Consultancy Corner: Advanced surgical techniques improve Liver transplantation success rate

Liver transplantation (LT) is a widely accepted & standard lifesaving therapy for advanced chronic liver disease and acute liver failure. Although, medical management provides a temporizing measure, unlike LT, it is not a definitive cure for the complications of end-stage liver disease (ESLD). Advances in surgical techniques and an increased awareness of transplantation might have had excellent long-term success but has also led to an increase in the transplant candidates and recipients. Unfortunately, livers remain a scarce resource, and the growth in the transplant waiting list far exceeds the supply of organs.

Patients are considered for elective transplantation if they have an anticipated length of life, in the absence of transplantation, that is less than that is obtained after an LT; with no effective medical or surgical alternatives. All patients selected for the elective adult LT list must have a projected 5-year survival after more than 70 per cent transplantation. Indications for LT are also based on the ability of transplantation to improve quality of life. In addition to lowered life expectancy and unacceptable quality of life, indications for elective paediatric transplantation include growth failure or impairment, reversible neuro-developmental impairment and the likelihood of irreversible end organ damages in the absence of LT.

Contraindications for liver transplantation and the de-listing criteria are as important as the indications for LT itself. If the prospective candidate were to be found physiologically unfit or unlikely to survive the stress of the surgery (advanced cardiac or pulmonary disease), or if there was active sepsis; it would be imprudent to offer the patient LT. In patients with metastatic disease LT should not be offered. Other contraindications include situations where the postoperative quality of life may be unacceptable to the patient. A more relative contraindication is when the surgical team deems the surgery technically impossible. Another absolute contraindication is when the patient does not want an operation. 

The ultimate goal of LT is to provide a survival benefit to those who need it most and to be able to provide this benefit to most. Identifying appropriate candidates for LT is a complex process that requires a multidisciplinary approach. Survival after liver transplantation has progressively improved, which has led to an expansion in the indications and contraindications for transplant. The methods for liver allocation have also evolved over time and made it easier to understand and treat various diseases.