How to Do a Liver Transplant (18 page)

At 38 weeks, like all expectant mums, I was really over the whole thing and couldn't wait to see my baby. I was almost at breaking point and I didn't know how much longer I could go on working at the usual pace. I was too proud to tell anyone about this, of course. Whenever they asked, I said everything was fine, but whenever I saw my obstetrician I offered her a financial incentive to put me out of my misery. A moment of utter disappointment came in that second-last week when I thought it might be time. I was pottering away on the back table in the corner of the operating theatre, preparing a liver for transplant. When you are working on the liver, it sits in a silver bowl filled with slushy ice to keep it cold and well preserved. I suddenly felt liquid running down my leg and it stopped me operating instantly. I was more than a little paranoid about my membranes rupturing because my friend had recently broken hers in the middle of a busy supermarket and had to limp back to the car leaving a trail of bloody fluid in
her wake. ‘This is it!' I thought excitedly. ‘My water has broken, time to stop work and lie down.' To my dismay, it was only the melted ice from the liver dish spilling over the edge of the table onto my crotch and down my leg. Realising that's all it was, I forlornly turned back to continue my work on the liver and had to wait another two weeks for my daughter to make her grand entrance.

It was my goal through the whole pregnancy to work right up until the day I had the baby. What I didn't know, however, was that the last week of pregnancy would be like wading through quicksand whilst peering through a thick fog. Everything was heavy, my brain slowed down, and all I could think of was how much I wanted it to be over. Even small tasks seemed a massive imposition. In addition, because I had worked so far into my pregnancy, I also had to endure many unhelpful comments from people who thought they were being really funny:

‘Haven't you had that baby yet?'

‘Gee, you really are huge, are you sure it's not twins?'

I wanted to scratch their eyes out. At 40 weeks and one day pregnant I was doing what I hoped would be my final liver transplant before I gave birth. Towards the end of the operation I felt increasingly uncomfortable. There was an unusual rhythmic tightening in my belly. It wasn't too painful, so I put it down to the usual Braxton Hicks contractions that I had been having over the preceding weeks. I kept stitching and putting the final finishing touches to
the transplant. I felt absolutely dreadful and as the pains got worse, for some reason I tried to talk myself out of the idea that I was probably in early labour. I was a tough girl and I was going to finish the job. I got through it and so did the patient, by the way. I scrubbed out and called Andrew.

‘I feel awful,' I told him. ‘Come and get me.' Andrew took one look at me and drove me straight to my obstetrician. She confirmed I was indeed in very early labour and that I should go home because delivery was still a while off. She was right because it was another 36 hours of pain before they used a pair of shiny cold forceps to pull my baby girl out by her colossal head. We named her Abigail, after Abigail Adams, an influential American woman who was the wife of one United States president and mother of another. Because the labour took so long, there was a great deal of anticipation and impatience among all the transplant secretaries and nurses. They were standing just outside the door as Abigail crowned and it didn't take them long to get sick of waiting and burst into the room, followed shortly after by my bosses who had decided to include me in their daily ward rounds.

‘Don't mind me,' I said, my legs still up in stirrups. They didn't seem to notice as they all took turns holding our brand new American.

Do you think I could have a piece of your liver?

A
round the world there are thousands of people who give away parts of themselves so others may have a chance to live a better life. This is called living donation. These people voluntarily put themselves in harm's way. They are selfless, brave and just incredible.

None more so than a quiet, unassuming man I met one day. His entire family were recent immigrants and understood little in the way of English. It turned out that
they had a family member who was very ill, his liver was failing so badly that he was being considered for a liver transplant.

During the course of his medical work up, an interpreter mentioned to the family that living donation – that is, a relative giving up part of their liver for transplant – was an option. They were given the necessary written information so that it could be explained to the rest of the family to see if there was anyone interested in volunteering. They went away to think about this and talk among themselves. The patient and his entire extended family returned to the clinic a week later and informed us through the interpreter that a potential donor had indeed been found. The crowd parted and from the back of the group a man was pushed, almost shoved, forward. He stumbled a little and looked very nervous.

‘Our cousin will be the donor,' the family patriarch proclaimed.

We smiled and thanked him, letting him know that it was a very generous thing he was contemplating. We began the arduous medical work up required for donation. As things progressed, we noticed that this man was far more uneasy than the usual donor. He seemed to be filled with dread.

During a private moment away from the rest of his family, we asked him, ‘Is there something bothering you? You know you can always pull out of this at any time.'

‘No, no, I am ready to die. I am ready to make this sacrifice for my dear cousin,' he replied stoically through his interpreter.

‘It is quite unlikely you will die, you know,' we told him, slightly puzzled as to why he would say such a thing.

A strange look crossed his face. ‘What do you mean? Of course I will die,' he said.

Then it hit us – this courageous man thought that he was going to be killed so his cousin could have his liver. Everything had been lost in translation. For some reason, the family had decided that this poor guy should be the one to make the big sacrifice. You can imagine his shock when he was told that not only could he be a good cousin and donate his liver, but he could stay alive too! I've never seen someone so relieved. Eventually we all began to smile cautiously, followed by laughter when we realised what had happened. This story serves to illustrate just one of the potential pitfalls that can arise in the lead-up to this complicated procedure.

Aside from learning how to do a standard liver transplant, an important objective of my time in Denver was to learn the process for getting someone through one of these ‘right lobe adult living donor liver transplants' – a long name for an even longer operation. This technique has gained acceptance around the world because of the demand for organs in countries where the donation rate is low.

Pioneering surgeons knew from cancer surgery that they could remove 70 per cent of a person's liver and not only would they survive, but they could still live a normal life. So it was a natural progression to think that they could remove half the liver from a healthy person to transplant into someone dying from liver failure. The halved liver does an extraordinary thing and grows bigger. It does this so quickly that within six weeks of the surgery it has reached its full potential again. Compared to living donor kidney transplant, however, the risks for liver donors are considerably higher. Unlike the kidneys that have completely separate blood supplies, the liver receives its blood from single blood vessels that split into two just before they enter the liver. This means that removing a kidney poses very little risk of damage to the other one. With the liver, the risk of damage to the remaining half in a living donor is very real. The stakes are high.

Professor Strong and his partner Professor Tat Ong had taken livers from deceased donors, cutting them in half for use in two recipients. Spurred on by the success of transplanting these ‘half livers', in 1987 they reported one of the first transplants exploiting this splitting technique, using a donated section of liver from a living person. This pioneering operation was first performed in Brisbane, Australia, between a parent and their child.

Of course, with living donation there is the possibility of ending up with two dead patients at the end of it all,
and one of them didn't even need an operation in the first place. But in this first instance, because it was a parent making a sacrifice for their child, the risk seemed acceptable and there were many parents who were willing to leap at the chance to rescue their child from a slow miserable death. The medical community also agreed with adult-to-child donation because the operation for the donor was relatively low-risk because it only involved removing a reasonably small section from the left side of the liver. By doing this, it avoided going near the important blood vessels that supply the rest of the liver, minimising the chance that the remaining section would be damaged. Encouraged by the good results the technique achieved in children, it was only a matter of time before the concept was adapted for transplants between adults.

Adults are bigger than children, so for an adult-to-adult living donor liver transplant, a larger section of liver is required. Adult living donor transplant continues to be mired in controversy because the very idea of subjecting a healthy person to this type of risk is difficult for people to accept. The decision for any transplant unit to do living donation is never taken lightly and we only do it when there are no other options. To procure this bigger piece, it is necessary to remove the right half of the liver from the donor. This is a far more technically demanding operation than taking a section from the left-hand side of the liver for transplanting from an adult to a child, and there is a
higher chance that the section of liver remaining in the donor may be in jeopardy. Transplants do not always turn out for the best.

The cold hard numbers report that for adult living donation, one in one hundred living donors will die during or after the removal of the right half of their liver. These donors might end up literally giving their life in an attempt to save another. There are risks for the recipient, too. Sometimes a donated liver just doesn't work – the blood vessels might clot or the donor might reject it. Some livers must be urgently removed within days of the transplant and suddenly the recipient can be fighting for their life again. One in ten recipients, in fact, will not be alive one year after the transplant. The donor might go through all this pain for nothing. This can leave a donor feeling devastated.

Being a live donor must be a sensation like nothing else imaginable. There is only a select group of people around the world who can tell you how they really feel on that morning just before they are wheeled through the doors of the operating room. I'm sure they don't sleep the night before, knowing that tomorrow they are going to be cut open to give away a quite important part of their body. They have been through dozens of medical and psychological tests and the work up has been an arduous rollercoaster ride. With each test might come the news that the whole thing will be called off. I'm sure some feel incredibly relieved when this does happen, no matter how
much they want to help – now they can bow out without terrible guilt.

For those who have been declared perfectly healthy and are willing, the day finally arrives. They have been very brave and strong up until that point but when they cross the threshold into the operating theatre, all of their bravado disappears. Donor and recipient lie side by side on narrow stretchers in the pre-surgery area, knowing that in a few hours they will be linked together for all time. Many will clutch each other's hands as tightly as possible until the last moment when they are taken to their respective theatres. One, the very picture of good health, the absolute antithesis of the other who is gaunt, yellow and dying. This is a very uncomfortable scene to watch. The best words I can use to describe the donor's demeanour are ‘white with fear'. They look like a person who is about to face their executioner. The sense of pride about the amazing thing they are doing seems to desert them at that moment and I've seen grown men shake and cry like babies. Families too are profoundly affected as they are torn in two directions: on the one hand this is the moment that life can begin again for the person dying of liver failure. For the other there is a real chance of dying healthy. No one knows how to feel. Should they be happy or sad? The confusion on all faces is obvious.

We do our best to reassure everyone that things will be fine. But any surgeon involved in donor surgery has also had
little sleep the night before. It is hard not to worry about operating on these donors. A rule of surgery is ‘first do no harm', and this is exactly the opposite of what we are doing to these donors. Everything has to go perfectly. The moves are rehearsed in our minds over and over. Every eventuality must be predicted and no detail left unaccounted for. The stress of this can be very difficult to handle and no matter how many cases you do, it never goes away.

For a while after the operation, life is not easy for the donor. They are very glum as they struggle with their pain. They find it hard to get out of bed and even coughing or taking a walk is not easy – all the things they previously took for granted. I'm sure that some might think, at least for a short time, that donating a part of their liver may have been the single biggest mistake of their lives. It is not difficult to figure out why. They had had nothing wrong with them and we have inflicted pain and suffering. Aside from doing a generous thing, they have no real reason to be in this situation.

The recipients of the transplant, however, are usually quite the opposite. They have every reason to feel better. In the space of a few hours they are no longer dying and, when the operation has gone well, they are typically up and around within a few days, suffering very little pain and looking forward to their new life. The large doses of immune suppressing drugs we give them can even make them euphoric. It can be a difficult time for donors to
see the recipient flourishing when they are feeling so low. There is an old saying that ‘time heals all wounds' and this is so true for these donors. Eventually, as the pain disappears and their wound fades, they begin to realise what they have done and feel the immense satisfaction of seeing the recipient start their life over again. So powerful is this feeling of pride that some donors even ask if they have enough liver left to do it again. They can't, of course, it is a once in a lifetime gig.