It is the team at the North Colombo Hospital at Ragama which pioneered living donor liver transplants in Sri Lanka. There are two teams in both the Ragama and the Colombo National Hospitals which perform liver transplants.
By Ravi Ladduwahetty 

There are two methods of doing liver transplants which means that one living donor could donate a liver to another.  The second mode is the cadaveric liver transplant where the liver of a brain-dead person, enables his/ her liver to be transplanted in another. There are  instances where there are persons who die in accidents who suffer from cerebral haemorrhage (internal bleeding of the brain)  but  their livers  and other organs, before they are dead, could be  transplanted  into another where the lives of those people are maintained on a life supporting machine. It is at these times that the liver and the other organs of those brain-dead people are taken out and transplanted.  

The Ragama Hospital team has successfully done four cadaveric liver transplants and a further four live donor transplants and it is the only institution in Sri Lanka which does both transplants, Dr Siriwardana told The Island.

“What is indeed professionally satisfying is that Sri Lanka has now the ability to perform this surgery in contrast to the earlier scenario where patients had to travel to Singapore for the same- spending the equivalent of Rs. 25 million and Rs. 10-12 million in India. The patients who could not afford this had no other alternative. The Sri Lankan private hospitals do it for around Rs. 5 – 5.5 million, but the state sector is totally free”, he said.    

Alcohol, not the only cause!

Contrary to rife speculation that alcohol was the primary cause for cirrhosis and therefore, liver ailments leading to transplants, it is not. In most cases, the presence of  fat  in the liver (fatty liver) is the primary cause for liver transplants  and a  small percentage, of them could  develop into cirrhosis after some time.  Over 50% of the cases that they had operated on had been cirrhosis induced by fatty liver. So, alcohol was not the commonest reason, contrary to popular belief, he said.    

Transplants are done to combat liver cancers as well where the entire liver is surgically removed and a new one implanted, which is the most effective way of combating  liver cancer, though it is the costly way out. 

The live donor transplant has been found to be very technically demanding as one has to take a part of a normally 100% healthy person’s liver and it is seen to be complicated for the  donor as well, as a substantial part of his liver is taken out. There is also an inherent 0.2% to 0.5%risk of the donor dying as well. 

 One of the principle constraints to liver transplanting is that there is a thorough shortage of donors. So, surgery has to be done fast as most of the recipients run the risk of living only up to six months. Live donor transplants are much in demand as the risk element to the life of the recipient is mitigated. Both surgeries are very complex and 30% of the recipients could have complications, which revolved round the long durations of surgeries during which infections could also set in during the post surgery period. Other main types of complications are related to bile ducts. 

“Medicines are given to suppress rejection as it is a totally new and foreign organ which is transplanted and that is the time that infections could set in as the immuno-suppression is low. There are times that the liver transplants are rejected but, unlike kidney transplants, liver transplants could be treated easily. If the surgery is successful, the recipient could have a long- term survival. One of the priorities is that the patient’s heart and lung conditions are tested as to whether he or she could go through the rigours of surgery,” he said.     

Responding to a question as to how complicated the post surgery period would be, he said: “In all cases, if all goes well, the patient could be discharged in two weeks. However, there are complications due to the time duration of the operation which is over 15 hours and the complexity of the procedures. The first six months is very crucial and the patients have to be conscious about their dietary habits and not allowing germs to get into the system. The immuno-suppression is brought down after six months of the surgery. 

Apart from liver transplants, Dr Siriwardana said liver resection was another area that has advanced recently in Sri Lanka.  One of the primary options that are offered to the patient with liver cancer was the liver resection.  There could be a primary cancer where it starts in the liver and secondary when it starts in the colon or other organ which could later spread into the liver.  Then, a part of the liver was surgically removed  and  the liver had a very good capacity  to regenerate as  it was one organ in the body  which could rebuilt itself from a 20% capacity, provided it was healthy. That was what’s known as a liver resection.  

Successful liver surgery 

 The liver surgery processes have also been very successfully done at the Ragama Hospital as well as the Colombo South Teaching Hospital at Kalubowila.  The liver is divided into eight parts according to the supply of blood vessels.  Surgeons call them eight segments and they are identified with the aid of an operative ultra sound scan.

“It is not that the liver is compartmentalized afterwards but identified by scans. Blood vessels and the tumour sites are marked, using a new instrument called “CUSA” which is akin to a refrigerator which is used to divide the liver parenchyma probe.    Then the parenchyma is dissected and the blood vesicles are preserved along with the separate structure of the liver.  The availability of the instruments enables the surgery to be done with ease.” he said. 

 Some of the drawbacks are that there are no donors for over 50 patients in the waiting list for surgery and the affordability. Efforts are underway to bring the live donor  transplant  as well  to Ragama to enable the patients to undergo surgery, though there are some initial expenses to the tune of Rs. 500,000 for which we are looking for sponsorships, Dr Siriwardana said.  

A liver transplant requires a team of around 40 persons per patient including the operating theatre staff and the minor staff, taking 12- 15 hours. It is not surgery that could be done everywhere but only with the right infrastructure, the right team and the determination to proceed against all odds.