'It Was My Dream To Conduct Liver Transplant For The Last 16 Years'

About two lakh people in India die of liver diseases every year, who could be saved by liver transplant. According to Sir Roy Calne, a pioneer in liver transplantation, it is the most complex surgery ever developed in the field of surgery. To aggravate matters, it is capital and technology intensive, discouraging hospitals to initiate liver transplant programme. Undeterred by these hurdles, a month after it obtained permission from the State Appropriate Authority to conduct transplant, Wockhardt Hospitals, Mumbai conducted the group's first ever liver transplant surgery, recently. The transplant was adult to adult living donor liver transplant (LDLT) on 53-year-old patient. The patient's son has donated part of his liver for the transplant. The 18-hour-long surgery was conducted by Dr S K Mathur, consultant surgeon for surgical gastroenterology and liver transplantation. In an interview with Rita Dutta, Dr Mathur, who is the president of Haepatobiliary Association of India, speaks about his maiden liver transplant surgery and about the dynamics of setting up a liver transplant programme in a hospital

Please brief me about the liver transplant surgery that you recently conducted.

Around a year back, the patient Mohammed Joglekar was initially diagnosed with and treated for liver abscess. When he still had pain in his tummy, he was brought to our hospital. The CT scan revealed that he had cirrhosis of liver with a cancerous tumour. Around 23 years back, the patient damaged his kidney in an accident and during blood transfusion had contacted Hepatitis C virus, which lead to cirrhosis of the liver. Liver transplant was his only ray of hope. The patient's son overheard the conversation that we had and stepped forward to donate a part of his liver.

Was the patient or his family a wee bit apprehensive, considering that this was the hospital and yours first liver transplant?

On our part, we told the patient and the donor that this was our first case and that this was a high-risk surgery. But the patient and his family had faith and still wanted to go ahead.

You had obtained permission for organ transplant only a month back. What kind of preparation did you undertake for the surgery?

We started right from purchasing equipment specifically for liver transplant. Hospital bought ultrasonic dissector (Rs 35 lakh) for liver dissection, argoan beam coagulator (Rs 15), intra-operative ultrasound with colour doppler (Rs 25 lakh), rapid infusion pumps and fluid warmers (Rs 10 lakh). We also set up a separate liver transplant ICU with hepa filters, epoxy flooring, positive pressure, barrier nursing and multi channel monitors. We prepared the unit in just 10 days. Our staff worked round the clock to achieve the impossible task. Earlier, hospital sent a team of anaesthetist, intensivist, ICU nurses, and OT nurses for a training to Delhi's Sir Gangaram Hospital.

What kind of tests did the recipient and the donor had to undergo before the surgery?

The patient had to undergo tests to check the functioning of heart, liver, lungs and kidneys. To rule out that the cancer has not spread its tentacles in other parts of the body, the patient had to undergo CT of the chest and bone scan. A team of cardiologists, pulmonologist, endocrinologist, nephrologists and psychiatrist evaluated him to check whether he can cope with the supra-major surgery. Additionally, the patient had to undergo CT Scan and MRI of liver to rule out other pathological disorders of the liver. The donor also went through similar tests to check whether he can donate liver. The ideal donor to patient liver weight ratio is 1:1. And fortunately, it was 1:1 in this case.

Was there any complication during the surgery? Was there any point of time when you felt that the surgery would not be a success?

No, there were no complications. Donor did not require any blood transfusion. While one requires 25 units of blood, 30 units of plasma and 25 units of platelets for a liver transplant, we used only three units of blood, six units of plasma and two units of platelets for the surgery, which is same as for any well-established international liver transplant centre. The most difficult phase in the surgery is anhepatic phase, when the recipient's damaged liver is taken out and he is without liver for an hour. Toxic waste gets accumulated in his body and this can cause damage. But luckily we did not have any problem. Around 12 hours after the surgery, the patient and donor were off ventilator, which is a rarity. Within five days, there were ready to be shifted out of ICU. The donor was discharged from the hospital on eighth day and recipient on the 21st day and now they are leading a normal life.

Why the success of the surgery is low in India?

The mortality rate for this surgery is 15 to 20 per cent anywhere in the world. You need a trained team and also the team needs to work in perfect co-ordination. The knowledge of surgeon, anaesthetists and intensivist about liver functioning should be as good as that of hepatologist for the surgery to be a success. If one team member goofs up, then the surgery may not be a success.

According to you, which institutes in India are doing good volume of liver transplant?

Around 10 institutes are conducting it. But the institute with good volumes and good results would be Sir Gangaram Hospital. However, we at Wockhardt Hospitals will soon be doing good volume with as good success, as exemplified by our first case.

Priced at Rs 18 lakh and above by most corporate hospitals, and the fact that liver transplant is not covered by insurance, the cost of surgery is still prohibitive for the common man. How did your patient manage funds?

Let us not look at the cost. We are glad that at least Indians do not have to go abroad for treatment now. In India, it is still cheaper as the cost of the surgery is Rs 1.5 crore in the US, Rs 75 lakh in the UK and Rs 50 lakh in Singapore. There is a certain section of Indians that can afford liver transplant in Indian corporate hospitals. We already have a line-up of patients for liver transplant. For patients who cannot afford, social organisations can help to raise the funds as is often done for cancer patients.

A few private hospitals are doing liver transplant for around Rs 4 lakh. For instance, Narayana Hrudayalaya (NH), claims to do paediatric liver transplant for only Rs 3 lakh. How are they managing it?

As you said, NH is doing paediatric liver transplant and the cost gets halved anyways .

Do you think it is a good idea to have a registry for liver transplant?

For cadaver liver transplant, in Mumbai ZTCC has a registry. For LDLT, we have not formed a registry yet, but its formation in the future cannot be ruled out.

What plans do you have now?

I harboured the dream of conducting liver transplant for the last 16 years. While the first LDLT in the world was conducted in 1990 by Russel Strong from Australia, I had suggested it in 1987 as a part of Common Wealth Fellowship project. At that time, I was doing liver resection and I thought LDLT is a good option. But my idea was rejected and ridiculed at that time. Today, I am glad that I have realised my dream with the support of Wockhardt Hospital. I want a regular cadaver liver transplant programme along with living donor programme. I want to conduct as many as 150 liver transplants in a year, the same numbers that a major centre abroad does.

rita@expresshealthcaremgmt.com