Living Donor Liver Transplantation Dr Shridhar G Iyer, Consultant Hepato-Biliary Surgeon

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1 Transplanting since Issue 2007/4 MICA (P) 126/04/2007 HIGHLIGHTS Living Donor Liver Transplantation A New Liver A New Lease of Life Welcome to A/Professor Madhavan and farewell to Beatrice 6 Editorial Committee Editor: Dr Stephen Chang Members: Dr Kenneth Mak Dr Dede Sutedja Dr Dan Yock Young Dr Marion Aw Dr Shridhar Ganpathi Ms Maureen Da Costa Ms Jasminder Kaur Mr David Lim Ms Jocelynn Seah Ms Germaine Yang Advisor: A/Prof K Prabhakaran A/Prof KK Madhavan What You Need to Know About Living Donor Liver Transplantation Dr Shridhar G Iyer, Consultant Hepato-Biliary Surgeon Background The demand for livers has grown tremendously for patients with end stage liver diseases like hepatitis B and C related liver cirrhosis, alcohol related cirrhosis, autoimmune diseases and cancer of liver. Due to organ shortage, many patients waiting for livers have poor outcomes while on the waiting list or become too sick to undergo a transplant. Donor organizations attribute this organ scarcity to not enough people fi lling out donor cards or discussing with their families their wish to donate organs. The shortage has given rise to living-donor surgery, where a portion of the liver, either the right or left lobe, depending on the age and body size of the recipient, is surgically removed from a healthy donor and transplanted into the recipient. If a patient can receive part of the liver from a relative, he or she need not wait for a cadaver organ. Thus, living donor liver transplantation can be an important alternative for many patients. The other advantage it offers is that the transplant can be scheduled electively. It is also possible that the quality of the liver may be better, as living donors are usually young and healthy adults who have undergone a thorough medical evaluation over several days or weeks. Preservation time (when the liver is stored) is less. However, the disadvantage is the need for healthy individual to donate. Evolution Although liver transplantation was well established in the Western countries in the 1980`s, many Asian countries did not see the introduction of cadaveric (brain dead donor) liver transplantation until the 1990`s due to various issues such as religious opposition, debate over brain death and public opinion. 1

2 Living donor liver transplantation (LDLT) was originally exclusively used in small children wherein a small part of the left lobe of the liver is removed from the adult and transplanted into the child. The next major challenge was the application of the procedure to large adolescents and adults who will need a larger portion of liver to meet their physiologic demands. Living donor liver transplantation for adults using the right lobe of liver was introduced in Japan in Since then the procedure has been widely performed in many parts of Asia including Korea, Taiwan, Hong Kong and Singapore. Even in Western countries despite higher cadaveric donation rates, there is an increasing gap between available donors and recipients on waiting list, leading to adoption of LDLT as an option for patients. In Singapore, the surgeons in the NUH liver transplantation team have also undergone training in LDLT and offer the procedure following a multidisciplinary evaluation of the potential donor and recipient. Some of the patients who have benefi ted from a living related liver transplant Donor Evaluation It is of paramount importance that the living donor s decision to donate must be completely voluntary without coercion and truly altruistic. It is the responsibility of the transplant team and the donor advocate to rule out any evidence of coercion. There should be an independent donor evaluator, ideally the donor is the one who initiates the evaluation process and the prospective donor clearly understand all aspects of the evaluation and procedure and in particular, the potential risks. Potential donors need to have the ability and willingness to comply with long-term follow-up. In Singapore up to second degree relatives or spouse between 21 and 55 years of age can donate provided they are healthy. The selection of donors for LDLT is stringent and entails extensive evaluation. The evaluation of a potential donor typically occurs in several phases. The purpose of evaluation is to identify contraindications as early as possible and with minimum invasive testing. Donors should be given adequate opportunities to reevaluate and reaffi rm their decision. Donors must be healthy, close to their ideal body weight, not taking many medications and not have had previous abdominal operation. The fi rst phase involves establishing relationship with patient, psychosocial support system, thorough history and physical examination, blood type compatibility; blood tests for screening of both the liver functionand kidney function, screens for metabolic diseases, tumor markers, serology for viral hepatitis and diseases, urine test, chest x-ray and ECG. The second phase involves assessment of the liver volumes, anatomy, blood vessels, biliary system on CT scan and MRI; lung function, cardiac evaluation, consultations with psychiatrist and an independent physician. The third phase involves any additional testing including liver biopsy, final informed consent and a meeting with the Transplant Ethics Committee. 2

3 The Operation Living donor liver transplantation is possible because the liver has the unique ability to regenerate, or grow. Regeneration of the liver happens over a very short period possibly days to weeks. So when surgeons remove a piece of the donor s liver, the part that remains in the donor grows back almost to its original size. With a right lobe adult LDLT, both the donor and the recipient are left with approximately half of the normal adult liver volume, which adds some risk to the procedure. In general, the added risk for the recipient is compensated for by their better health status at the time of the transplant. Because of the remarkable regenerative capacity of the liver, both hemi-livers rapidly regenerate to reach the volume of a normal human liver. Typically, the remaining liver reaches greater than 85% of initial hepatic volume within 1 week after transplant, and regeneration is complete within about 3 months. Donor liver marked before splitting Living donor liver transplantation requires two operations: a partial liver resection performed on the donor; and a hepatectomy (removal of the recipients liver) with liver transplantation of partial graft on the recipient. In adult LDLT, usually, about percent of the donor s liver is removed. The liver is divided into a right lobe and a left lobe. The anatomical division between the lobes permits surgeons to divide the liver into two parts, which can function independently of each other. The right lobe comprises approximately 60 percent of the total liver volume, and the left lobe comprises approximately 40 percent. During the surgery, the donor s gallbladder is also removed. When the recipient is a small child, a piece of the donor s left lobe, called the left lateral segment, is removed. Transecting the donor liver The main risks of LDLT are those associated with any major liver surgery which includes bleeding, infection, a negative reaction to the anesthesia, and, rarely, death. Complications may occur in 10% to 30% of donors. There is a risk of bleeding and more commonly, bile leakage from the cut edge of the liver. This is usually treatable without surgery though rarely re-operation may be necessary. Other common complications include hernia and bowel obstruction. The estimated risk of death from donor hepatectomy for adult LDLT is 1 death in 300 patients undergoing right lobe donations (0.2%-0.5%). It is lower in donation for children. 3

4 The Operation (Continued) Surveys of donor quality of life post-transplant is that most donors report feeling good, are happy with their decision to be a donor, and would do it again if they could. These sentiments tend to be expressed regardless of whether or not the recipient has had a positive outcome. Furthermore, an evaluation of donors revealed minimal evidence of psychological impairment within the 6 to 12-month period following the procedure. Majority of donors return to pre-donation activities by a median time of 2 to 3.3 months. Donor liver graft after splitting Remnant liver in donor Continuing refinements in surgical techniques, research and more refined donor selection protocols will contribute to successful living donor transplant outcomes, reducing the risks of morbidity and mortality for both donor and recipient. LDLT will increasingly be an alternative hope for the patients on the liver transplant waiting list. If you would like more information about the NUH Liver Transplant Programme, visit our website at Liver_Transplant@nuh.com.sg Telephone No: / Fax:

5 A NEW LIVER AND A NEW LEASE OF LIFE When Esther Aw is not attending classes at the Association for Persons with Special Needs (APSN), she helps out at a Western food stall three times a week. In her free time, the 20-year-old enjoys TV drama serials and listening to music. Before January 2007, however, life was very different. Esther was diagnosed with biliary atresia when she two months old. Biliary atresia damages the liver because bile ducts inside or outside it are blocked, leading to a build-up of waste within the body. Although her condition improved slightly after an operation to clear the blockage then, it took a turn for the worse as she grew older. In 2001, at the advice of doctors from NUH, Esther s mother, Mdm Siow Siew Choo, agreed to put her on the liver transplant waiting list. Her condition gradually deteriorated and she started getting sick often. She would have to be admitted into hospital every month and sometimes stayed for as long as four weeks, she says. Her liver condition worsened drastically last year and she would complain of pain and discomfort all over, especially near the abdomen. Her legs also became very swollen. She was so tired, she had to rest in bed all day. There was no medication to improve her condition. Being ill made her very frustrated so she became bad-tempered too. And the worst part about it was, I could not do anything to help alleviate her suffering. Says the part-timer cleaner who has two other daughters aged 17 and 11, We had been waiting for such a long time that I was beginning to resign myself to Esther s condition. The doctors said her condition was at its worst stage and was affecting her lungs. According to them, a transplant was her only hope. I had, in fact, wanted to donate part of my liver to her, but it was not suitable. It was only in January this year that Esther underwent a deceased donor liver transplant successfully. Mdm Siow and Esther say they will always be thankful for the liver donor s generosity and kindness. We don t know who the donor was. After the liver transplant, we wrote a thank you card to the donor s family to express our gratitude, Mdm Siow reveals. Esther returns to the hospital for a checkup every month. Her condition has improved steadily since the transplant. Meanwhile, Esther is looking forward to fulfi lling her childhood ambition. I want to become a kindergarten teacher. I enjoy looking after younger children because I can tell them what to do. Now that would be fun, wouldn t it? she muses. Esther (extreme right) with her mother and younger sisters 5

6 A WARM WELCOME TO OUR NEW DIRECTOR OF LIVER TRANSPLANT AND HEAD OF HEPATOBILIARY SURGERY Let us warmly welcome Associate Professor Krishnakumar Madhavan who has joined us as Director of the Liver Transplant programme. A/Prof Madhavan obtained his medical degree MBBS in 1979 from University of Poona, India. After training in General Surgery at the Post-graduate Institute of Medical Education & Research in India, he obtained his FRCS from Royal College of Surgeons of Edinburgh 1989 while serving as Medical Offi cer in Ahmadi Hospital, Kuwait from January June He then migrated to United Kingdom, and subsequently served as Consultant Hepatobiliary and Transplant Surgeon in the Scottish Liver Transplant Unit, Royal Infi rmary of Edinburgh ( ). A/Prof Madhavan is married to Seema and blessed with two children, 20 and 17 years old. His children are now receiving education abroad and his wife will soon be joining him in Singapore. He has special interest in liver, kidney and pancreatic transplantations and hopes to build a multidisciplinary team and take liver transplantation in Singapore to a sustainable high that can consistently serve the people of Singapore. In addition, he would like to establish within the next few years, a close connection between liver, kidney and pancreatic transplantation, and along with cardiac and thoracic organ transplantation, build up an Asian Centre of Organ Transplantation. We are certainly looking forward to an exciting era of transplantation in Singapore! Welcome on board, A/P Madhavan! We would also like to take this opportunity to thank A/Prof K. Prabhakaran for his leadership and guidance as Director over the past years. Thank you! Farewell to Beatrice.. It is with a heavy heart that we say farewell to Beatrice Chang, our liver transplant dietician for the last 6 years. Her knowledge and involvement in the programme has been invaluable. We wish her all the best in her future undertakings back in Taiwan.. This newsletter is supported by 6