Before, During, and After Liver Transplant Surgery

What You Should Know About Liver Transplants

Four Surgeons At Work
MedioImages/Getty Images

A liver transplant is a complex surgical procedure during which a diseased liver is removed by surgeons and replaced with a donated liver from a living or deceased donor.  The procedure is the only cure for end-stage liver disease or liver failure, which can be fatal. 

For individuals with severe liver disease, a liver transplant can mean the difference between dying of liver failure and a decade or more of good health.

Liver Functions

The liver is a large organ that rests in the upper right area of the abdomen, and weighs about three pounds in most adults.  It has many functions, but the primary functions performed by the liver are the following:

  • Making bile: The liver produces up to a liter of bile on a daily basis. Bile is then stored in the gallbladder where it is concentrated and stored for release into the digestive tract where it helps make food easier to digest and the nutrients better able to be absorbed by the body.
  • Storing sugar: The liver is able to remove glucose from the body and store it in the form of glycogen until it is needed.
  • Filtration: The liver works hard to remove drugs and toxins from the bloodstream. The liver is also responsible for removing alcohol from the body. Excessive exposure to some medications, toxins or excessive or prolonged alcohol abuse can lead to severe liver damage.
  • Storage of fat-soluble vitamins and minerals:  The liver stores excess digested vitamin A, D, E and K and saves it for use when the body has a need for it. It is also responsible for storing some minerals such as copper.
  • Removing ammonia from the body: The body creates ammonia when proteins are broken down, then the liver removes ammonia from the body by turning it into a substance called urea. Urea is then removed from the body as urine. Urea is also responsible for giving urine its unique yellow color.
  • Production of clotting factors: The liver is responsible for the formation of clotting factors, which are responsible for preventing and stopping bleeding in the body. Without clotting factors, something as small as a paper cut would lead to death as the bleeding would never stop.
  • Creation of albumin: The liver is responsible for making plasma proteins, including albumin, which help regulate the amount of fluid in the bloodstream. Without albumin in the blood, fluid begins to leak out of the blood vessels and into the surrounding tissues.  This can lead to ascites, a collection of fluid in the abdomen, and is often a sign of liver disease.

The liver is responsible for many other bodily functions including the activation of enzymes, hormone production, the production of cholesterol and more. The sheer number of functions the liver performs is one of the reasons that individuals with liver disease can become sick very quickly and need a liver transplant in order to lead a healthy life.

Liver Failure

Liver failure happens when a disease or injury makes it impossible for the liver to function well enough to keep the body alive. The liver has many important functions and when it is not able to perform these functions well, an individual will become very ill, and in severe cases will die from liver failure.

The wide range of functions the liver performs means an individual with severe liver disease will have a wide variety of symptoms ranging from the color of the skin changing to bleeding easily.

Types of Liver Failure

Chronic liver failure happens slowly over the course of years, often due to disease or alcohol abuse.  Acute liver failure happens suddenly, with a patient with no history of liver disease developing symptoms rapidly. This may happen after exposure to a virus or toxin or possibly an injury.  

Acute on chronic liver failure means that individual had long-standing liver disease, but is having an acute (sudden) worsening of that disease.

For example, a patient may have a long history of hepatitis C but has a sudden worsening of their liver function due to using too much Tylenol for pain after an injury.

Causes of Liver Failure

There are many causes of liver failure, ranging from exposure to a virus to rare genetic problems that lead to liver disease. Some can lead to liver disease that over time worsens and becomes liver failure, or an individual may rapidly develop liver failure in some circumstances.

Some of the most common causes of liver failure are:

  • Fatty liver: Non-alcoholic fatty liver disease (NAFLD) and Non-alcoholic steatohepatitis (NASH) can lead to liver failure when severe. This is a condition where the liver becomes filled with fat instead of normal liver cells, which decreases the ability of the liver to work and can lead to cirrhosis.
  • Viruses: A virus, such as hepatitis B or hepatitis C, can lead to liver failure.  While hepatitis B can be prevented with a vaccine and there are treatments that can cure hepatitis C, some individuals are very ill at the time of diagnosis.
  • Alcohol abuse: Excessive alcohol intake can lead to liver failure.
  • Liver cancer: For some patients, treating liver cancer means removing the liver entirely and transplanting a donor liver that is healthy.
  • Bile duct diseases:  Primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC) are rare diseases that can lead to liver failure over time. These diseases affect the ducts that carry bile out of the liver to be used for digestion.
  • Metabolic diseases: These issues are inherited and interfere with the function of the liver.  Wilson's disease interferes with the body’s ability to process copper, while hemochromatosis prevents the body from processing iron properly.  Some metabolic diseases can be cured with a transplant and others will eventually damage a transplanted liver with the same disease process that damaged their liver originally.
  • Tylenol overdose: Acetaminophen, also known as Tylenol, is processed and removed from the body by the liver. Taking the maximum dose of Tylenol for a prolonged period of time or taking too much Tylenol can cause liver damage. Taking the recommended dose can also be too much for individuals with other types of liver damage, such as taking Tylenol and abusing alcohol at the same time, even when the dose is the one recommended on the packaging.

Signs and Symptoms of Liver Failure

The signs of liver disease and liver failure can vary widely based on the issue that is causing damage to the liver. For example, a patient with Wilson’s disease will have trouble getting rid of excess copper in the body, and may be diagnosed when someone notices copper rings around the colorful part of the eye. Others may not know there is a problem until routine blood work shows an issue with the liver.

Patients may experience a variety of issues when they are diagnosed with liver disease that vary on a case by case basis.

These are the most common signs and symptoms of liver disease and liver failure:

  • Hepatic encephalopathy is confusion that occurs due to liver failure, primarily because ammonia begins to build up in the bloodstream.
  • Liver enzymes, also known as hepatic function tests, will be elevated in patients with liver failure or significant liver disease.
  • Jaundice is a yellowing of the skin and other tissues, often noted in the whites of the eyes
  • Weight loss
  • Fatigue
  • Nausea and vomiting
  • Gallstones are more common in individuals with liver failure
  • Bruising easily due to the decrease in the ability of the blood to clot
  • Enlarged veins that are visible in the abdomen
  • Enlarged veins in the esophagus 
  • Bleeding more easily than usual
  • Enlarged liver 
  • Enlarged spleen
  • Fluid accumulation (water retention) in the legs or abdomen

Liver Transplant

A liver transplant is needed when liver failure is present or liver disease is worsening with liver failure expected in the future. In severe cases of liver disease or damage, a liver transplant may be the only treatment that will increase the expected lifespan of the patient.

Transplant Risks

In addition to the general risks of surgery and the risks of general anesthesia, transplant patients face their own unique risks associated with surgery. After surgery medication is given to trick the immune system into accepting the new liver. These medications can increase the risk of infection both during recovery and in the months and years that follow.

Rejection is always a risk and while medication is given to prevent rejection, it is a possibility that the recipient of the liver could reject it, a condition that can cause serious illness and death if it is unable to be treated with medication.

While rare, it is possible to contract an infectious disease through a transplanted organ. In some cases, a liver from a donor with an infectious disease may be transplanted into a recipient who does not have it. This is often a calculated risk if the recipient is very ill and in danger of dying before a liver becomes available and a donated organ from a hepatitis positive donor becomes available, that organ may be accepted based on the knowledge that they can live with hepatitis B or die without a new organ. This circumstance is not common but can happen in very ill recipients.

Bile duct issues are often a problem after a liver transplant. In a few cases, the bile duct is damaged during the surgical process of removing the liver from the donor, or when transplanting the liver into the recipient.  More common is that over time the bile duct becomes narrowed and does not allow the movement of bile to the gallbladder.

Types of Surgeries

Donated livers come in two general types: an organ from a living donor or an organ from a deceased donor. It is possible to donate a segment of your liver to a friend or loved one. Due to the liver’s amazing ability to regenerate, the liver can return to its full weight within a few weeks of donation, and within a few months is back to normal size in a healthy donor.

A cadaveric liver, also known as an allograft or donation from a deceased donor, comes from an individual who died and they or their family decided to donate their organs after their death.  

The Transplant List

Once a diagnosis of liver disease is made, it may be years before a liver transplant becomes a need.  Once the diagnosis of significant liver disease is made, a gastroenterologist—a specialist in the digestive system—can make a referral to the transplant center.  At the transplant center, a variety of types of tests will be performed to determine if the patient is a candidate for a transplant.

If the patient is a candidate, the MELD score is used to calculate how ill the patient is, using blood tests.  The sicker the patient is, the higher the MELD score is, and the higher the patient rises on the waiting list.  This allows the sickest patients to receive an organ first.

If the liver disease was caused by drug abuse, such as alcoholism, ongoing abuse will make the individual ineligible for transplantation. Individuals in recovery from addiction may be a candidate for transplantation depending on their unique situation.

The Procedure

Once a liver is obtained for transplant, the recipient is taken to the operating room and given general anesthesia.  Once the patient is under anesthesia, the procedure begins with a large abdominal incision that exposes the liver.

A normal liver is large, approximately three pounds, but most diseased livers are much larger and can weigh twice as much as a normal liver. For this reason, the full-size incision is used, rather than minimally invasive techniques.

The patient’s own liver is surgically removed from the body, taking care to preserve blood vessels where possible, so that the new liver can be sewn into place.  Once the new liver is in the patient and reconnected to the blood supply and ducts, the incision can be closed and the patient taken to the recovery area.

Recovery

Most patients will recover from liver transplant surgery in the surgical intensive care unit. There they will be allowed to wake slowly from anesthesia and may remain on the ventilator for hours or several days while they regain their strength.

Most patients are able to go home in ten to fourteen days and return to normal activities in three to six months.  Transplant patients will require antirejection medication for the rest of their lives, this allows the body to tolerate the foreign organ. Follow up appointments will be frequent in the first few months after surgery, then will be less frequent as the patient heals and begins to return to their normal life. 

Coping after a transplant can be challenging, and support groups are available for both donor families and transplant recipients and their families.  In the case of organs being donated by a deceased donor, if both the recipient and the donor family wish to meet, that can be arranged by the local organ procurement organization.

A Word From Verywell

A liver transplant is a very serious surgery, but the journey to an organ transplant is often a difficult one emotionally and physically. Waiting for an organ to become available can be difficult, especially as most people become sicker with each passing day.  It is a double-edged sword—one must be sick enough to be high enough on the waiting list to receive an organ, but not so sick that they cannot tolerate the physical stress of surgery.

This can make the process more challenging than a more typical surgery, but the rewards of receiving a healthy liver are enormous.

Sources:

Liver Disease. NIDDK.

The Progression of Liver Disease.  American Liver Foundation.