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Liver transplantation
Liver transplantation is the replacement of a diseased
liver with a healthy liver allograft.
The first human liver transplant was done in 1963 by
Dr. Thomas Starzl in Denver, Colorado, United States. Dr. Starzl
performed several additional transplants over the next few years
before the first short-term success was achieved in 1967. Despite the
development of viable surgical techniques, liver transplantation
remained experimental through the 1970s, with one year patient
survival in the vicinity of 25%. The introduction of cyclosporine
markedly improved patient outcomes, and the 1980s saw recognition of
liver transplantation as a standard clinical treatment for both adult
and pediatric patients with appropriate indications. Liver
transplantation is now performed at over one hundred centers in the
USA, as well as numerous centers in Europe and elsewhere. One year
patient survival is 85-90%, and outcomes continue to improve, although
liver transplantation remains a formidable procedure with frequent
complications. Unfortunately, the supply of liver allografts from
non-living donors is far short of the number of potential recipients,
a reality that has spurred the development of living donor liver
transplantation.
Indications for liver transplantation
Liver transplantation is potentially applicable to any
acute or chronic condition resulting in irreversible liver
dysfunction, provided that the recipient does not have other
conditions that will preclude a successful transplant. Most liver
transplants are performed for chronic liver diseases that lead to
irreversible scarring of the liver, or cirrhosis.
Techniques of liver transplantation
Virtually all liver transplants are done in an
orthotopic fashion, that is the native liver is removed and the new
liver is placed in the same anatomic location. The transplant
operation can be conceptualized as consisting of the hepatectomy
(liver removal) phase, the anhepatic (no liver) phase, and the
postimplantation phase. The operation is done through a large incision
in the upper abdomen. The hepatectomy involves division of all
ligamentous attachments to the liver, as well as the common bile duct,
hepatic artery, and portal vein. Usually, the retrohepatic portion of
the inferior vena cava is removed along with the liver, although an
alternative technique preserves the recipient's vena cava ("piggyback"
technique). After the hepatectomy is accomplished, the allograft liver
is implanted. This involves anatomoses (connections) of the inferior
vena cava, portal vein, and hepatic artery. After blood flow is
restored to the new liver, the biliary (bile duct) anastomosis is
constructed, either to the recipient's own bile duct or to the small
intestine. The surgery usually takes between five and six hours, but
may be longer or shorter due to the difficulty of the operation and
the experience of the surgeon.
The large majority of liver transplants use the entire
liver from a non-living donor for the transplant, particularly for
adult recipients. A major advance in pediatric liver transplantation
was the development of reduced size liver transplantation, in which a
portion of an adult liver is used for an infant or small child.
Further developments in this area included split liver
transplantation, in which one liver is used for transplants for two
recipients, and living donor liver transplantation, in which a portion
of healthy person's liver is removed and used as the allograft. Living
donor liver transplantation for pediatric recipients involves removal
of approximately 20% of the liver.
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Immunosuppression for liver transplantation
Like all other allografts, a liver transplant will be
rejected by the recipient unless immunosuppressive drugs are used. The
immunosuppressive regimens for all solid organ transplants are fairly
similar, and a variety of agents are now available. Most liver
transplant recipients receive corticosteroids plus either tacrolimus
or cyclosporine. Acute rejection is generally less of a problem in
liver transplantation than is the case for heart or kidney
transplantation.
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