How to Do a Liver Transplant (15 page)

Dying of cirrhosis is torturous and cruelly takes many years to kill its victim. When these people are as close to death as they can get, it is my job to swoop in and save their lives. It is a really cool thing to do.

Donor livers for transplant are a very precious commodity. In Australia on average there are only about 200 that become available each year. That is 200 lives we can save. In an ideal world, it would be fantastic to transplant a liver into everyone who might get some benefit from one. At the moment though, because there are so few livers on offer, we have to be very careful about who we choose to receive one. We must select the patients who have a very good chance of having a successful recovery. If more donor livers were available, we could push the limits of transplant to try and help those people who have more difficult problems to cure. These are the patients who are suffering from cancers like bowel and breast that have spread to the liver. They will usually die from their disease, but a small number of them might have a slight chance of recovery if they had a liver transplant. Even a ten per cent chance of a cure is better than none. Most patients with cancer, however, will die faster with a transplant than with no treatment at all because of the anti-rejection drugs they must take. Keeping cancer at bay relies on an immune system that works, so for most people on these drugs, cancer can return quickly after the operation. So, transplant is not for everyone.

It is our onerous task to find the people who transplant
is
good for. Patients must be sick enough to need a transplant, but not too sick in order to survive the operation. It is a delicate balance to get right. In Australia, liver failure is caused by many things but the most common are the
hepatitis C virus (frequently acquired from sharing drug injecting needles in the distant past) or drinking too much alcohol. More recently, being overweight seems to be contributing to liver failure, too. Sadly, liver failure will often make its victim pay for their silly teenage mistakes 20 years after they have well and truly overcome their addiction demons. For a minority, however, addiction is never far away and sometimes the only thing that has stopped them drinking or taking drugs is the fact that their livers are so bad that they are too sick to lift a glass to their lips any more. These patients who have not dealt with their problems are often the ones who will fall off the wagon within a few months of their transplant.

It is addiction and all its attendant social issues that make the selection of patients for transplant very tricky. It is something we take very seriously and we try our very best to try and identify the patients who might relapse. A formidable panel of doctors, nurses and social workers assess all patients for transplant. Such is the number of tests and interviews these patients have to go through I often wonder if actually undergoing the liver transplant might be less stressful. When all the tests are done, the patient is brought before us and they tell us how liver failure is affecting their lives. We carefully consider each potential recipient for many hours with their medical background, their sobriety and their family support structure all being factored in. After transplant, the most important thing
is that there are caring family members willing to look after the recipient when they go home. Without all these boxes checked, we do not go ahead. But, even with all the tests done, in the end we have to take a leap of faith and trust that the person will do their very best to look after the liver they might be given. Happily, most of them do. They realise that they have been granted the rare gift of a second chance to live and do everything we ask of them even though it is difficult and even painful at times. Many of them will even become avid crusaders for organ donation and do everything in their power to repay their debt of gratitude by living a healthy, happy and productive life.

No matter how many tests we run, it is impossible to always get the selection of patients for transplant right. As a doctor (and a human), it is difficult not to be affected when someone is sitting in front of you begging for their life, knowing you have the potential to save it. The vast majority of the time, we give people the benefit of the doubt. When we say no to someone wanting a new liver because they are at very high risk of going back to drugs or alcohol, it is impossible not to feel gutted. Deciding whether someone will live or die is a truly terrible thing to have to do but I try to remember that the precious organ needs to go to the person who needs it most and will look after it the best. It still doesn't make it any easier. Humans are fallible creatures and no matter how hard we try there is still a small number of people that get through the selection process
and will return to drinking or drug taking after transplant for one reason or another.

There have been some world-famous examples of this publicised in the media over the years. These are the most difficult patients for any transplant unit to deal with and when it happens we feel disappointed to our core. The power of addiction is so strong that it causes these patients to somehow block out the memory of what it felt like to be so close to death and the journey that took them there in the first place. There are even rare people who are never able to quit their poison and carry on a series of complex deceptions throughout the transplant work up process. A man I spoke to who continued to actively use drugs the entire time told me, ‘Doc, wouldn't you lie to you to save your own life?'

But there was one patient who took the prize for the worst relapse we have ever seen. This chap was ready for discharge from hospital ten days after his liver transplant, for a long past addiction to alcohol. He was sick of eating the hospital food and, despite being sober for years, he thought it would constitute sound judgment to go to the pub and have a counter meal of fish and chips washed down with a beer instead of going straight home. We don't know whether it was his new medications or something else that impaired his judgment, but one beer quickly turned into five and less than one hour later, he was returned by ambulance to the Emergency Department. He had got into
a drunken bar brawl and ended up with a broken arm. As one of my colleagues succinctly put it, ‘Today, the Liver Transplant Unit has reached a new low.'

When these events occur, it is really demoralising for everyone on the team who spends their lives helping these people. We feel as though we have failed the donor family who has chosen to give such a precious gift. I try and remember the 99.9 per cent of people who do the right thing and love their new liver by living a great life.

How to do a liver transplant

A
fter I had been in Denver a few months and had spent many hours assisting Dr Kam, he became confident enough of my abilities to take me through my first liver transplant as the primary surgeon. I was thrilled. This was followed a few months later by my first solo transplant, that is, without one of the bosses scrubbed. This was a big day and I was every bit as nervous and excited as I was with my first appendix. I didn't even know it was going to happen until I was well into it. Dr Kam sat in the corner of the OR preparing the new liver for transplant while I started the operation with
the surgical registrar. Of course my first brilliant manoeuvre was to make an inadvertent hole in a major blood vessel and it was difficult to mask the sound of the blood rocketing up the suckers and the flurry of activity as I forcefully requested the required stitch to patch the hole.

‘Kelleeeeeee, everything going OK?' Dr Kam asked, looking up from his work in the corner.

‘Yes, Dr Kam, no problems,' I said, sewing up my hole as quickly as possible, trying to keep my racing heart under a hundred. I did not want him to have to take over to get me out of trouble. This was part of being a grown-up surgeon. With a few quick stitches and the tying of a knot, everything came under control and Dr Kam turned back to what he was doing. Things then proceeded in an orderly fashion and after a while Dr Kam announced that he would be going upstairs for a while.

‘I am on my phone,' he instructed. ‘Call if you need help.' With that, he left the OR and everyone turned to look at me. This had not happened before. I beamed behind my mask and then just felt anxious as I realised the trust he was placing in me. I would not let him down. When I successfully put the last stitch in and tucked the patient into the Intensive Care Unit, I dropped into Dr Kam's office to tell him I had finished.

‘Everything OK?' he enquired.

‘Yes, thank you for letting me do it,' I said, secretly so chuffed with myself. I found out later that everyone
had shared my excitement at my first solo case from the moment Dr Kam arrived at the office. In the American system, trainee surgeons are rarely left alone and I knew that this was a nod of confidence in my skills and especially my ability to call for help if I needed it. In surgery, trust is everything.

When a liver transplant goes well, I experience a high that any drug in existence would be hard pressed to provide. This rush will last long after I get home and I am usually so wound up that I have trouble falling asleep as I replay every single stitch and every gush of blood over again in my mind. I revel in the precision of this operation, where one mistake or error of judgment can mean the case will end with fatal results. I feel so proud of what I have done that it is difficult to stop my heart bursting out of my chest. It is an interesting sensation, knowing that you have taken someone who could have been dead tomorrow and helped to give them the possibility of returning to a relatively normal life. It is their life in your hands and it is an awesome responsibility. I still can't believe they let me do it.

Of course, right along with the big highs come the lowest of lows. As I've mentioned, not everyone survives a liver transplant. Some die in the months after the operation, but an unfortunate few do not make it off the operating table alive. Surgery has a way of keeping you humble and just when you think you are pretty awesome, a
complication will happen to keep your ego well in check. It all becomes very real when you have two litres of someone's blood soaking through your gown onto your underpants and have to change before going out to the waiting room to ruin the lives of a hopeful family.

Actually doing a liver transplant can feel a lot like running a marathon. There are moments of breathlessness, fatigue, extreme focus – it can be physically torturous. The wear and tear on a transplant surgeon's body can be so significant that many find the physical demands impossible to deal with after a certain age. Almost every transplant surgeon retires with a bad back and arthritic knees. Transplant can also be dangerous work for all of my surgical staff. Many of the recipients have hepatitis B, C or HIV and sometimes all three. In an operation that often involves using hundreds of stitching needles, a stab to the hand with one of them can mean contracting a disease that will end your career and possibly your life.

Then there is the incredibly uncomfortable outfit I need to suit up in each time I do a transplant. For a start, I don scrubs, a plastic apron and a long-sleeved gown with gloves. My head is adorned with a complex arrangement comprising a surgical mask, heavy black glasses with microscopic lenses protruding from them, and finally a tight headband carrying a light, that after a few hours begins to feel like a crown of thorns. Sweat runs in a constant trickle down my back under the layers of plastic that protect me
from the blood, and by the end of the operation I am dripping wet and the patient's congealed blood is pooling in my shoes.

Because the liver is tucked all the way up and under the ribs on the right-hand side of the patient, I need to contort my body into a half sideways pose, facing toward the patient's head, quickly turning from side to side to get the right angle to place a stitch. It is a most unnatural way to stand for the long hours that it takes to do the surgery. One moment I am on my tippy toes, in a dominating position over the liver in order to lift it up, and the next I am almost kneeling on the ground so I can look under it and release it from its deepest attachments. ‘Doctor, your dick is not stuck to the operating table,' one of my bosses would yell at me, meaning to keep moving my ass so as I could get in the right position to place a stitch as accurately as possible. Then there are the bladder issues. During a transplant it is not unusual to go for six hours or more without taking a pee. It is like my body goes into a kind of crisis mode when I am concentrating so intensely. All non-essential systems temporarily shut down and the urine simply does not get made. It can't be good for you.

The only reason that surgeons get away with cutting into people's flesh is that the normal functions of the body help to repair the damage we have inflicted. Healthy people have blood that clots and wounds that heal and the liver plays a crucial role in this process. So much so, that
if a patient in the final stages of cirrhosis undergoes any sort of operation
other
than a transplant, the few liver cells they have left will not be able to meet the demands of surgery. They will simply give up the fight and the patient will perish. Aside from the body's own healing ability, two other things ensure that we have a live patient at the end of a liver transplant operation – a beautiful healthy donor liver and a big team of people who include specialist anaesthetists and nurses. The anaesthetists are charged with the responsibility of keeping the patient alive while I am doing things that would otherwise kill them. Cutting a knobbly, diseased liver out of a person can be a real blood bath and without the folks at the top end doing their thing, the operating theatre would quickly become a crime scene rather than a place of salvation.

The anaesthetists begin their work on the patient a couple of hours before I even show up. Two of them work together to constantly make fine adjustments in response to the numbers they see on their monitors. They render the recipient unconscious with a white liquid injected into a vein called Propofol. Yes, that
is
the same drug that reportedly killed the singer Michael Jackson and which he used to help him sleep at night. The difference in the operating theatre is that when the receiver of the Propofol inevitably stops breathing, the anaesthetist is there to help them out by inserting a breathing tube down their throat. Plastic tubes the size of drinking straws are plunged into
the major veins of the neck, arms and groin so bags of blood and fluorescent yellow clotting serum can be given as quickly as a litre in 30 seconds if necessary. The patient can manage to lose blood
that
fast if I make a big hole in a blood vessel. The anaesthetist will also use powerful drugs to constrict the blood vessels of the recipient's legs and arms during moments of copious blood loss. This causes blood to be diverted to the heart and brain to make sure they are not deprived of oxygen. A quarter of the room is filled with their equipment, all there to keep the patient going. If it wasn't for the patient in the middle of it all you would be forgiven for thinking we were there to launch the space shuttle.