of irreversible liver disease and a life    expectancy of less tha...
CROSS SECTION OF A NORMAL LIVER.    The Holes Are Bile Ducts.
“FATTY LIVER” –ALCOHOLIC LIVER DISEASE.NOTICE THE YELLOW COLOUR AND SWOLLENAPPEARANCE
LIVER   WITH CIRRHOSIS DUE TO ALCOHOLCONSUMPTION   .   NOTICE THE   SMALL NODULES.
A   LIVER   WITH METASTATICADENOCARCINOMA.
CLOSE UP OF AN        ALCOHOLIC HYALINE LIVER.
AN EXAMPLE OF   HAEMOSIDEROSIS.
HEPATIC CELL CARCINOMA.
HCC
CONTRAINDICATIONS TO LTXo   Presence   of a malignancy in any other part of the    body.o   Presence   of an active infect...
DEFINITIONS OF COMMON TERMS   ALLOGRAFT – an Organ or Tissue Transplanted from one    individual to another.   SYNGENEIC...
Where does a Liver for a transplant come from ?  There are two types of LTX options:  Living donor transplantation        ...
LIVER TRANSPLANTATION- DONORS   Live related donors:    The patient’s blood relative. Rate of success is better if the li...
DONOR EXCLUSION CRITERIA Age > 60 Dopamine >10 mcg/kg/min Cardiac arrest > 15 min. Hospitalization > 3 days Transamin...
RECIPIENT PROCEDURES Most     difficult part of LTX.   Hepatectomy with removal of corresponding abd.    Aorta & IVC.  ...
PRE Opr. INVESTIGATIONS….o   Computed tomography.o   Ultrasound to determine blood flow to the liver.o   Echocardiogram to...
PRE OPERATIVE VOLUMETRIC DETERMINATIONOF LIVER   Helical CT     Used   to directly measure liver volumes    Formula for...
SELECTION CRITERIA FOR ORGAN ALLOCATION…o   United Network for Organ Sharing (UNOS) governing    body for organ allocation...
PROCEDURE…. In liver transplant surgery the diseased liver is removed through an incision made in the upper abdomen. The n...
Normalanatomicallocation             Right upper quadrant of theof the                abdomenLiver…
UPPER ABDOMINAL INCISION…
No…         Not the Entire Liver-just a portion of the normal live donor Liver is required .                            ( ...
LIVER RESECTION MODES…o   Finger fracture, kelly clamps.o   Cavitron Ultrasonic Surgical Aspirator (CUSA)    ultrasonic di...
Donor Graft
Donor graft
HepaticPortal                                          arteryvein                                           Common        ...
Anastomosis of Full size cadaver Liver
Living donor graft
Comparison   –before and after transplantation
POST OPERATIVE COMPLICATIONS…    Right pleural effusion    Hepatic edema secondary to aggressive resuscitation &     inc...
OUTCOMELTx improves the quality and duration of life in most recipients. Overall LTX outcome has improved progressively  ...
Dr.Tom Starzl                1st orthotopic Liver                Transplant                (1963) Denver
Overall the future of LTX remainspromising.The potential future       obstacles in India includes:   Organ shortage   Ex...
TYPES OF GRAFT REJECTIONHYPERACUTE: Immediate      graft destruction due to pre    formed anti HLA/ABO anti bodies.   Ch...
ACUTE /CELLULAR REJECTION   Occurs during first 6 mths, mediated by T cell    dependent immune response. Reversible   in...
CHRONIC ALLOGRAFT REJECTION ..   Occurs after first 6 months. Most   common cause of graft failure. Non immune factors ...
HLA      ANTIGENS Are the most common cause of graft  rejection Their physiological function is as antigen    recognitio...
IMMUNOSUPPRESSIVE              THERAPYMost immunosuppressive protocol use a combination of immunosuppressive drugs.Individ...
Thus   …..remember…….LIVER IS PRICELESS
• Watch those drugs !                               •      All drugs are chemicals,                                   and ...
•   Dont eat too much fatty food…    I make the cholesterol your body needs, and I     try to make the right amount.     G...
•   Dont drown me in beer, alcohol   or    wine!    Even one drink is too much for some    people and could scar me for li...
•   Be careful with aerosol sprays!                       •                           Remember, I have to detoxify what   ...
WARNING: I cant and wont tell you Im in trouble untilIm almost at the end of my rope... and yours.Remember: I am a non-com...
?
Thanx aBunch
Liver Transplantation present scenario in India
Liver Transplantation present scenario in India
Liver Transplantation present scenario in India
Liver Transplantation present scenario in India
Liver Transplantation present scenario in India
Liver Transplantation present scenario in India
Liver Transplantation present scenario in India
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Liver Transplantation present scenario in India

  1. 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. 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. 3. Couinad’s segmental divisionof the liver..
  4. 4. Structures in the Hilum of the Liver: HDL : Common Bile duct, Hepatic artery, portal vein.
  5. 5. Functions of the liver… Detoxification Storage of iron, Production of chemicals vitamins, of bile minerals ManufactureStorage of energy Production of proteins and blood clotting factors
  6. 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. 7. HOWEVER……IF…. The functioning of the liver is inadequate to meet the requirements of the body liver failure
  8. 8. CAUSES OF LIVER FAILURE…oo 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. (Wilsons disease, Menkes disease).o 7. Liver (HCC) & Bile D cancer (CC).
  9. 9. Treatment…. Liver Transplantation
  10. 10. LIVER TRANSPLANTATION“The only option for people whose liver can no longer function”
  11. 11. In the last 40 years, Liver transplantationhas evolved from an experimental procedureconfined to laboratory to a clinicallytherapeutic intervention that is appliedworld wide to virtually all form of end stageliver disease.• In 2010 alone 9040 Liver Transplants weredone in 157 Transplant centers world wide.• In India the rate is 120-125 Transplants ayear at various centers.
  12. 12. Since early times, the idea of tissue andorgan Transplantation has captured theimagination of the successive generation andover the centuries numerous fancifuldescriptions of successful transplants havebeen recorded.One of most widely cited early example isthat of Christian Arab Saints Cosmos andDamian performing a miraculoustransplantation of the leg.
  13. 13. 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).
  14. 14. 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).
  15. 15.  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%)
  16. 16. INDICATIONS FOR LTx:Fulminant Hepatic Failure :o Alcoholic Liver Diseaseo Chronic Hepatitis C & Hepatitis B infection.o Non-alcoholic steatohepatitiso Autoimmune Hepatitiso Primary Biliary Cirrhosiso Primary Sclerosing Cholangitiso Hepatic tumorso Metabolic and genetic disorders
  17. 17. 27000 patients need LTX in India
  18. 18. 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 patients ability to work or with his quality of life.o Progression of liver ds that will predictably results in mortality exceeding that of transplantation.
  19. 19. CROSS SECTION OF A NORMAL LIVER. The Holes Are Bile Ducts.
  20. 20. “FATTY LIVER” –ALCOHOLIC LIVER DISEASE.NOTICE THE YELLOW COLOUR AND SWOLLENAPPEARANCE
  21. 21. LIVER WITH CIRRHOSIS DUE TO ALCOHOLCONSUMPTION . NOTICE THE SMALL NODULES.
  22. 22. A LIVER WITH METASTATICADENOCARCINOMA.
  23. 23. CLOSE UP OF AN ALCOHOLIC HYALINE LIVER.
  24. 24. AN EXAMPLE OF HAEMOSIDEROSIS.
  25. 25. HEPATIC CELL CARCINOMA.
  26. 26. HCC
  27. 27. CONTRAINDICATIONS TO LTXo 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.
  28. 28. 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.
  29. 29. 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.
  30. 30. 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.
  31. 31. 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
  32. 32. 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.
  33. 33. 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
  34. 34. PRE OPERATIVE VOLUMETRIC DETERMINATIONOF LIVER Helical CT  Used to directly measure liver volumes Formula for association with BSATOTAL LIVER VOLUME = 706.2 X BSA (in m2) + 2.4
  35. 35. 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]
  36. 36. 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 patients blood vessels and bile ducts.
  37. 37. Normalanatomicallocation Right upper quadrant of theof the abdomenLiver…
  38. 38. UPPER ABDOMINAL INCISION…
  39. 39. 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
  40. 40. LIVER RESECTION MODES…o Finger fracture, kelly clamps.o Cavitron Ultrasonic Surgical Aspirator (CUSA) ultrasonic dissectoro Harmonic scalpelo Radiofrequency dissecting sealero Argon laser
  41. 41. Donor Graft
  42. 42. Donor graft
  43. 43. HepaticPortal arteryvein Common bile duct ivcAnastomoses done between the Portal vein,Hepatic artery, IVC and Bile duct of the donor liver and the recipient
  44. 44. Anastomosis of Full size cadaver Liver
  45. 45. Living donor graft
  46. 46. Comparison –before and after transplantation
  47. 47. 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
  48. 48. OUTCOMELTx 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.
  49. 49. Dr.Tom Starzl 1st orthotopic Liver Transplant (1963) Denver
  50. 50. Overall the future of LTX remainspromising.The potential future obstacles in India includes: Organ shortage Expanding recipient pool Financial constraints Religious myths. Rigid govt. policies* *Chinese model
  51. 51. TYPES OF GRAFT REJECTIONHYPERACUTE: Immediate graft destruction due to pre formed anti HLA/ABO anti bodies. Characterized by intravascular thrombosis. Very rare in LTX.
  52. 52. 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.
  53. 53. 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.
  54. 54. 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.
  55. 55. IMMUNOSUPPRESSIVE THERAPYMost 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.
  56. 56. Thus …..remember…….LIVER IS PRICELESS
  57. 57. • Watch those drugs ! • All drugs are chemicals, and when you mix them up without a doctors 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 arent necessary is a bad habit. All those chemicals can really hurt a liver.
  58. 58. • Dont 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, Ill really do my stuff for you!
  59. 59. • Dont drown me in beer, alcohol or wine! Even one drink is too much for some people and could scar me for life.
  60. 60. • 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!
  61. 61. WARNING: I cant and wont tell you Im in trouble untilIm 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
  62. 62. ?
  63. 63. Thanx aBunch

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