Liver transplantation is a surgical procedure done by a hepato-biliary surgeon or liver transplant surgeon to replace the diseased liver with a healthy liver. The healthy liver is either retrieved from a cadaver or it can also be donated by a living person. The living donor, in this case, is usually a relative of the patient requiring the liver transplantation. Liver transplant is done in cases of end-stage liver diseases and in cases of acute liver toxicity/failure not amendable to medical therapies. The type of liver transplantations performed is of the following two types.
Cadaveric Liver Transplant:
In a cadaveric liver transplant, the liver is taken from a brain-dead patient. Since the number of brain-dead patients is limited, the order of patients receiving the liver is decided on an objective scale/priority. The liver transplant team uses a score called as ‘Model for End-Stage Liver Disease’ (MELD) score to prioritise the potential recipients. Patients who are the sickest are allotted a higher priority than the lesser sick patients. Thus a waiting list is prepared and the recipients are called for liver transplant as and when their number in the waiting list comes up. On declaration of a brain-dead patient, the hospital’s dedicated organ donation team counsels the next-of-kin of the deceased person.
When the patient’s family consents for donating the organs/liver, this can be retrieved for any patient on the hospital’s waiting list or in case of exhaustion of the list, the hospital notifies the hospitals in the district/state/national panel of recognized liver transplant centres. On a request from a hospital, the liver is extracted from the cadaver and sent for transplanting into a potential donor. This involves a long waiting period for the patient and the surgery is planned for on an urgent basis on the availability of liver from a brain dead individual. The recipient is these cases end up receiving the organ at a later advanced stage of their disease which increases the postoperative outcome.
Also, prolonged storage of the retrieved organs in cold environment can lead to inflammatory changes, which can get aggravated after reperfusion, thus posing a theoretical threat to the outcome of the liver transplanted after a cadaveric retrieval.
Living Donor Liver Transplant:
In case of liver taken from a living donor, the concept of waiting list is not involved. With increasing number of liver transplants being carried out, there is always a long waiting list involved and limited number of cadaveric livers. This problem is not encountered in cases of living-donor liver transplant. The donors, in this case, are usually relatives of potential recipients. Most of these cases are done in paediatric liver transplant where the donors are generally parents of the sick child. This gives a psychological positive boost to the donor donating the liver.
Also, the surgery can be carried out in a well-planned manner. As there is no waiting list involved, the recipient need not be waiting to the extent that his/her disease is severe enough to prioritise him/her on the list for liver requirement. Thus the transplant can be performed at a much earlier stage of the disease, thereby increasing the likelihood of post-operative survival and better healing process.
Also, the cold storage involved is for a lesser period in cases of living donor and thus the inflammatory damage of reperfusion is less to the liver. Living donor surgeries are associated with lesser rate of immunological rejections as the liver is usually resected from a genetically related individual and transplanted within a short cold storage time. But the surgical disadvantage in cases of living donor transplant is the level of dissection of the bile duct and blood vessels.
In cases of living donor surgery, the level of dissection of the bile ducts and blood vessels is at a much lower level, usually the right lobe. Thus the vessels and bile duct in the donated liver is of a much smaller caliber and this involves much surgical expertise in suturing the bile duct and revascularization. This affects the survival and success of the transplant and leads to much more blood loss. This surgery involves risk to the donor as well which was not the case in case of cadaveric transplant. This type of a major surgery involves a considerable mortality risk to the donor. Other risks faced by the donor are biliary complications, infections, bleeding and post-operative pain.
Conclusion:
For patients who are advised liver transplant, there is a long wait for the organ if they opt for cadaveric liver. This is further prolonged as the waiting list for recipient is prepared on the basis of the severity of the liver disease of the recipient. So the patients end up receiving the liver at a later stage of disease progression.
The advantage of opting for living donor liver transplant is that the patient need not wait to deteriorate to an advanced stage and can receive the organ earlier with the surgery being scheduled in a more planned manner. This can improve the postoperative outcome of the recipient but involves significant risks to the donor as well which the donor should consider.
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