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Live 52...thanks to SGRH

New Delhi-based Sir Ganga Ram Hospital (SGRH) is the first hospital in South Asia to successfully complete 100 liver transplants. Sushmi Dey delves into the reasons behind the success of the hospital's liver transplant programme.

The implications of revolution in medicine cannot be overemphasised. Neither can the economic implications. It is not just the effects on our health, but also the products, devices and processes that are emerging from laboratories that have made enormous impact.

One such complex surgical procedure is liver transplant that is deemed as one of the most complex surgical procedures, marked by low success rate. Statistics show that close to 20,000 people need liver transplant in India annually. Even as few Indian hospitals attempt to, the success rate and volume are unimpressive.

But one hospital that has touched a rare medical milestone in this genre is the 750-bed Sir Ganga Ram Hospital (SGRH). A charitable hospital, it has become South Asia's first hospital to complete 100 liver transplants with a stupendous success rate of 94 per cent.

The hospital does not just provide liver transplants to patients in India alone, but also from Pakistan, Nepal, Afghanistan, Sri Lanka, Bangladesh, Malaysia and the UAE. It surely is some record that 32 foreign patients have undergone liver transplantation at SGRH so far.

But what deserves a special mention is the paediatric liver transplant department. It is indeed a feat when a hospital has operated on 11 children successfully. According to Dr AS Soin, Senior Consultant and Hepatobiliary Surgeon, Liver Transplant, SGRH, the success mantra is the unflinching dedication of trained and multi-disciplinary team. Besides this, factors like world-class infrastructure, management support, surgical expertise, and patient care have also contributed to the success.

Right place, right time

Success leads to success. The conquest of the kidney transplantation programme at SGRH initiated the idea of liver transplantation six years ago. With the cost of liver transplantations skyrocketing abroad, India was innundated with patients seeking liver transplantation. "Indians are not given priority abroad. We, at SGRH were flooded with patients who needed liver transplantation," recalls Dr BK Rao, Chairman, Board of Management, SGRH. For SGRH, liver transplantation was not a difficult project. Being a multi-speciality hospital, it had infrastructure in place to support liver transplantation.

Thus came about the first successful liver transplantation at SGRH performed by a team, led by Dr Soin. That was in 2001 with just three trained people. Today, the liver transplant team is supported by more than 50 people which includes two senior liver transplant surgeons, 10 junior surgeons, two senior liver transplant physicians (hepatologists), five senior anaesthetists, four intensive care doctors, four radiologists, four staff members of the blood bank, 10 nurses, and 10 operating theatre technicians. The hospital has a specially-trained medical and nursing staff for ICU, nephrologists, liver pathologists, clinical microbiologists, physiotherapists, and nutritionists for the purpose.

Says Dr Neelam Mohan, Consultant, Paediatric Gastroenterologist, Hepatologist, Therapeutic Endoscopist & Liver Transplant Physician, SGRH, "Intensivists are the backbone of the team. However, while the team is crucial, the leader is the motivating factor."

"Initially, we sent the doctors to UK for a special training programme. Now, we train our experts here," adds Dr Rao.

Core strength

SGRH's fame has not come easy. To be world-class, the hospital has had to work at sprucing up its infrastructure. Little wonder, why the hospital is capable of catering to both adults and children for cadaveric as well as live donors. "We now run one of the busiest programmes in the world performing two to three cases a week. Without doubt, the achievement is attributable to our state-of-the-art facility," says Dr Soin, the driving force behind making the programme an international success.

The hospital has twin German-designed OTs, equipped with thromboelastograph which help in minute monitoring of the coagulation status of the patient during transplant. There are also multi-channel invasive/non-invasive monitors, invasive and non-invasive cardiac indices monitoring devices, and arterial blood gas and electrolyte monitoring machine. SGRH also has modular OTs with ceiling suspended equipment and highest specification surgical instruments available in developed countries which includes rapid infusers which can transfuse blood at a rapid rate of a litre a minute. Besides, the OTs have stat laboratory which provides on-site facility for immediate determination of blood parameters during surgery. It is equipped with the latest anaesthesia machines. The hospital has also made arrangements for bloodless transplants and owns equipment like CUSA and Argon beam coagulators for bloodless splitting of liver tissues. Apart from these, SGRH has a dedicated ICU for liver transplant. The blood banks of the hospital are equipped with special platelet separator and lymphocyte filters. Besides, there is a separate liver high dependency unit (HDU).

To meet demand from its patients, the hospital constructed a new building in 2003, as it mostly has around 25 patients awaiting liver transplant. According to Dr Soin, the hospital is waiting for another two floors to boost the transplant rates. The current rate is two to three cases per week. The department is planning the expansion through an international wing to accommodate the increasing demand from overseas patients.

Small marvel

One-year-old Sheryar from Pakistan is the youngest recipient of liver transplantation in India. Sheryar developed jaundice soon after his birth. When he was 10-week-old, he was diagnosed with biliary atresia, which implies the congenital absence of bile duct. While Sheryar underwent a corrective surgery in Pakistan at the age of three months, the surgery failed to cure his disease. After which, the doctors gave up on the infant. Sheryar's parents then contacted doctors at SGRH. Sheryar had come to India in April 2006, undernourished and with a rare congenital liver disease. "Shreyar was just six kgs when he arrived. He was suffering from several vitamin and mineral deficiencies. His bones were weak and he had severe infection and diarrheoa," recollects Dr Mohan. Dr Mohan with her team toiled for 50 days to make him fit for the surgery. At a pre-operative stage, he weighed 8.2 kilograms. He finally got his diseased liver successfully replaced with a part of his grandmother's organ on June 21. However, it was not an easy task. The surgery took almost eight hours. The portal veins, which is the main blood supply to child's liver, were irreparably blocked due to which a rare technique called cavo-portal transposition was done. Sheryar was discharged after 30 days of the transplantation. Today, he is healthy and leads a normal life.

It's all about care

Being a very complex surgery, liver transplants require immense care—both pre- and post-surgery. According to Dr Mohan, "More patients die due to the lack of pre- and post-surgery care. There are pre-operative issues like treatment of hepatic complications, nutritional growth, vaccination, etc." SGRH takes special care of a patient's diet and fitness before and after the surgery, which is neglected in many hospitals.

According to the liver transplant experts at SGRH, paediatric liver transplants are more difficult than those on adults. The paediatric team at SGRH works through positive as well as negative reimbursement. For instance, doctors reward the young patients with toys when they stick to the diet recommended and vice versa when they do not meet requirements. "Adult-oriented hospitals should stay away from paediatric transplantations. Emotional involvement with patients is a must. We counsel children and make them accept their situation," tells Dr Mohan.

The hospital also endeavours to provide world-class care to patients at a fraction of its cost abroad. The cost at SGRH is Rs 12 lakh for children and Rs 17 lakh for adults.

Future plans

Meanwhile, the hospital is venturing into providing similar facilities across the country and in neighbourhood countries as well. "Eleven institutes from India and five centres from Pakistan, Bangladesh, Burma and Greece will pay a visit to imbibe our techniques," informs Dr Soin. The hospital offers two surgical training fellowships of one year duration for hands-on experience, training to (nationally accredited) DNB postgraduate surgical students. Besides, it also offers three short fellowships of two, four and twelve weeks each for observation, discussion and didactic teaching. So far, SGRH has trained 62 surgeons and anaesthetists.

However, there are several messages that the team at SGRH wishes to disseminate. The first is about stepping up awareness about cadaveric donation. The hospital's counselor often meets up with relatives of brain dead patients to convince them of donating the liver of the patient. The hospital also provides incentives like free treatment and other medical facilities to families of cadaveric donors to encourage cadaveric donation. SGRH recently entered into a public-private partnership to train teams of doctors and technicians from AIIMS and Sanjay Gandhi Institute of Medical Sciences, Lucknow, on ways to establish a liver transplant department.

The hospital also hopes to see more paediatric liver transplantation in the country and worldwide. "It is sad to see that 90 per cent of the liver patients reported are adults and only 10 per cent are paediatric. Even the worldwide pediatric liver transplantation ratio is 20 per cent," says Dr Mohan.

If the efforts at SGRH are sustained and rightly co-ordinated, a large number of people who suffer immensely because of unavailability of liver donors or lack of awareness about liver transplantation programme would be able to lead a better and more productive life.

healthcare@expressindia.com