The operation took longer than is normally the case which suggests it was challenging
A COLLECTIVE sigh of relief could be heard once Meadhbh McGivern emerged from theatre following a successful liver transplant operation at King’s College Hospital.
With the unfortunate events of the first attempt to transfer her to London fresh in people’s memories and in the knowledge that her condition had deteriorated in the intervening weeks, an added national concern for her welfare is palpable.
The length of time she was in the operating theatre – 14 hours – suggests the procedure was technically challenging. Surgeons must first remove her diseased liver in a way that allows ready access to the blood vessels, nerves and ducts that must then be painstakingly connected to the donor liver.
The liver is a tough and resilient organ with an ability to regenerate itself. But if extensively damaged by infection – such as hepatitis – or a disease such as cirrhosis, liver failure occurs. A transplant becomes necessary when the liver has been damaged to such an extent that it cannot perform its normal functions; a multifaceted organ, it has myriad functions.
It produces proteins for the body, makes a substance called bile by breaking down part of the blood pigment (haemoglobin), stores iron and vitamins, destroys old blood cells and makes the clotting agents that ensure blood clots correctly.
One of the organ’s main functions – and one that is central to human life – is its role in deactivating hormones. Some are broken down completely by the liver, others are combined in the liver with other substances to render the hormone harmless.
Many drugs, including alcohol, are also processed by the organ. After paracetamol and other medications have performed their desired function, it is the liver that deactivates them. The liver is the most important site in the body for the metabolism of drugs. They are converted from fat-soluble to water-soluble substances that can be excreted in urine or via bile from the organ.
About one litre of bile flows from the liver every day, with 50 per cent flowing directly into the small intestine. The other 50 per cent is diverted into the gall bladder. Much of the bile is reabsorbed, but in the case of the breakdown products of drugs and cells within the bile, these are excreted in stools.
The most common type of liver transplant, which Meadhbh underwent, is an orthotopic transplant, where a entire liver is taken from a recently deceased donor.
But split transplants are also carried out, with a child and an adult benefiting from a single donor liver. The donated organ is split into the left and right lobes. Normally, an adult is given the larger right lobe and the child receives the smaller left lobe.
In a third procedure, living donor transplantation, the donor will have an operation to remove either the left or right side of their liver. Right-lobe transplants suit adult recipients because of their bigger size, with the smaller left lobe used if the recipient is a child.
Once the transplant was complete, Meadhbh was moved to an intensive care unit (ICU) to recover. She was placed on a ventilator and is heavily sedated. Most people are well enough to move out of ICU and into a hospital ward within a few days. Meadhbh can expect to leave hospital in three to six weeks’ time, while she can expect to return to normal activities in three to six months.
What are the main challenges that lie ahead?
- Acute liver rejection: This occurs when the immune system suddenly attacks the new liver. It is a common complication, occurring in up to 40 per cent of cases, usually in the first seven to 14 days.
- Graft failure: This means the transplanted organ is not working properly. It is one of the most serious complications of a liver transplant and occurs in about one in 14 cases. The most common cause is an underlying problem that is disrupting the blood supply to the transplanted liver. The only treatment is to carry out a fresh liver transplant.
- Infection is a risk from all types of surgery, but the need to take powerful anti-rejection drugs makes it more likely following organ transplant. The recipient is especially vulnerable to fungal infections and to infection with cytomegalovirus, both treatable.
- Immunosuppressants: As the risk of rejection is highest in the first three months after a transplant, Meadhbh can expect to be given high doses of drugs to dampen down her immune system. Because of significant side effects, the dose will be gradually reduced to the minimum possible.
- Steroids and drugs called calcineurin inhibitors – which block the activation of T cells in the blood – are routinely prescribed. But with excellent medical care and a modicum of luck, Meadhbh can look forward to a full recovery.