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The Center for Liver Diseases and Transplantation, Apollo Hospitals, India is equipped with the state-of-the-art technology for liver surgery using the laparoscopic Argon Beam Laser as well as Tissue Link™ in combination with other methods of liver resection like CUSA™ and Laparoscopic Vascular Stapling. Bloodless Liver Surgery is performed with high success rates.
Who is eligible for liver transplant?
While a liver transplant is the best cure for most patients with non-metastatic liver cancer, the limited organ supply may make this option unviable. The eligibility criteria for transplantation is the presence of a single HCC tumor 5 cm or less in diameter, or fewer tumor nodules, each 3 cm or less in diameter. Both living relative and cadaveric liver transplants are options for patients at the Center for Liver Diseases & Transplantation, Apollo Hospitals,India. Patients who will obtain maximum benefit from liver transplantation include those who are estimated to have less than one to two years of life and have no alternative medical or surgical therapies. The liver transplant procedure helps prolong the patient's life for at least five years and/or to restore the patient to a normal or near normal functional status. Thus, the overall goals of liver transplantation are to prolong life and improve the quality of life.
What are the conditions for which liver transplant is done?
- Irreversible cirrhosis with at least two signs of liver insufficiency
- Fulminant hepatic failure: coma - Grade 2
- Unresectable hepatic malignancy that is less than 5 cm in diameter and confined to the liver
- Metabolic liver disease that can be treated by liver replacement
- MELD score of 12 or higher
Other specific indications for liver transplantation include Budd-Chiari Syndrome, benign hepatic tumor and autoimmune liver diseases. In addition, there should be no alternative forms of therapy and no contraindications for the procedure. Finally, the patient and family members should be able to accept the procedure and provide for its costs.
The most common indication for liver transplantation however is end-stage chronic liver disease, accounting for approximately two-thirds of all patients.
General clinical and biochemical indications for liver transplantation in patients with chronic cholestatic liver diseases (e.g., primary biliary cirrhosis and primary sclerosing cholangitis) include:
- Serum bilirubin > 8-10 mg/dL
- Intractable Pruritus
- Intractable bone disease
- Malnutrition or recurrent bacterial cholangitis
- Severe or intractable encephalopathy
In patients with chronic hepatocellular diseases (e.g., chronic hepatitis with cirrhosis), general biochemical indications for liver transplantation include:
- Serum albumin < 3.5 g/dL
- Prothrombin time > 3 seconds above control or INR >1.3
- Encephalopathy
- Ascites
- Bilirubin > 2 mg/dL
Patient Selection for Liver Transplantation
Minimum Listing Criteria for Liver Transplantation
- CTP score > 7 (CTP Grade B)
- MELD ≥ 12
- Life expectancy < 85% at 1 year without liver transplantation
- Evidence of Clinical Decompensation in Chronic Liver Disease
In all/any category of advanced liver disease, the following conditions necessitate liver transplantation without further delay since they are associated with a very high incidence of life threatening complications:
- Severe fatigue and unacceptable quality of life
- Recurrent variceal bleeding
- Intractable ascites requiring frequent paracentesis
- Intolerance to diuretics (low serum sodium/elevated kidney functions)
- Recurrent or severe hepatic encephalopathy
- Spontaneous bacterial peritonitis
- Hepatorenal syndrome
- Development of small hepatocellular carcinoma seen by liver imaging (CT Scan/Ultrasound)
Contraindications to Transplant
Contraindications to liver transplantation can be divided into those that are absolute and those that are relative, i.e., are expected to complicate and increase the risk of transplantation. Absolute contraindications to liver transplantation include:
- AIDS or HIV positivity
- Irreversible brain damage
- Multi-system failure that is not correctable by liver transplantation
- Malignancy outside the liver (except skin cancer)
- Infection outside the hepatobiliary system
- Active alcohol or substance abuse
- Advanced cardiopulmonary or other systemic disease
- Moderate to severe uncorrectable pulmonary artery hypertension
- Completely occluded porto-mesenteric venous system
Factors that increase the risk of liver transplantation include the following:
- Advanced age
- Advanced chronic renal failure
- Cholangiocarcinoma
- Chronic Hepatitis B virus infection with high viral counts
- Hepatocellular carcinoma beyond Milan Criteria
- Hypoxemia from intrapulmonary shunts
- Massive ascites
- Portal vein thrombosis
- Prior portosystemic shunt surgery
- Prior biliary tract surgery
- Severe malnutrition
- Severe abdominal atherosclerosis
The Liver Transplant team at Apollo Hospitals, India uses the above general principles as well as prognostic indices that are under development for conditions such as fulminant hepatic failure, primary biliary cirrhosis and primary sclerosing cholangitis. Early referral for pre-operative evaluation for liver transplantation is critical and allows evaluation before the development of multiple or advanced complications, which decrease the survival and increase the costs of liver transplantation. Early referral allows close follow-up of patients with end-stage liver disease with the referring physician and an adjustment of priority status for transplantation. In addition, the family members and patient have ongoing education regarding the liver transplant process.
How is a patient evaluated prior to liver transplant?
The majority of pre-transplant evaluations can be completed on an outpatient basis over a two-three day period. Candidates for transplantation are typically seen by the transplant surgeon, transplant hepatologist, transplant nurse coordinator, psychiatrist, nutritionist/dietitian, financial counselor and other consultants as appropriate. (Consultations/consults for cardiology, pulmonary, oncology, etc. are performed by specialty physicians at Apollo Hospitals, who have expertise in working with patients with end-stage liver disease and organ complications/interactions from other systems. These consultations by our physicians are necessary for subsequent patient listing and transplantation). The transplant coordinator is the key contact person who facilitates the pre-transplant evaluation.
Transplant candidates over the age of 55-60 years or candidates over the age of 50 with risk factors for coronary disease, or those with a history of cardiac disease, undergo cardiology consultation with appropriate cardiac studies, often including stress thallium and/or cardiac catheterization. Doppler of carotid or peripheral vessels may also be appropriate. Cancer screening as per standard recommendations (Pap smear, mammogram, fecal occult blood testing, and flexible sigmoidoscopy depending upon age/gender), is completed.
Once the pre-transplant evaluation is completed, the patient’s profile is presented to the selection committee for categorization and prioritization. Patients are generally assigned to one of four categories:
- Suitable and ready, with listing and initiation of donor search
- Suitable but too well, with placement on inactive status and followed with consultation with physician
- Potentially reversible current contraindication, with treatment and recategorization at a later date
- Irreversible absolute contraindication with denial of transplantation
Transplant options for alcoholic cirrhosis
There are a number of specific indications and/or circumstances regarding liver transplantation that undergo special scrutiny. One of these conditions is alcoholic cirrhosis. Apollo’s experience, as well as that of other transplant centers, has indicated that properly selected patients with alcoholic cirrhosis experience excellent survival and good quality of life following liver transplantation. All patients referred to Apollo Hospitals, India undergo careful evaluation by a hepatologist, psychiatrist and social worker with attention to indicators for continued sobriety and compliance with the post-transplant long-term follow up. In particular, previous social stability, employment record, psychiatric status and length of sobriety are evaluated. For patients with the diagnosis of alcohol dependence or abuse, the referring physician will ask the patient to sign an alcohol contract and participate in alcohol recovery while awaiting transplantation. Only patients having psychosocial factors predicting long-term sobriety are accepted for transplantation.
Transplant options for chronic Hepatitis B Virus (HBV) Infection
Patients who have chronic Hepatitis B Virus (HBV) Infection are a subset of patients who present a special problem because of recurrent infection of the transplanted organ. Based on encouraging results from a number of European and US centers, we are currently treating all patients with Lamivudine & Hepatitis B Immune Globulin (HBIG) (selective) post-transplant in an attempt to reduce the rate of recurrence of infection in the allograft (now less than 10%). We are currently accepting patients with chronic HBV infection whether they are HBeAg/HBV DNA negative or positive. We also use lower doses of immunosuppressive medications post-transplant in hopes of reducing clinically significant HBV infection.
Liver transplants in older patients
Older patients also undergo special scrutiny. All candidates referred for liver transplantation past the age of 60 undergo particularly thorough evaluation, with particular attention to silent coronary or vascular disease. If patients have no other major organ disease and are expected to live five or more years, they are typically approved for transplantation.
Liver transplants for patients with hepatocellular carcinoma
Patients with hepatocellular carcinoma undergo special scrutiny and adjunctive therapy. They have a long-term survival after liver transplantation, which is less than that for patients undergoing transplantation for other indications. In order to improve these results, we currently offer adjuvant therapy in the form of chemo-embolization or chemotherapy to control the spread of cancer cells or unrecognized micrometastases. All patients undergo thorough evaluation for identifiable malignancy outside of the liver, including chest CT scan, abdominal and pelvic CT scan & bone scan. Finally, the abdominal cavity is explored carefully at the time of transplantation before proceeding with the hepatectomy and transplantation.
Follow-up
All cases are followed-up for life with maintenance of master records under the Liver Transplant Program at Apollo Hospitals. Regular patient communication with liver transplant coordinators or transplant physicians and referring doctors is implemented to enhance the optimal long-term results.
Ablation (Radiofrequency or Cryoablation)
Patients who are not candidates for resection or transplantation due to inadequate liver reserve, large or multiple lesions in multiple lobes, fibrosis or cirrhosis can benefit from treatments such as CT-guided, laparoscopic or open radiofrequency or cryoablation.
With new radiofrequency (RF) ablation technology, liver tumors up to 7 cm in diameter can be treated. The ideal patient for RFA generally has no more than three lesions that are no greater than 5 cm (about 1.5 inches) in size.
RF ablation delivers radiofrequency energy to the tumor, heating it to high temperatures thereby destroying the lesion. During cryoablation, argon gas is delivered through probes inserted into the liver, creating an ice ball that freezes the tumor and destroys its cells.
Another option for patients who are not surgical candidates is PEIT, which involves the injection of alcohol into the tumor, causing immediate dehydration of the cytoplasm with consequent coagulation, necrosis and fibrous reaction. PEIT results in complete ablation in upto 75% of selected patients with hepatocellular carcinoma.
Hepatic Arterial Pumps
Indicated for patients with metastatic colon cancer, hepatic arterial pumps deliver chemotherapy to the liver through a catheter placed in the hepatic artery. The catheter is typically inserted via laparoscopic or open surgery and a pump, which delivers the chemotherapy, is implanted subcutaneously. The pump is generally filled with chemotherapy medication once a month.
Why Choose Apollo Hospitals
With the use of advanced technology and surgical methods, patients now have more options than ever before for the treatment of hepatobiliary disease. Apollo Hospitals Center for Liver Disease & Transplantation offers comprehensive specialty care for diseases of the liver, pancreas and bile duct. We emphasize on ongoing communication with referring physicians and incorporate them in the decision process of their patient's medical management. Following treatment, we follow up our care with an organized discharge report to the referring physician. Our physicians are trained at the world’s most renowned centers in Hepatobiliary surgery and Liver Transplantation and are actively involved in clinical research and offer multiple studies in areas such as hepatocellular carcinoma, gastroenterology and viral hepatitis.
For patients requiring hospitalization, we have a dedicated Hepatobiliary Critical Care Unit, a heptobiliary physician on call, anesthesia staff and a specialized OR nursing team. At the Center, our focus is on providing experienced, personalized care for all our patients.
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