A liver transplant usually takes between six and twelve hours. Removing the diseased liver is the most difficult part of the operation. This is because of the risk of developing serious haemorrhage from a combination of portal hypertension (with large veins throughout the abdomen) in combination with defective clotting and less commonly increased and unwelcome breakdown of clots (fibrinolysis).
The careful selection of patients and the improvements of surgical techniques have resulted in large reductions in blood loss. The average requirement for transfusion is now about four units of blood. Some patients do not even need this transfusion. After the operation most patients spend one or two nights in intensive care, although sometimes this can be longer. Next the patient is stepped down to high dependency and then spends around another two weeks in hospital recovering from the operation. Again these times are dependent on the patient’s speed of recovery, and sometimes can be longer.
For the first two months after the operation your liver functions tests will be checked most weeks. After that the out-patient visits become less frequent, and after a year or so only two or three visits per annum are needed. Blood tests at clinic look for rejection and other complications of liver transplantation including kidney damage.
The shortfall in donor livers has resulted in the development of new techniques to make the best use of the livers available. At present these only account for a small percentage of transplants. Most transplants still involve whole livers from deceased donors.
Since it can regenerate, the liver from a donor can be split into two pieces and transplanted into two different recipients. Once transplanted, each piece will grow into a fully functioning organ. Split liver transplants produce the best results when the larger right lobe is given to an adult and the smaller left lobe goes to a child. In some rare cases, split liver transplants may be appropriate for two adults, depending on donor and recipient size.
The number of split liver operations is still low. They may become more widely used if ways to accelerate liver regeneration can be developed. Split liver transplants carry a higher risk of biliary complications, possibly because bile ducts are more likely to be heavily damaged when the liver is divided.
Liver reduction techniques
This is a similar process to splitting a liver, except that one of the lobes is not used. Liver reduction techniques were developed to overcome a shortage of size-matched livers for young children. The success of medical science in being able to reduce liver size to make them suitable for transplanting in small children has also increased the potential donor pool.
Auxiliary Liver Transplants
This technique has been revisited for patients undergoing liver transplantation several years after the first attempts. It involves grafting part of a donor liver onto a patient’s diseased liver to allow it to regenerate. The advantage of this technique is that it offers the possibility of long-term survival without the need for immunosuppressive drugs. The operation has a success rate similar to the standard liver transplant.
It appears that in around 80% of those who survive the operation the native liver regenerates. About two thirds of patients can be tapered off immunosuppressive drugs after two years. When the immunosuppressant drugs are stopped the body then rejects the auxiliary graft and it should just wither away.
Between 2001 and 2005, 52 auxiliary transplants were carried out in the UK (mostly at Kings College Hospital in London). Out of the 52, just 5 of the operations were on people with post hepatitis C cirrhosis.
Living Donor Transplants
In a living donor transplant, a piece of liver is taken from a live person, usually a relative (although livers do not require close genetic matching like some other organs) and transplanted into the patient where it will grow back to full size. While living donor transplants have the potential to dramatically increase the supply of organs, the procedure is not without risk to the donor.
A study in the USA published in 2003 found that 65 of 449 donors (14.5%) experienced at least one complication. These included bile leakage, infection, and excessive bleeding and even death. There were 31 living donor transplants in the UK between 2001 and 2005. 5 of these were for HCV-induced cirrhosis.
In the USA transplant survival rates amongst HCV patients have been significantly lower for those who received livers from living donors. It is now thought that this is due to the complexity of the operation and the surgical teams’ lack of experience in performing this type of transplant. In units with greater experience of the operation, survival rates were similar to those who received livers transplanted from people were dead (cadaveric transplantations).