Liver transplantation
Liver transplantation is a surgical procedure performed on individuals with severely diseased livers that can no longer function normally. The primary reason for liver failure in adults is cirrhosis, often caused by alcohol or drug abuse, leading to the formation of scar tissue in the liver. Other causes of liver disease include hepatic cancer, chronic hepatitis B, and bile duct obstructions. The transplantation process involves either a liver from a deceased donor or a segment from a living donor, with a focus on ensuring a close immunological match to minimize rejection risks.
The surgery itself requires general anesthesia and involves significant incisions to access the liver. Postoperative care typically includes monitoring in an intensive care unit, with patients needing immunosuppressive medications to prevent rejection of the new liver. These medications, however, increase susceptibility to infections and other complications. Since the first successful liver transplant in 1967, the number of procedures has significantly increased, with over 9,500 transplants performed in the United States in 2022. The outlook for successful outcomes has improved due to advancements in surgical techniques and better management of donor organs, making it a critical option for patients with end-stage liver diseases.
Liver transplantation
Anatomy or system affected: Abdomen, gallbladder, liver
Definition: Surgery performed to replace a diseased, nonfunctional liver with one that is healthy and capable of carrying out normal liver functions
Indications and Procedures
Livertransplantation is performed on individuals whose livers are severely diseased and unable to carry out normal liver functions. The most common cause of liver failure in adults is cirrhosis, which results from alcohol and/or drug abuse. In this condition, the liver becomes filled with tough, nonfunctional scar tissue. Symptoms of cirrhosis, as well as other liver diseases, include abnormal levels of liver enzymes in the blood, jaundice, a lack of blood-clotting factors, the inability to dispose of bile, and the failure to detoxify metabolic by-products and other poisons, which can lead to coma and death. Other conditions that can lead to liver disease include hepatic cancer, long-term hepatitis B infection, and obstruction of the bile passages in the liver.
The donor liver may be obtained from a recently deceased individual, or a section of the liver can be obtained from a living donor. In either case, the donated organ must be a close immunological match to reduce the chance of transplant rejection. A preoperative injection is given to the recipient to dry up internal fluids and promote drowsiness, and general anesthesia is administered. A vertical incision is made from just below the breastbone to the navel. Muscles are moved aside, and a second incision is made through the outer membranous lining of the body cavity, revealing the internal organs. Bypass tubes are inserted into the hepatic veins and connected to veins in the arm to divert the flow of blood from the liver. When this is completed, the hepatic veins are cut, and the liver and gallbladder are removed from the body cavity. The veins of the donor liver are connected to the recipient veins, and the bypass tubes are removed. The new liver is then connected to the intestine, and the incisions are closed.
Uses and Complications
Liver transplantation is performed only when the individual has no other chance of survival. Typically, there is a long waiting list for available organs. Certain factors, such as blood type and protein markers on cell surfaces, must be matched as closely as possible to avoid rejection by the recipient’s immune system. A liver from a recently deceased donor may be kept functioning only for five hours with specific cooling fluid, thus limiting its ability to be transported long distances. Because of the lack of available transplant organs and the necessity of compatibility, many people die before an appropriate organ becomes available. It is possible to transplant a segment of liver from a close relative; the liver can grow considerably and regenerate itself. This is a preferable situation and eliminates the pressure of transporting a donor liver between hospitals while attempting to keep it functioning.
After liver transplantation, the patient is kept in an intensive care unit for several days and in bed for at least a week. Pain from the incisions is alleviated with drugs. Rejection is the major danger, even with closely matched donor organs. Drugs such as cyclosporine are administered to suppress the immune system and, in most cases, must be taken for life. These immunosuppressive drugs inhibit the normal functioning of the immune system, thus making the individual much more susceptible to frequent—and more severe—infections, including bacterial, fungal, and viral infections. Other possible complications of the long-term use of immunosuppressive drugs include cataracts, impaired wound healing, peptic ulcers, and steroid-induced diabetes mellitus. About 20 percent of patients suffer graft rejection, obstruction of the arteries, or infection. In the case of serious complications, another transplantation may be the patient’s only hope for survival. In successful surgeries, patients are able to return to normal, active lives within a few weeks of the surgery.
Perspective and Prospects
The first successful liver transplantation procedure was performed in 1967. Nevertheless, this surgery was considered an experimental procedure until 1983, when a National Institutes of Health (NIH) conference on liver transplantation accepted it as a routine procedure. In 1984, more than 250 liver transplantations were performed in the United States. Within five years, that number increased dramatically to 2,188 transplantation procedures performed in 1989; by 2002, the number had climbed to more than 5,300 transplants and rose to an average of about 6,000 per year. In 2022, 9,528 liver transplants were performed in the United States. Long-term results are steadily improving; about 75 percent of recipients with early-stage liver cancer survive for five years or more following a transplant, according to the Mayo Clinic in 2022. Improvements in survival rates are attributable to improved methods of preserving donor livers, the advent of living donor transplantation, better methods to prevent graft rejection, more suitable selection of recipients (for example, hepatic cancer patients typically have a high rate of recurrence of the disease in their transplanted liver), and improved surgical techniques.
Future prospects include further improvements in surgical techniques and advanced drug therapy to prevent graft rejection but not totally compromise the disease-fighting ability of the patient’s immune system. Efforts at public education regarding the need for donor organs may cause more individuals to contact donor organ societies, family, and friends regarding their wishes to donate organs in the event of untimely death. In addition, improved treatments for the diseases that lead to liver failure may help to decrease the need for this surgical procedure.
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