Liver Transplantation

(Liver Transplant, Hepatic Transplant)

Procedure Overview

What is a liver transplant?

A liver transplant is a surgical procedure performed to replace a diseased liver with a healthy liver from another person. The liver may come from a deceased organ donor or from a living donor. Family members or individuals who are unrelated but make a good match may be able to donate a portion of their liver. This type of transplant is called a living transplant. Individuals who donate a portion of their liver can live healthy lives with the remaining liver.

An entire liver may be transplanted, or just a section. Because the liver is the only organ in the body able to regenerate, a transplanted portion of a liver can rebuild to normal capacity within weeks.

Anatomy of the liver:

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The liver is the largest organ in the body. It is located in the upper right side of the abdomen, beneath the diaphragm, and on top of the stomach, right kidney, and intestines. Shaped like a cone, the liver is a dark reddish-brown organ that weighs about three pounds.

The liver holds about one pint (13 percent) of the body's blood supply at any given moment. The liver consists of two main lobes, each made up of thousands of lobules. These lobules are connected to small ducts that connect with larger ducts to ultimately form the hepatic duct. The hepatic duct transports the bile (fluid that helps break down fats and gets rid of wastes in the body) produced by the liver cells to the gallbladder and duodenum (the first part of the small intestine).

The liver carries out many important functions, such as:

• making bile and producing certain proteins for blood plasma
• changing food into energy
• clearing the blood of drugs and other poisonous substances
• regulating blood clotting

Reasons for the Procedure

A liver transplant may be recommended for persons who have end-stage liver disease (ESLD), a serious, life-threatening liver dysfunction. ESLD may result from various conditions of the liver.

The most common liver disease for which transplants are done is cirrhosis. Cirrhosis is a long-term disease of the liver in which a fiber-like tissue covers the organ and prevents toxins and poisonous substances from being removed. Other diseases that may progress to ESLD include, but are not limited to, the following:

• acute hepatic necrosis - the death of tissue in the liver
• biliary atresia - a condition in which the bile ducts are absent or have developed abnormally
• metabolic disease - conditions that affect the chemical activity in cells that are affected by the liver
• liver cancers - primary tumors (that start in the liver) that have not spread outside the liver
• autoimmune hepatitis - chronic inflammation of the liver, resulting in liver cell damage and destruction

There may be other reasons for your physician to recommend a liver transplant.

Risks of the Procedure

As with any surgery, complications can occur. Some complications from liver transplantation may include, but are not limited to, the following:

• bleeding
• infection
• blockage of the blood vessels to the new liver
• leakage of bile or blockage of bile ducts
• initial lack of function of new liver

The new liver may not function for a brief time after the transplant. The new liver may also be rejected. Rejection is a normal reaction of the body to a foreign object or tissue. When a new liver is transplanted into a recipient's body, the immune system reacts to what it perceives as a threat and attacks the new organ, not realizing that the transplanted liver is beneficial. To allow the organ to survive in a new body, medications must be taken to trick the immune system into accepting the transplant and not attacking it as a foreign object.

The medications used to prevent or treat rejection have side effects. The exact side effects will depend on the specific medications that are taken.

Contraindications for liver transplantation include, but are not limited to, the following:

• current or recurring infection that cannot be treated effectively
• metastatic cancer - cancer that has spread from its primary location to one or more additional locations in the body
• severe cardiac or other medical problems preventing the ability to tolerate the surgical procedure
• serious conditions other than liver disease that would not improve after transplantation
• noncompliance with treatment regimen

There may be other risks depending upon your specific medical condition. Be sure to discuss any concerns with your physician prior to the procedure.

Before the Procedure

In order to receive a liver from an organ donor who has died (cadaver), a recipient must be placed on a waiting list of the United Network for Organ Sharing (UNOS). Extensive testing must be done before an individual can be placed on the transplant list.

Because of the wide range of information necessary to determine eligibility for transplant, the evaluation process is carried out by a transplant team. The team includes a transplant surgeon, a transplant hepatologist (physician specializing in the treatment of the liver), one or more transplant nurses, a social worker, and a psychiatrist or psychologist. Additional team members may include a dietician, a chaplain, and/or an anesthesiologist.

Components of the transplant evaluation process include, but are not limited to, the following:

• psychological and social evaluation: Psychological and social issues involved in organ transplantation, such as stress, financial issues, and support by family and/or significant others are assessed. These issues can significantly impact the outcome of a transplant.
• blood tests: Blood tests are performed to help determine a good donor match, to assess your priority on the donor list, and to help improve the chances that the donor organ will not be rejected.
• diagnostic tests: Diagnostic tests may be performed to assess your liver as well as your overall health status. These tests may include x-rays, ultrasound procedures, liver biopsy, and dental examinations. Women may receive a Pap test, gynecology evaluation, and a mammogram.

The transplant team will consider all information from interviews, your medical history, physical examination, and diagnostic tests in determining your eligibility for liver transplantation.

Once you have been accepted as a transplant candidate, you will be placed on the United Network for Organ Sharing (UNOS) list. Candidates in most urgent need of a transplant are given highest  priority when a donor liver becomes available based on UNOS guidelines. When a donor organ becomes available, you will be notified and told to come to the hospital immediately.

If you are to receive a section of liver from a living family member (living-related transplant), the transplant may be performed at a planned time. The potential donor must have a compatible blood type and be in good health. A psychological test will be conducted to ensure the donor is comfortable with the decision.

The following steps will precede the transplant:

• Your physician will explain the procedure to you and offer you the opportunity to ask any questions that you might have about the procedure.
• You will be asked to sign a consent form that gives your permission to do the surgery. Read the form carefully and ask questions if something is not clear.
• For a planned living transplant, you should fast for eight hours before the operation, generally after midnight. In the case of a cadaver organ transplant, you should begin to fast once you are notified that a liver has become available.
• You may receive a sedative prior to the procedure to help you relax.
• The area around the surgical site may be shaved.
• Based upon your medical condition, your physician may request other specific preparation.

During the Procedure

Liver transplantation requires a stay in a hospital. Procedures may vary depending on your condition and your physician’s practices.

Generally, a liver transplant follows this process:

1. You will be asked to remove your clothing and given a gown to wear.
2. An intravenous (IV) line will be started in your arm or hand. Additional catheters will be inserted in your neck and wrist to monitor the status of your heart and blood pressure, as well as for obtaining blood samples. Alternate sites for the additional catheters include the subclavian (under the collarbone) area and the groin.
3. You will be positioned on the operating table, lying on your back.
4. A catheter will be inserted into your bladder to drain urine.
5. After you are sedated, the anesthesiologist will insert a tube into your lungs so that your breathing can be controlled with a ventilator. The anesthesiologist will continuously monitor your heart rate, blood pressure, breathing, and blood oxygen level during the surgery.
6. The skin over the surgical site will be cleansed with an antiseptic solution.
7. The physician will make a slanting incision just under the ribs on both sides of the abdomen. The incision will extend straight up for a short distance over the breast bone.
8. The physician will carefully separate the diseased liver from the surrounding organs and structures.
9. The attached arteries and veins will be clamped to stop blood flow into the diseased liver.
10. Depending on several factors, including the type of transplant being performed (whole liver versus a portion of liver), different surgical techniques may be used to remove the diseased liver and implant the donor liver or portion of the liver.
11. The diseased liver will be removed after it has been cut off from the blood vessels.
12. The physician will visually inspect the donor liver or portion of liver prior to implanting it.
13. The donor liver will be attached to the blood vessels. Blood flow to the new liver will be established and then checked for bleeding at the suture lines.
14. The new liver will be connected to the bile ducts.
15. The incision will be closed with stitches or surgical staples.
16. A drain may be placed in the incision site to reduce swelling.
17. A sterile bandage/dressing will be applied.

After the Procedure

In the hospital:

After the surgery you may be taken to the recovery room before being taken to the intensive care unit (ICU) to be closely monitored for several days. Alternately, you may be taken directly to the ICU from the operating room. You will be connected to monitors that will constantly display your EKG tracing, blood pressure, other pressure readings, breathing rate, and your oxygen level. Liver transplant surgery requires an in-hospital stay of seven to 14 days, or longer.

You will most likely have a tube in your throat so that your breathing can be assisted with a ventilator until you are stable enough to breathe on your own. The breathing tube may remain in place for a few hours up to several days, depending on your situation.

You may have a thin plastic tube inserted through your nose into your stomach to remove air that you swallow. The tube will be removed when your bowels resume normal function. You will not be able to eat or drink until the tube is removed.

Blood samples will be taken frequently to monitor the status of the new liver, as well as other body functions, such as the kidneys, lungs, and blood system.

You may be on special IV drips to help your blood pressure and your heart and to control any problems with bleeding. As your condition stabilizes, these drips will be gradually weaned down and turned off as tolerated.

Once the breathing and stomach tubes have been removed and your condition has stabilized, you may start liquids to drink. Your diet may be gradually advanced to more solid foods as tolerated.

Your immunosuppression (anti-rejection) medications will be closely monitored to make sure you are receiving the optimum dose and the best combination of medications.

When your physician feels you are ready, you will be moved from the ICU to a private room on a regular nursing unit or transplant unit. Your recovery will continue to progress here. Your activity will be gradually increased as you get out of bed and walk around for longer periods of time. Your diet will be advanced to solid foods as tolerated.

Nurses, pharmacists, dietitians, physical therapists, and other members of the transplant team will teach you how to take care of yourself once you are discharged from the hospital.

At home:

Once you are home, it will be important to keep the surgical area clean and dry. Your physician will give you specific bathing instructions. The stitches or surgical staples will be removed during a follow-up office visit, if they were not removed before leaving the hospital.

You should not drive until your physician tells you to. Other activity restrictions may apply.

Notify your physician to report any of the following:

• fever - may be a sign of rejection or infection
• redness, swelling, or bleeding or other drainage from the incision site
• increase in pain around the incision site - may be a sign of infection or rejection
• vomiting and/or diarrhea

Your physician may give you additional or alternate instructions after the procedure, depending on your particular situation.

What is done to prevent rejection?

To allow the transplanted liver to survive in a new body, you will be given medications for the rest of your life to fight rejection. Each person may react differently to medications, and each transplant team has preferences for different medications. The anti-rejection medications most commonly used include:

• cyclosporine
• tacrolimus
• steroids such as prednisone
• azathioprine
• mycophenolate mofetil

New anti-rejection medications are continually being developed and approved. Physicians tailor medication regimes to meet the needs of each individual patient.

Usually several anti-rejection medications are given initially. The doses of these medications may change frequently, depending upon your response. Because anti-rejection medications affect the immune system, persons who receive a transplant will be at higher risk for infections. A balance must be maintained between preventing rejection and making you very susceptible to infection.

Some of the infections you will be especially susceptible to include oral yeast infection (thrush), herpes, and respiratory viruses. You should avoid contact with crowds and anyone who has an infection for the first few months after your surgery.

The following are the most common symptoms of rejection. However, each individual may experience symptoms differently. Symptoms may include, but are not limited to, the following:

• fever
• jaundice - yellowing of the skin and eyes due to bile pigments in the blood
• dark urine
• itching
• abdominal swelling or tenderness
• fatigue or irritability
• headache

The symptoms of rejection may resemble other medical conditions or problems. Consult your transplant team with any concerns you have. Frequent visits to and contact with the transplant team are essential.