How to Do a Liver Transplant (14 page)

When everything is in place and both teams are ready, someone cries out ‘Cross-clamp!' Then it is on for young and old as the clock is ticking. Up to this point, it has been a careful and considered surgery. Now it is all about speed. We move like Edward Scissorhands, chop, chop, chop.
This is the trickiest part – to move fast without cutting something you shouldn't. Our success is measured by the time it takes to get the organs into their new owners, because from this moment everything is dying. It all happens at once: the aorta, a hosepipe-sized artery carrying blood from the heart to the legs via the abdomen, is clamped; the inferior vena cava, the massive vein carrying blood from the legs to the heart, is severed and the donor is exsanguinated. Five litres of blood floods into the body cavities. At the same time, the hanging bags of preservation solution are run through, full speed. The blood in the veins is replaced by the ice-cold fluid and almost instantly the deep red colour of the liver fades to beige, the heart stops beating and the only noise in the room is the sound of blood being removed by the suckers.

The heart and lungs are lifted out of the body first. The heart surgeons cut the blood vessels that suspend them in the chest. Just before the windpipe is divided, the anaesthetist delivers several final puffs of air via the breathing bag in order to blow the lungs up to their full capacity. This stops the delicate air sacs from getting glued together during transport. The two lungs and heart are then lifted out of the chest, like fully inflated balloons. This is a clumsy block of tissue. Imagine trying to manipulate two wet pillows tenuously connected in the middle by a wobbly heart. It requires two hands to clutch the jiggly parcel and carry the organs to a waiting sterile table, wrap them carefully in
three layers of plastic bags and bury them in ice. It is then my turn to free the liver from its last few attachments as fast as I can and place it into its own bags. Like the lungs, the kidneys are also delivered as a pair, but are separated into right and left once they are out of the body. They are bagged separately, the left one being the more favoured by transplant surgeons as its naturally longer blood vessels make it a little easier to transplant. Then we are done and I stitch the skin wound closed, gather the labelled and bagged organs, and hit the road.

In case you were wondering, yes, I have gone close to seeing an organ dropped on the floor. We were returning back to the University Hospital in Denver one night when we opened the trunk of the car and the cooler fell out, spilling ice and bags of organs all over the pavement. Luckily there were no breakages of the bags of organs; even though they were shaken, they were buffered from the impact by the fluid surrounding them. We hurriedly scooped them all up and stuffed them back in the cooler before anyone could see what had happened. They worked just fine.

When I returned to home base, the next hour was spent preparing the liver for transplant in a procedure called ‘the back table'. This is absolutely critical, because the moment the liver or kidney is lifted out of the ice by the transplant surgeon, everything has to be ready to sew it straight in. It is vital to get blood flowing through the organs again
as fast as possible because the moment they start to warm up, they begin to decay. On the back table, any extra tissue and fat from the donor is trimmed off the blood vessels until they look a lot like glistening tubes of calamari. If the vessels are too short, they are made longer with spare arteries taken from the donor's arms or legs. There are always a few little holes made in these blood vessels during the course of the donation surgery and these must be painstakingly repaired with fine blue nylon stitches. It is very easy to miss one or two of these holes when the organs are cold like this and they become pretty obvious once the organ is transplanted. Blood pours out of them and they have to be rapidly repaired at a time in the transplant when a lot of things are happening all at once. This bleeding can cause a great deal of chaos and the repair of these holes is usually accompanied by a little good-natured cursing of the backtable surgeon, especially if they have already gone home to bed and are not in the room to defend themselves.

Because every donor has slightly different anatomy, it is relatively easy to make a mistake when you take the liver out in the controlled cutting frenzy at the end of the donor operation. Any unrecognised error can sentence a recipient to months of problems after their transplant and may even result in death. The back table is the place where these potential problems are identified and sorted out. When I was learning, I certainly made my share of errors, inadvertently cutting the wrong thing at the wrong time. I would cop a
mouthful from my bosses if I cut something I shouldn't and would have to spend an extra hour on the back table, painstakingly sewing the severed ends of my blunder back together. Another boss, having made a few mistakes of his own, was more generous and would say, ‘That's why stitches were invented.'

We have found a new liver for you

C
an you imagine what it must be like to sit at home waiting for a telephone call that has the potential to save your life? Can you also imagine what it must be like to know that the call may never come and your life will just dwindle away? This is the daily reality for a patient on the liver transplant waiting list. When the telephone rings to say that there is a suitable liver available, I expect it must feel like escaping the hangman's noose. Some patients will wait for more than two years for their reprieve to come. Some are so close to the end that they are in hospital when that offer of a precious
organ finally arrives. One man was so near death that when I told him that we had found a new liver for him, he thought I was an angel sent from heaven to comfort him on his way to the pearly gates. Sadly, some patients will never get that wonderful call to come to the hospital to receive their new organ and they will die waiting.

Liver transplant is never a walk in the park for any patient. They will be on anti-rejection drugs for the rest of their days and these have side effects that can make life difficult sometimes.

A new liver also doesn't always mean that everything will be all right. I tell people that transplant surgery is a lot like riding a roller coaster – there will be lots of ups and downs. Some will not even make it out of the gates, dying of complications in the first few weeks or months before they ever get to enjoy the benefits a new liver can bring. For a rare few, their new organ will not work at all and they will need to be urgently re-listed for a second liver that may not materialise in time. For the rest, some may have to endure multiple operations and painful tests; some may have their liver disease return; and, over time, some will even get cancers as the anti-rejection drugs reduce their ability to fight off deadly tumours. For all these reasons, a patient has to be really close to death to go on the waiting list for a liver transplant. Their chances of being alive in one year need to be higher with a new liver than with their old one.

The most common reason for someone to need a liver transplant is because they have cirrhosis. For many people, the word cirrhosis conjures up the image of a red-nosed alcoholic perched on a bar stool with the top of their butt peeping out of their shorts. But really, alcohol is only one of the causes and cirrhosis is simply the term doctors use to describe irreversible scarring of the liver. Cirrhosis and liver failure can be the result of anything that damages the liver: fat, viruses, immune diseases or genetic defects account for most cases. There is not a single person from any walk of life that it cannot touch and cirrhosis can occur at any age from newborn babies to 90-year-old great-grandmothers.

The liver has a huge job to do and it influences the function of every other system in the body. There is no machine that can duplicate its actions and so, unlike a kidney patient who can be sustained for a while with dialysis, there is no temporary solution to replace it should it fail. The liver makes protein to strengthen muscles and molecules that help the blood to clot. It makes bile to help us absorb our food. The liver removes all sorts of toxic products of digestion as well as breaking down many types of medications and drugs. It deactivates the ammonia produced by the bowel into a form that can be passed easily in the urine. It makes and stores sugar, vitamin A, D, B12, iron and copper and it regulates the cholesterol level in the blood. It even makes a hormone that controls blood pressure and,
in a foetus, it makes blood. So, it is really pretty important and when a patient has cirrhosis, all these systems will slowly fail and the body will fall apart.

We are all born with far more liver than we need and in fact I can easily remove 70 per cent of a healthy person's liver and they will notice no difference at all. The remaining section will rapidly grow and within six weeks the liver will be back to its normal size. When someone has cirrhosis, the liver cells that have been repeatedly injured over a number of years will eventually die and become replaced by hard scars. This happens very quietly, in the background, and quite unbeknown to the victim. A fighter until the very end, the liver continually tries to repair itself, forming little nodules of new and hopeful liver cells among the sea of scar tissue. As it does this, its appearance changes from being smooth and glossy to shrunken and knobbly.

It is only when the liver has dwindled to around a quarter of its former self that signs begin to appear that something is seriously wrong. These symptoms make a lot of sense if you can understand what is happening inside the liver during this process of scarring. The thousands of blood vessels that run through the liver are trapped in the scar tissue and become convoluted and squashed. The resistance to blood flow increases so much that the blood will eventually move in reverse. When this happens, the blood that usually gets back to the heart via the liver must find another way. Normally insignificant veins that
meander through the abdomen will expand and become conduits for massive volumes of blood. These varicose veins are paper-thin, under explosive pressure, and they coat all surfaces of the bowel in an intricate purple spider web. These little veins are simply not designed to carry so much blood and there are consequences. These can be as minor as spontaneous nose bleeds or catastrophic when the presence of liver disease can announce itself in a most spectacular way. When the fragile walls of these veins are exposed to acid in the stomach, they can rupture and blood will pour out of the jagged tears. Because the stomach can hold several litres of liquid, the bleeding can continue unabated until the amount is sufficient to make its presence felt by a voluminous vomit of bright red blood. A bleed like this can put on an extraordinary display. In the most extreme case I have ever seen, we were taking a patient to the operating theatre to have her liver transplant. We were in the elevator when, without warning, she told us that she needed to vomit. We all stood aghast as she left everything in that elevator, including us, dripping in blood. It looked like a grisly murder scene. We rushed her into the theatre where, luckily for her, the new liver was standing by. As the anaesthetist squeezed bags of donated blood into her veins, we stopped the bleeding by transplanting the liver into her. This instantly dropped the pressure in the veins feeding the bleeding in her stomach, because blood was now flowing through the new liver in its natural direction.
That lady was very fortunate that day, because very few people will survive a bleed like this.

More often, the onset of liver disease is far more subtle but no less deadly. There is a reason that blood goes through the liver to get to the heart. This blood is rich in toxic waste, a product of the digestion of the food we eat, and the liver does a terrific job of stopping us from being poisoned by it. The poisons enter the liver cells and get taken apart, shielding our body from their harmful effects. But because the blood is bypassing the liver in patients with cirrhosis, these poisons are let loose into the body's general circulation and have terrible consequences. The afflicted person's complexion will slowly change and big spider veins will appear on their face and chest. Their skin will dry out and turn brown. The whites of their eyes become an alien shade of yellow as their level of jaundice deepens. The person's faculties gradually slow as the level of ammonia (the same stuff that is used to clean drains) rises. Victims of cirrhosis develop a peculiar smell as the deadly ammonia is blown out on their breath. They become fatigued and cannot get through a day of work without having to take a nap. Eventually there is outright confusion, followed by coma and death.

Because the liver can no longer make protein, the blood becomes thin. Water will leak out of the blood vessels making the skin swollen and boggy. The abdominal cavity fills with litres of fluid as the liver literally weeps
and the sufferer appears to be nine months pregnant. This can happen so slowly that the patient might only seek help when they notice they can no longer see the television over their swollen tummy. This fluid can also run into the scrotum and patients have to take to a wheelchair when they can no longer carry around the weight of their own balls. Their belly button will protrude with the pressure of the fluid and the skin covering it will thin out until it ruptures. Then, a steady stream of clear yellow liquid will dribble out through the hole in a continuous stream. All they can do is catch it in a plastic bag. A liver with cirrhosis will no longer break down oestrogen and men will take on some female characteristics. They grow small breasts, lose their body hair and their testicles shrivel up.

As if all of this is not enough, in one final and fatal blow, cirrhosis is fertile soil for cultivating cancer. Deadly tumours develop and, like invaders, will just keep on coming as long as the damaged cells are there. These cancers are particularly aggressive and spread their tentacles into major blood vessels, growing toward the heart and lungs. Because they love to invade big blood vessels, these tumours are notorious for rupturing, usually resulting in the patient bleeding to death.