Precautions to be taken while waiting for a transplant
While waiting for the transplant, it is important that patients undergo regular testing, adhere to all appointments and medical advice, and comply with treatment and dietary restrictions. In order to remain healthy, prevent any infections, prevent any complications, enable early identification of any problems or significant change in condition, and allow prompt treatment before transplant, some simple precautions can be taken.
- Washing hands and scrubbing for at least one-minute with soap and water, including between fingers, under the fingernail and around the nail beds before eating, after using the bathroom, and when they are dirty
- Using Antiseptic hand-rubs frequently
- Malnourished patients may be advised a few weeks of medical nutrition therapy
- Performing light exercises, walk and remain active (as much as possible)
- Getting enough rest
- Taking only the prescribed medicines. Do not take any new medicines, including vitamins, herbs or supplements without discussion with the transplant team
- Children are advised to undergo all vaccinations appropriate for age because they cannot receive live vaccines after the transplant
- Following a low salt diet, as prescribed, and adhering to liquid intake restriction. This will help to control ascites (fluid in the belly)
- Eating smaller meals that are low on fat, high on protein, and provide adequate calories, keeping the muscles strong
- Patients can consider taking nutritional supplements if they are unable to get enough calories or proteins in their diet, as advised by the dietician
- The transplant team should be informed about any significant change in the health or any hospitalizations
- Stop consuming alcohol. If the transplant team has any doubt about a patient’s lifelong commitment to sobriety or abstinence from alcohol or illicit drugs, it can perform random blood or urine tests for the same. If the patient tests positive, he/she may be taken off the waiting list
- Patients should quit smoking before the transplant because it can cause lung infections after surgery, and prolong recovery from ventilator after surgery
- The transplant team should be notified of any unexpected change in health such as blood vomiting, black stools, changes in mental condition, excessive sleepiness (drowsiness), confusion, nose bleeding, weight gain, swelling in abdomen or arms and feet, severe or sudden abdominal pain, fever, fainting spell, severe vomiting or loose motions
- Patients may be able to continue to work and even travel while on the waiting list after discussing the same with the transplant team. It may not be safe for patients with very low platelet counts, high INR, history of GI bleed or encephalopathy to travel. While travelling, the co-ordinators should be updated with the patient’s contact numbers. Patients should also identify a doctor locally who can take care of any urgent problems while travelling. Patients should keep the phone numbers of their family members, and the transplant team handy to deal with any urgent situations
Getting admitted to the hospital for transplant
In the case of living donor transplants, patients and donors are admitted to the hospital a day prior to the surgery. Both donors and recipients must not eat or drink anything after midnight before the operation.
Deceased donor transplants are performed on an emergency basis when a cadaveric liver is available. Patients are called to the hospital urgently; they undergo a rapid review and tests before surgery to ensure that they are healthy and ready for surgery. Patients should not eat or drink anything once they receive intimation for the transplant.
After the patients are admitted, the transplant team has a discussion about the quality of organ and transplantation process and ask the patient to sign the consent form after a complete understanding of the process. Patients should inform the transplant team about pre-existing health problems, current medicines, and known drug allergies to prevent any accidental use and interaction with transplant medicines. If patients develop new unexpected problems such as fever, if review tests show significant change compared to previous reports, or if any new concerns or active problems are discovered the patients might need treatment first, and the transplant may have to be postponed.
The timing of donor and recipient surgeries are synchronised to ensure minimal ischemia (storage /damage) to the liver. In deceased donor transplants, the patient’s surgery commences only after donor liver has been examined, and found satisfactory. The operation does not start immediately after the patient is taken to the operation theatre because it takes about 2 hours to prepare for the operation. Both donors and recipients undergo the operation under general anaesthesia, where they are put to sleep, with no consciousness, pain, awareness or recollection of the operation. While under anaesthesia, they are put on ventilator and various lines/catheters (arterial line, central line, endotracheal tube, urinary catheter, naso-gastric tube, etc.) are used to accurately monitor various parameters and allow rapid administration of blood products, IV fluids and drugs. During the surgery, various blood and other tests are continuously performed for to monitor the patient.
The living donor operation involves removal of a portion of the liver and may be done using different types of incisions or even with laparoscopy (keyhole) or robotic surgery. The choice of incision depends on the donor’s body habitus, and findings during surgery. This decision is best made during surgery. The transplant surgeons always keep in mind the cosmetic results and safety while choosing an incision.
The liver is split into two parts as planned pre-operatively. One of these parts is removed along with the blood vessels and bile ducts going in and out of the lobe, leaving the other half in the donor with its blood vessels and bile ducts intact. The surgery lasts about 6-8 hours. In addition to the planned portion of the liver, the gall bladder is always removed because it is stuck to the under surface of the liver. A drain tube is kept in the abdomen to monitor any bleeding, and the incision line is closed using very fine absorbable sutures or staples.
The first step is to remove the entire cirrhotic liver (including gall bladder) to make space for the new liver. The cirrhotic liver is shrunken, stiff with multiple thin-walled blood vessels around it under high pressure, and may be stuck to surrounding organs because of previous infection or surgery. This part of the operation is done slowly to minimize chances of bleeding. This is followed by transplantation of the new liver by joining (anastomoses) all blood vessels and allowing blood circulation through the liver. The liver starts working immediately. Bile ducts of the new liver may be joined with the patient’s own bile duct or directly with the intestine. A drain tube is kept in the abdomen to monitor for any bleeding and the incision line is closed using staples. The recipient surgery generally takes 8-12 hours and about 5-10 units of blood products are used, however, in difficult cases; it may be much longer with significantly more blood product requirement.
At the end of the surgery, the donor is taken off the ventilator and shifted to the ICU for overnight observation; the recipient is generally shifted to the ICU on a ventilator. While the operation is going on, family members should stay in waiting lounge. The transplant team will talk to them at the end of the surgery.
Post-operative care & recovery after transplant
Recovery from liver transplantation depends on many factors including patient’s age, overall health, severity of liver disease, infections, secondary organ dysfunction, and complications before or after the operation. A good understanding of the process, moral support, and encouragement from family, a positive attitude and strong will-power are important in patient’s recovery.
In the hospital
Donors wake up immediately after the surgery, though they might feel drowsy for a few hours. They are able to get out of bed in 1-2 days and made to walk in 2-3 days. Various lines, catheters and drains are removed as they recover. Generally, they can follow a liquid diet followed by normal diet in 2-3 days, shifted to the ward in 1-2 days and discharged in 5-7 days. Pain killers are given depending on the donor’s pain threshold. Some patients prefer to take pain medicines before walking or any exercise that may trigger pain or just before going to sleep for a comfortable night. Upon discharge, they are generally given painkillers and vitamins. Most donors will have an uneventful recovery although some might have mild problems such as fever, loss of appetite, nausea or even vomiting because of slow bowel movement after surgery, which can easily be treated and resolves over time.
Patients (recipients) are kept on a ventilator overnight. It is removed only when they are fully awake. Patients are closely monitored for any bleeding, infection or other complications. First 24-48 hours are critical and their condition and liver function are monitored through frequent blood tests. Various lines, catheters and drains are removed as they make progress/recover over 3-4 days. Patients are to follow a liquid diet, and then a normal diet after 2-5 days. For patients whose bile duct has been joined directly with the intestine, the naso-gastric tube may be kept longer. Such patients’ resumption of a normal diet may be delayed. Patients are helped out of bed in 1-2 days; they participate in the physiotherapy program, walk in 4-5 days and gradually become more active. Patients should gradually use an incentive spirometer to prevent collapse of lungs, lung infections and to recover faster. Patients should learn to support their incision with a pillow when coughing. Patients generally do not have a lot of abdominal pain after surgerythough they may experience back and shoulder pain because theylay down on the operation table for a long time period. Patients are given pain medicines according to their need. Some patients may be confused, agitated or have mood changes because of the effect of sedatives or disturbance in sleep pattern after surgery.This usually only lasts a few days. Patients are shifted to the ward in 3-5 days and remain in the hospital for about 10 -15 days. At, discharge patients receive anti-rejection drugs, antibiotics and some other medicines.
Blood tests, ultrasounds and chest x-rays are performed regularly on both donors and recipients to monitor liver function and recovery as per standard protocol. The patients’ families are generally updated about their progress by the transplant team once a day or more often, if appropriate. While it is natural for patients and families to be anxious, questions for the transplant team should be asked during the counselling sessions or during ward rounds. Visiting hours and the number of visitors is restricted to prevent infections.