Hepatobiliary and Liver Transplant Surgeon, MBBS(AIIMS), MS (AIIMS), FRCS (Edin), FRCS (Glas), FRCS (Transplant Surgery)-Cambridge, UK 

Dr A S Soin is recognized all over the world over for his pioneering work in establishing liver transplantation in India. He has been awarded the Padma Shri in 2010 for pioneering liver transplant in India.

Dr Soin has performed more than 2600 living donor liver transplants in India, which is the highest in the country, and the second highest in the world. He and his team currently perform 22-25 live donor liver transplants every month with 95% success - results which are at par with the world's best centres. Apart from referrals from all over the country, he handles cases from the rest of South Asia, The Middle East and Africa.

In Dr. Arvinder Singh Soin's extensive experience of 21 years as a Liver Transplant Surgeon and Hepatobiliary surgeon, he has performed more than 1500 liver transplants and more than 12000 other complex liver, gall bladder and bile duct surgeries.

Milestones Achieved By Dr. A.S.Soin and his Team in Liver Transplants

Meet Dr. A.S. Soin and his team for Transplants and Consultations

Dr. Arvinder Singh Soin and his surgical team have extensive experience in both cadaveric and living donor liver transplantation for adults and children, microvascular surgery and liver resection (removal of parts of liver as in donor surgery or in case of tumours in the non-transplant situation). Now as a part of the Jaslok Medanta Liver Transplant Programme, Dr. A.S. Soin and his team will also be available at Jaslok Hospital, Mumbai.

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All About Liver Transplants

Who needs a Liver Transplant?

According to international guidelines, any patient suffering from liver cirrhosis who is assessed to have a life expectancy of less than a year should be considered for a transplant. Severity of liver disease is graded from A to C. Usually all Grade C and most grade B patients are candidates for transplant. Any patient with any of the liver failure symptoms listed below should seek specialist opinion so that liver experts can assess whether a transplant or medical treatment is more suitable for them. In any case, the better the condition of the patient at the time of transplant, the better are the results of surgery. In patients who are critically ill in ICU, malnourished, have active infection, or other organ damage such as kidney impairment at the time of the operation, the results of transplantation are dismal. Therefore, timely transplant is of essence in obtaining good results. A timely transplant done on a patient who is in a reasonable condition, with a good donor liver has around 80% chance of success.

In most instances, the above causes initially result in Hepatitis which can usually be treated. However, if the offending factor is not removed or treated on time, cirrhosis develops and then it is usually too late to change the course of the disease.

Symptoms of liver failure due to cirrhosis

• Black stool
• Blood vomiting
• Water in the abdomen (ascites)
• Drowsiness and mental confusion
• Excessive bleeding from minor wounds
• Jaundice
• Kidney dysfunction
• Excessive tiredness
• Low hemoglobin and other blood counts

Pre-transplant evaluation (Liver Transplant Assessment)

The liver specialist usually suggests this evaluation once he has diagnosed end-stage liver disease. Recipient evaluation is done in three phases and normally takes 5-7 days in hospital.

• To establish definite diagnosis, determine the severity of liver disease and the urgency of the transplant.

• To determine the fitness of the patient for a transplant. The other systems such as heart, lungs, kidneys, blood counts are tested and the presence of any infection is ruled out. The liver specialist then decides how successful the surgery is likely to be depending on the status of the patient and the cause and severity of liver disease.

• The final phase entails the psychological and mental preparation of the patient. The patient and the family are counseled about the procedure, hospital stay, the likely course after surgery, follow up and aftercare.

After evaluation, the patient is either placed on the waiting list for cadaveric donation, or , if there is a willing and blood group matched family donor available, he/she is evaluated for donation and a transplant is scheduled.

While on the cadaver waiting list, the patient follows up with the Transplant Team until a suitable liver becomes available. If the patient's condition shows signs of deteriorating, we normally suggest the family to consider living liver donation.

Liver Cirrhosis

What is liver cirrhosis and what causes it?

Cirrhosis implies irreversible scarring of the liver which can be a potentially life-threatening. In an advanced stage, 80-90% liver may be damaged and replaced with scar (dead) tissue. Cirrhosis is caused by sustained liver damage over several years either by alcohol, viral infection (Hepatitis B, C), a toxic substance (for eg. excess copper or iron in the liver), or by blockage of biliary system such that the liver undergoes progressive scarring that slowly replaces all of normal liver cells.

In most instances, the above causes initially result in Hepatitis which can usually be treated. However, if the offending factor is not removed or treated on time, cirrhosis develops and then it is usually too late to change the course of the disease

Symptoms of liver cirrhosis

Initially, there may general symptoms such as tiredness, lethargy, yellowness of eyes and urine (mild jaundice), swollen feet, excessive itching and anemia (low hemoglobin). In more advanced stages, the patient may have several life threatening complications such as blood vomiting, bloated stomach due to water (ascites) in the abdomen which may develop serious infection, mental deterioration and coma, deep jaundice and kidney impairment.

In addition, the patient may have bleeding tendency due to low levels of a liver protein prothrombin, and low platelet count both of which are vital for normal clotting of blood.

Living with cirrhosis (do's and don'ts)

Although cirrhosis implies irreversible damage to the liver, a person with early cirrhosis (stage Child's A or early Child's B) can have several years of fairly active life provided appropriate treatment is given by liver specialists. Advanced or Child's C Cirrhosis on the other hand, clearly dictates the need for a liver transplant for which expert opinion should be sought.

Some Do's 

• Intial detailed evaluation with a liver specialist is essential to grade the disease and chalk out appropriate therapy.
• Regular liver function tests and follow up with your specialist is necessary every 1-3 months in early cirrhosis and 1-4 weeks in advanced cirrhosis. The exact interval between check ups will be decided by your liver physician depending upon your symptoms and severity of disease.
• Nutritious diet is essential for optimal liver function in presence of chronic liver disease. Contrary to popular belief, the digestion remains normal until very late stages of liver disease except in the presence of severe jaundice. Hence, the need for complete avoidance of fatty food and proteins in all forms of liver disease is a myth. This is not only unnecessary in most cases, but also harmful since it results in malnutrition, weight loss and faster deterioration in health.

Some Don'ts

• Alcohol must avoided at all costs in alcohol-induced cirrhosis and restricted in all other forms of cirrhosis, especially Hepatitis C.
• Excessive physical activity should be avoided especially in virus related cirrhosis.
• At the same time, forced bed rest should be avoided and reasonable degree of mobility and activity should be maintained.
• Contact sports should be avoided in advanced stages of cirrhosis due to poor clotting and a bleeding tendency.
• Self-medication is dangerous since the liver is suboptimal and may harm the already damaged liver.

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Liver Cancer

Liver Cancer (Hepatoma, HCC)

Liver cancer or Hepatocellular carcinoma (HCC) is one of the commonest cancers in the world especially in countries like India which have a high incidence of Hepatitis B infection. Apart from Hepatitis B, it may be caused by other diseases that lead to cirrhosis of the liver (see below) such as Hepatitis C infection, and alcohol abuse.

Unfortunately, like many other cancers, liver cancer may go undetected until a late stage. It is often brought to attention by an ultrasound or CT scan done for pain in the upper abdomen or another unrelated symptom. It may also develop in a person previously known to have cirrhosis of the liver. Once suspected, Alpha feto protein (AFP) is a simple blood test to confirm its presence. At times, a malignant tumour in the liver may be due to a secondary spread from a cancer elsewhere, commonly the large intestine.

What can be done about it?

The best possible treatment a liver cancer is surgery wherein the affected portion of the liver is removed ("hepatectomy"). Dr. Soin's and his team have one of the largest experience of hepatectomy in India, performing nearly 50 such operations annually with 95% success.. If surgery is performed at a time when the cancer is confined to a removable portion of the liver and has not spread elsewhere, there is a high chance of cure. Traditionally, considered to be a high risk surgery until 10 years ago, a hepatectomy can now be performed with high degree of success in India, thanks to the bloodless liver splitting techniques devised by surgeons. A combination of low venous pressure anaesthesia, an experienced surgeon adept at using a special machine called CUSA along with special tissue burning equipment can facilitate the division the liver with hardly any bleeding. Two unique features of the liver help in good recovery of patients. One is the tremendous reserve due to which liver function remains normal even if upto 70% liver is removed as long as the remaining liver is not diseased. The second is the power of regeneration due to which the liver recovers its original weight within few weeks after removal of up to 60-70% of liver.

In some suitable cases, especially those where the liver has cirrhosis along with cancer, liver transplantation is also possible. This procedure can treat both liver cirrhosis and cancer at the same time.

Treatment without operation

If an operation is not possible or safe, there are now several other treatment options available. Alcohol injection and radiofrequency thermoablation (RFA, burning the tumour with a special probe without operation) are two excellent options. Both these procedures destroy the tumour without any significant harm to the rest of the liver or the body and can be done on an outpatient basis without the need for admission to hospital. However, their major limitation is that they are only effective for cancers less than about 2 inches in size and fewer than three in number. 

Another method by which liver surgeons can deal with large or multiple tumours that are confined to one side of the liver is by blocking the blood supply of the cancerous area of the liver with chemotherapy impreganted material (transarterial chemo-embolization or TACE) resulting in death of tumour cells. All above treatments can and should only be carried out in specialized liver centres by experienced liver surgeons, physicians and radiologists.

Liver Cancer Prevention

Prevention of liver cancer is possible at two levels. The first level of prevention is to avoid alcohol abuse and to prevent the occurrence of Hepatitis B or Hepatitis C. These are acquired from infected individuals via blood or rarely other secretions, by sharing of infected needles among addicts, or by the sexual route. Their transmission can be avoided by use of disposable needles in hospitals, by strict and universal screening of all blood donors in blood banks and refusing donations from infected persons. The spread of Hepatitis B can be curbed by universal vaccination of all newborns and the rest of the non-infected population.

The second level of prevention is in patients who have liver cirrhosis. A significant proportion of them will develop cancer. This can be avoided if they undergo a timely liver transplant and the diseased liver can be removed. All those with cirrhosis should see a liver specialist to find out if a liver transplant is suitable for them

About Jaslok Hospital and Research Centre,Mumbai

The Jaslok Hospital & Research Centre is one of the oldest tertiary care, multi-specialty Trust hospitals of the country and is NABH Accredted.

In the late 60s, when the establishment of large private hospitals was not common, the institution was conceptualized & endowed to the city of Mumbai by Seth Lokoomal Chanrai. Jaslok Hospital is situated at Dr. G Deshmukh Marg, Peddar Road which is a main artery of South Mumbai and overlooking the Arabian Sea. The hospital was inaugurated on 6th July 1973 by the erstwhile Prime Minister Mrs. Indira Gandhi.

Jaslok Hospital is a private, full-fledged multi-speciality hospital with 364 beds of which 75 are ICU beds. The number of consultants has increased from the initial 50 to around 265 with 140 fully trained resident doctors.