Orthotopic Liver Transplantation (OLT)

Overview

The usage and success of orthotopic liver transplantation (OLT) has increased, and liver transplantation has become an accepted therapy for a variety of reasons of irreversible liver disease. Since it was founded, 194,777 liver transplants had been documented as of May 2022.

With the rising number of transplants, the risks of a transplant patient developing post-transplant complications are increasing. Basic understanding of medical care involved in transplant patient therapy will aid in evaluation.

Alcoholic liver disease, nonalcoholic steatohepatitis, hepatitis C virus, hepatocellular carcinoma, cholestatic disease, acute liver failure, and hepatitis B virus are the most prevalent indications for liver transplantation in the United States.

The chances of surviving after OLT are good, with a 5-year survival rate of 75%. Infection, rejection, and malignancy are the most prevalent reasons of mortality in liver transplant patients.

 

Types of Liver Transplant

There are four different types of liver transplant that may be offered to a person:

• Orthotopic transplant or transplant of a liver from a recently deceased donor.
• Living donor transplant.
• Split type of liver transplant.
• Auxiliary liver transplantation.

 

1. Orthotopic transplant
   The most frequent form of liver transplant is an orthotopic transplant. A recently deceased donor's whole liver is removed. This is generally from a donor who has volunteered his or her organs for donation before to death and has no communicable diseases or tumors that might be passed on to the receiver.
   
   
2. Living donor transplant
   A living donor transplant occurs when the donor is a willing living individual. The donor has the first procedure, in which the surgeon takes either the left or right side (lobe) of their liver.
   
   Adults often have right lobe transplants, whereas minors receive left lobe transplants. This is because the right lobe is larger and more suited for adults, whereas the left lobe is smaller and better suited for children.
   
   
3. Split type of liver transplant
   Split donation is the transplantation of a recently deceased individual's liver to two recipients. This is possible if the next appropriate receivers are an adult and a kid. The donated liver will be separated into the left and right lobes. The adult usually gets the larger right lobe, while the child gets the smaller left lobe.
   
   As with living donor transplants, the transplanted sections of the liver regenerate to their former size. This strategy benefits two people at the same time.
   
   
4. Auxiliary liver transplantation
   Auxiliary liver transplantation is a type of liver transplantation in which the recipient's own liver is not removed fully. Its objective is to keep the native liver in case of spontaneous recovery or if there is a possibility of future gene therapy in instances of genetic or metabolic liver disorders (save in situations of primary oxalosis, Wilson's disease, or tyrosinaemia, when the remaining liver is at danger of malignancy).

 

Indications for Liver Transplantation

The list of indications for liver transplantation includes all the causes of end stage liver disease which are irreversible and curable by the procedure:

• Acute Liver Failure (ALF)

Encephalopathy, jaundice, and coagulopathy are symptoms of fulminant hepatic failure (ALF and sub-fulminant hepatic failure). It accounts for 5-6% of all patients who have a liver transplant. Acetaminophen poisoning is the most prevalent cause of ALF in the Western world, followed by hepatitis A, E, B, and seronegative hepatitis. Idiosyncratic drug-induced liver damage is the leading cause of sub-fulminant hepatic failure.

Patients who meet the King's College Criteria for Urgent Transplantation have an extremely narrow window of time, and they must be transplanted as quickly as possible. If these selected individuals do not receive transplantation, they will die, either from liver failure or from sepsis and multiorgan failure.

Patients with subacute failure have a dismal prognosis, with virtually universal mortality if not transplanted; these patients may need a transjugular liver biopsy to determine if they have massive or submassive liver cell necrosis. In these individuals, prompt referral is critical since mortality from sepsis and cerebral oedema might ensue in the absence of transplantation.

 

• Chronic Liver Failure

The end stage of chronic, progressive liver disease is chronic liver failure. It typically signifies that scar tissue has replaced too much of your liver tissue, which has little blood flow. Cirrhosis of the liver is another name for this condition. When your liver functions begin to break down, you’ll show signs of “decompensated” liver disease.

• Alcoholic Liver Disease (ALD)

If a patient with ALD has been abstinent for at least 3-6 months and has been evaluated by a psychiatrist, he is considered for transplantation if he experiences portal hypertensive bleed or an episode of spontaneous bacterial peritonitis. These people may have a hepatitis B or C virus infection that needs to be evaluated. They are also predisposed to hepatocellular cancer. A time of abstinence is required to guarantee that they do not relapse, as well as to provide such a trial period of alcohol-free lifestyles during which the liver function may recover. The length of abstinence is not consistent, although a 6-month guideline of abstinence is currently observed in most US and European liver transplant programs.

Acute alcoholic hepatitis (AAH) is a contra-indication for liver transplantation as the required period of abstinence is lacking, and there is very little and mixed experience of liver transplantation in this situation.

• Viral Hepatitis

HCV: Today, HCV-related cirrhosis is the most common indication for OLT. Approximately 3.9 million Americans suffer from chronic HCV infections, and it has been estimated that around 20% of these individuals will develop cirrhosis within 20 years of the onset of chronic infection. The process seems to be accelerated by alcohol abuse. 

HBV: Hepatitis B virus-related chronic liver disease is another common indication for transplantation, and this was previously also associated with a high prevalence of recurrent infection in the graft. However, the availability of hepatitis B immunoglobulin (HBIG) and oral nucleoside or nucleotide therapy reinfection of the graft and recurrent hepatitis B disease is rare. The duration of HBIG therapy and oral antiviral therapy is still controversial; a few programmes give HBIG for one year while others are using it lifelong.

• Primary Malignancy

Primary liver cancer, also known as hepatocellular carcinoma, is a kind of cancer that develops in the liver. If the cancer does not spread beyond your liver, removing the liver can cure it. Your doctor may be able to remove just a portion of your liver containing the tumor (partial liver resection). However, if your liver is in poor condition, you may require a transplant.

 

How Long Can I Live Without a Liver Transplant?

You may recover if you have acute liver failure, but this cannot be predicted. Those who do not recover may perish within a few days. Chronic liver failure develops over time. People with cirrhosis can live with it for months or years while waiting for a liver transplant, but the need becomes more urgent when complications such as portal hypertension emerge.

If you are awaiting a liver transplant to treat primary liver cancer, the cancer may still be in its early stages. Liver transplant surgery is only used to treat liver cancer if it has not gone beyond the liver. The majority of persons with primary liver cancer, however, also have chronic liver disease. As a result, your outlook is influenced by a variety of personal circumstances.

 

Criteria to Qualify for an Orthotopic Liver Transplant

There is a high demand for liver transplants, and not everyone who wishes to have one will be able to. Those that do will need multiple surgeries and rehabilitation. Healthcare practitioners want to do all possible to guarantee the success of the transplants they perform. That is why you must satisfy specific requirements in order to be considered for a liver transplant.

The minimum requirements to qualify for a liver transplant are:

• That you have clinical signs of liver failure or primary liver cancer.
• That you are well enough to have the surgery and recovery.
• That you are not considered at risk of future alcohol or drug abuse.

There's a lot that goes into establishing these things. Your physical and mental health, as well as any history of substance dependence, will be thoroughly evaluated by healthcare providers. If you have any pre-existing conditions, they must be addressed first. If you meet the minimum criteria for a liver transplant, you will be added to the national waiting list.

 

What Determines the Liver Transplant Waiting List Ranking?

A limited number of persons in critical condition due to acute liver failure are placed at the top of the list. These people get ill unexpectedly and are only on the list for a few days. The majority of those on the list have chronic liver disease and/or liver cancer. If you are one of them, your healthcare professional will rank your condition using a score system.

MELD (Model for End-Stage Liver Disease) or PELD is the chronic liver disease score system (Pediatric End-Stage Liver Disease). It's calculated by blood test results. The tests measure:

• Bilirubin. High bilirubin levels indicate that bile is leaking into your bloodstream.
• Prothrombin Time. This is how long it takes for a sample of your blood to clot.
• Creatinine. This is a measure of how well your kidneys are functioning. It’s used for adults.
• Albumin. This measure of kidney function is used instead of creatinine for children.

These elements influence how well your liver continues to operate. Exception points are extra points that might be added to your score for various reasons. These include additional issues and complications that increase the urgency of your situation. Low growth rates in children offer exceptions. Your overall score determines your position on the waiting list.

If you have hepatocellular carcinoma (primary liver cancer), your healthcare expert will determine your mortality risk based on tumor size and wait time.

 

How You Prepare For Orthotopic Liver Transplantation?

If your doctor advises a liver transplant, you may be referred to a transplant facility. You can also choose a transplant facility on your own or from your insurance company's list of preferred providers.

Specific tests, procedures and consultations you may undergo include:

• Laboratory tests, such as blood and urine tests to assess the health of your organs, including your liver
• Imaging tests, such as an ultrasound of your liver
• Heart tests to determine the health of your cardiovascular system
• A general health exam, including routine cancer screening tests, to evaluate your overall health and to check for any other illnesses that may impact the success of your transplant

Your evaluation may also include:

• Nutrition counseling with dietitians who assess your diet and make recommendations on how to plan healthy meals before and after your transplant
• Psychological evaluation to assess and treat any underlying issues, such as depression or anxiety, and determine whether you fully understand the risks of a liver transplant
• Meetings with social workers who assess your support network to determine whether you have friends or family to help care for you after transplant
• Addiction counseling to help people who are having difficulty stopping their use of alcohol, drugs or tobacco
• Financial counseling to help you understand the cost of a transplant and post-transplant care and to determine what costs are covered by your insurance

Following the completion of these tests and consultations, the transplant center's selection committee meets to examine your condition. The committee decides whether a liver transplant is the best treatment for you and whether you are in good enough condition to undergo the surgery.

 

What Happens During Orthotopic Liver Transplant Surgery?

Orthotopic liver transplant surgery is a complex procedure that can last anywhere from six to 12 hours. During the procedure, you will be sleeping due to general anesthesia. During this form of treatment, doctors place a number of tubes in your body to perform certain functions while you are asleep. The tubes will remain in place for a few days after your surgery. You will have:

• An intravenous catheter (IV) is inserted into a vein in your arm or hand to administer fluids and drugs.
• An IV is inserted into a vein in your neck or thigh to monitor your blood pressure and collect blood samples.
• A tube that goes through your mouth and into your windpipe and is connected to a mechanical ventilator. The ventilator will mechanically expand your lungs to keep you breathing during surgery.
• In your belly, tubes drain blood and fluid from the area around your liver.
• A nasogastric tube inserted through your nose into your stomach to drain secretions from your stomach. It will be there for a few days until your digestive function returns to normal.
• A catheter is inserted into your bladder to discharge pee.
• To begin the procedure, your surgeon will make one large incision across your abdomen in order to get access to your liver. 
• They'll carefully separate your liver and clamp any blood vessels or bile ducts that were attached to it. 
• Then they’ll install the new liver and attach it to your blood vessels and bile ducts. 
• They'll admit you to intensive care after closing your wound.

 

After Orthotopic Liver Transplant Surgery

Following surgery, you may be kept in intensive care for many days. Your medical team will keep an eye on your status and look for symptoms of problems. They'll take blood samples to see how well your new liver is functioning. Through your IVs, they may need to actively control your fluid/electrolyte balance, blood sugar levels, and blood volume.

When your health has stabilized, your tubes will be removed and you will be sent to a rehabilitation facility for another one to three weeks. It will take a few days for your bowels to resume normal function. You'll start with liquids and gradually reintroduce solid foods. Before you go home, you'll gradually wean yourself off your IV pain medication.

 

Follow-up Care

You'll have regular checkups with your healthcare team while you continue to recover at home. They will continue to do blood tests to monitor your new liver. After a few weeks, you may have your incision stitches removed. You'll be on numerous drugs immediately following surgery, and some of them will be with you for the rest of your life.

Your healthcare team will teach you:

• How to care for your incision wound?
• How to take your medications?
• How to check your own blood pressure and pulse?
• How to recognize signs of infection?
• How to recognize signs of organ rejection?
• When it is important to contact them?

 

Risks or Complications of Orthotopic Liver Transplant Surgery

The most significant risks from the procedure itself include:

• Blood clots. Liver transplantation is a more involved procedure, and the longer you remain on the operating table, the more likely you are to develop blood clots. The risk is still less than 5%.
• Hemorrhage. The liver bleeds a lot, especially when you have a blood clotting disorder due to liver damage. Liver surgeons expect this and often use automatic blood transfusion technology.
• Bile duct injury. Injury during surgery might cause toxic bile to flow into the abdominal cavity. Scar tissue can form where your bile ducts were injured after surgery, producing a stricture or obstruction and causing bile to back up into your liver.
• Liver failure. Sometimes the donor liver is damaged during transport and may not function well after transplantation. If this occurs, you will require a new donor liver as soon as possible. This happens in roughly 5% of the cases.

 

What are the Long-term Consequences of Orthotopic Liver Transplant?

The most significant post-operative complications of liver transplant are organ rejection and infection.

• Organ rejection

Anti-rejection drugs (immunosuppressants) will be prescribed by your healthcare team to assist prevent your immune system from attacking your new liver. Nonetheless, moderate "rejection events" are frequent in the first year following your transplant. Acute organ rejection occurs in 25% to 50% of all liver transplant recipients within the first year, with the highest risk period being in the first four to six weeks after transplantation.

In most cases, elevated liver enzymes in your blood test are the first sign of severe organ rejection. To confirm the diagnosis, a needle-based liver biopsy will be done at the patient's bedside. They'll deal with it by changing your medications. Chronic organ rejection affects around 5% of the population and is defined by recurring episodes that persist after treatment. Chronic organ rejection can eventually lead to liver failure.

• Infection

There is some risk of infection with any surgery, but more with organ transplantation. This is one of the side effects of immunosuppressive medications. These drugs decrease your immune system, making it less capable of defending you against illness. This covers infections acquired in the hospital as well as those acquired after leaving. You'll be more susceptible to typical cold and flu viruses, as well as bacterial and fungal illnesses, from now on.

 

• Others

Possible long-term complications include:

1. Hypertension. Liver transplant recipients may not be able to control their blood pressure as effectively as others.
2. High blood sugar and Type 2 diabetes are potential side effects of immunosuppressant drugs in some people, especially if you already had metabolic syndrome.
3. Kidney disease and kidney failure. Previous liver disease can deteriorate kidney function, and in some transplant recipients, this process continues in spite of the new liver.
4. Cancer risk. People who’ve had liver transplants are more at risk of acquiring certain cancers, especially skin cancer and viral lymphoma, due to their suppressed immune systems.

 

What is the Success Rate of Orthotopic Liver Transplant Surgery?

The success percentage for the transplant operation itself is between 75% and 90%. That indicates the transplant was successful, the new liver was functioning, and the patient survived the year-long recovery process. Your prior health issues, as well as the quality of the donor liver, may have an impact on the operation's effectiveness.

 

How Long Can You Live After Orthotopic Liver Transplant?

This is determined by a variety of factors, including your age, overall health, and the underlying liver disease that necessitated a liver transplant. That disease may recur or continue in certain circumstances. Following five years, the average survival rate after a liver transplant is 75%, and after 20 years, it is 53%.

 

Conclusion

The replacement of a dysfunctional liver with a healthy liver from another person is known as liver transplantation or hepatic transplantation (allograft). Although donor organ availability is a major barrier, liver transplantation is a therapeutic option for end-stage liver disease and acute liver failure. The most usual approach is orthotopic transplantation, which involves removing the native liver and replacing it with the donor organ in the same anatomic location as the original liver. The surgical technique is complicated, involving thorough harvest of the donor organ and implantation into the recipient.

Liver transplantation is highly controlled, and only conducted at certified transplant medical facilities by highly qualified transplant physicians and accompanying medical team. Depending on the outcome, the procedure might take anywhere from 4 to 18 hours. A well-calibrated live or cadaveric donor match, as well as careful screening for eligible recipients, are required for favourable results.