Liver transplant, or liver transplant as it is medically termed, is a surgical procedure that irreversibly replaces a diseased liver with a healthy liver. Before this operation, heavy and complex, the patient follows an equally long course due to the shortage of liver transplants.

Liver transplantation involves replacing a diseased liver with a healthy liver.

Different types of transplant exist:

• orthotopic liver transplantation: the most common, it consists of replacing the diseased liver with a whole liver from a deceased donor (in a state of brain death);
• partial or “split” liver transplantation: a whole liver taken from a deceased donor is divided in two to be given to two recipients;
• partial living donor transplantation: part of the liver is removed from a family member to be transplanted into the patient. This practice remains rare in France because of the risk for the recipient;
• auxiliary liver transplantation: this involves transplanting a liver or part of a liver, while keeping the liver or part of the liver of the recipient. It is intended for patients suffering from a severe hepatic pathology (such as fulminant hepatitis) but having a hope of recovery for their native liver (their original liver).

We will talk here about orthotopic liver transplantation, the most common in France.

Registration on the national transplant waiting list

To benefit from a liver transplant, the patient must be registered on the national waiting list for liver transplantation managed by the Biomedicine Agency, a transplant management organization in France. For this, it is the subject of a pre-transplantation assessment aimed at eliminating the operative contraindications (heart, lung, kidney disease, anatomical evaluation, etc.), but also the contraindications to long-term use. immunosuppressive therapy. The multidisciplinary medical team thus assesses the benefits / risks of liver transplantation.

As soon as he is a candidate for a liver transplant, the patient is regularly followed (at least every 3 months) in the hospital in order to carry out various examinations (blood tests, medical imaging examinations). He must also be up to date with his vaccinations (Diphtheria, Tetanus, Polio, whooping cough Haemophilus influenzae b). Vaccination against influenza, hepatitis A, hepatitis B, pneumococcus, MMR, chickenpox) is strongly recommended.

While waiting for a donor, the patient may wait several months before being transplanted, this time varying depending on the indication for the transplant but also on the severity of his condition.

The call for the transplant

When a liver from a donor is available, the graft distribution center of the Biomedicine Agency offers it to the recipient’s transplant team, according to well-defined priority rules and certain criteria: blood accounting ( the graft must have the same blood group as the recipient) and the size of the graft in particular. The collection team will only leave to collect it if the examinations carried out on the graft reveal that it is healthy.

The recipient is contacted: he must be reachable at any time, and available immediately to go to the hospital where a check-up is carried out in order to rule out any last-minute contraindication to the transplant. Meanwhile, a surgeon from the transplant team removes the donor’s liver and examines it to make sure it can be transplanted. Even after hospitalization for the transplant, the procedure can be canceled:

• if the graft is of poor quality;
• if the recipient has an acute infection contraindicating the transplant;
• if another recipient becomes a priority, for example in case of fulminant hepatitis.

Liver transplantation

Liver transplantation takes place under general anesthesia. A venous line, a urinary catheter, a gastric tube and a tracheal intubation are placed.

Long and complex, the intervention takes place in two stages:

• removal of the diseased liver (hepatectomy): the surgeon makes a horizontal incision under the ribs, and vertical towards the sternum. It cuts the ligamentous attachments of the liver, the blood vessels arriving at the liver (hepatic artery and portal vein), those leaving it (hepatic veins) as well as the main bile duct, then removes the diseased liver;
• healthy liver transplant: the surgeon places the graft in the abdomen, connects the blood vessels to quickly replenish the graft, then the various vessels carrying bile. The surgeon then tests the circulation of blood and bile. Small redons are placed to evacuate liquids, as well as a bile drain (Kehr drain or Escat drain).

These two steps must be perfectly synchronized, because the graft must remain deprived of blood circulation as short as possible.

Anti-rejection treatment is started in the operating room.

A liver transplant is used in cases of end-stage liver failure, that is, when the liver is no longer able to perform its functions. Different pathologies can lead to this hepatic insufficiency:

• alcoholic liver disease, or alcoholic cirrhosis. Management of alcoholic illness is therefore imperative;
• posthepatic cirrhostosis (B, C or D);
• fulminant hepatitis;
• certain hepatocellular carcinomas (single lesion <5 cm in diameter or up to 3 nodules <3 cm in diameter);
• bile duct atresia
• cirrhosis of biliary origin;
• sclerosing cholangitis
• congenital disease of the bile ducts.

Operative suites

The patient remains in intensive care for at least 72 hours, during which he is subject to increased surveillance day and night (monitoring by scope, blood pressure, blood test every 8 hours, ultrasound of the liver) for his ensure that the organism recovers well from the operation, that the graft is functioning correctly and that the patient supports the anti-rejection treatment.

After the procedure, a period of confusion is frequent. It is due to the operation and anti-rejection treatments. It will disappear spontaneously after a few days.

Once stabilized, the patient is transferred to the hepato-biliary surgery department, where he is hospitalized 10 to 20 days before returning home or to a convalescent home.

The bile duct is removed between 3 and 4 months after the transplant. During this period, his dressing should be regularly changed by a home nurse. Convalescence lasts about 6 months, depending on the patient’s condition. 

Follow-up

After a transplant, an immuno-depressant treatment, more commonly called anti-rejection, is prescribed for life. This treatment makes it possible to modulate the immune defenses and thus reduce the risk of rejection of the transplant.

At the same time, the transplant recipient must carry out regular check-ups at the transplant center (ultrasound, blood tests) to check the functioning of the liver, prevent possible rejection and detect the side effects of the anti-rejection treatment. The frequency of follow-up is less and less frequent over time (every week for the first 3 months, then once or twice a year after the 1rd year).

Risks and complications

During the operation, the risk of bleeding is high.

During the postoperative period, various complications are feared:

• the primary non-function of the graft (the liver does not function);
• early thrombosis of the artery;
• blood loss ;
• bilar stenosis or leakage;
• an infection ;
• kidney failure because anti-rejection drugs are indeed toxic to the kidneys. Sometimes dialysis is needed temporarily.

Rejection has now become rare thanks to anti-rejection treatment. If suspected, a liver biopsy will be done.

Finally, it should be noted that after a transplant, the cardiovascular risk and the risk of cancer are increased. A follow-up and a healthy lifestyle are therefore recommended.