Pediatric Liver Transplant Surgery

The procedure of surgically replacing a diseased or damaged liver with a healthy donor liver in children is called paediatric liver transplant.

The different types of paediatric liver transplants include:

1. Living donor transplants: This procedure involves replacing the damaged or diseased liver of the recipient with a portion of a living donor’s liver. The donors are usually family members or friends of the child recipient.
2. Whole cadaver transplants: This procedure involves the replacement of the damaged or diseased recipient’s liver with the entire liver from a deceased donor.
3. Split cadaver transplants: This procedure involves the replacement of the damaged or diseased recipient's liver with a part of the deceased donor’s liver. The donor liver is divided into two parts and then transplanted into two recipients, who are usually children or petite adults in this procedure.

A paediatric liver transplant is recommended in children having severe liver problems who may die without a new liver. The various conditions that may require a liver transplant include:

• Liver cancer and other liver tumors
• Acute or sudden liver failure due to an autoimmune disease (when the body’s immune or disease-fighting system attacks its own tissues), an overdose of certain medications like acetaminophen, or other unknown causes
• Other hereditary or genetic liver diseases
• Viral hepatitis (a viral infection causing liver damage and inflammation)
• Congenital conditions like Alagille syndrome (an inherited condition in which bile builds up in the liver) or cholestatic disorders (conditions in which the flow of the bile from the liver slows down or stops)
• Hemochromatosis (too much iron buildup in the body causing damaged organs)
• Alpha-1 anti-trypsin (an inherited disorder that increases the risk of liver disease)

The following symptoms could indicate the need for a liver transplant in a kid:

• Nausea
• Diarrhea
• Vomiting 
• Loss of appetite
• Fever
• Fatigue
• Jaundice
• Easy bruising 
• Sleepiness
• Mental confusion
• Swelling in the feet and legs
• Pain in the abdomen
• Ascites (fluid in the abdomen)
• Pale stools 
• Dark urine

A paediatric liver transplant procedure is performed by a multidisciplinary team that consists of liver transplant surgeons, hepatologists, transplant coordinators, paediatric intensivists, psychologists, dietitians, social workers, and several other team members.

The following diagnostic tests may be performed before a paediatric liver transplant surgery:

1. Physical examination: The child’s overall physical health will be evaluated by the doctor. The symptoms, medical history, and family history of the child are noted.
2. Blood tests: These tests help to determine how well the liver of the child functions and to assess the kidney function of the child.
3. Chest x-ray: It helps the doctor to detect any infection in the lungs and check the status of the bones of the child in the chest region.
4. Electrocardiogram (ECG): This test helps the doctor to check for any changes in the heart rhythm of the child.
5. Pulmonary function tests: These tests help to measure the lung capacity of the child. The child is asked to breathe into a machine, blood is then drawn to determine how well the oxygen is being absorbed from the lungs.
6. Ultrasound: This test helps to check the flow of blood to and from the liver of the child, and to detect if there are any abnormal masses present in the liver.
7. Computed tomography (CT) scan: This is an imaging test that helps in obtaining a clear picture of the liver size and shape, its blood supply, and checking for the presence of any liver lesions.
8. Liver biopsy: If the doctor suspects a liver tumor, a small sample of the suspected tissue growth is excised and sent to the laboratory for further evaluation.

The following preparation is needed before a paediatric liver transplant surgery:

• If a child requires a liver transplant, the doctor will refer the child to a transplant center.
• The child is evaluated physically and mentally to check if he/she can undergo a liver transplant surgery and take the prescribed medications after the treatment.
• The child is evaluated by a team of healthcare specialists, which include surgeons, hepatologists, transplant coordinators, pharmacists, dietitians, psychologists, child life specialists, social workers, and advanced practice providers.
• The doctor should be told about any medical disorders that the child may be having.
• The doctor should be told if the child is currently taking any medications, supplements, or herbs.
• If the child is allergic to any anesthetic agents, medications, latex, iodine, or tape, inform the doctor about the same.
• If the child is eligible for a liver transplant, the child’s name is put on an organ waiting list to find the right donor for the child.
• The family members can decide internally if liver donation from a family member is an option.
• As soon as an appropriate donor is found, the child is called to the hospital for a liver transplant.
• While waiting for a donor, make sure that your child eats healthy food, takes all the medicines as directed, and goes for all the medical appointments with the doctor.
• Once a donor has been found and the child is called to the hospital for the transplant, avoid giving anything to your child to eat or drink.
• Once in the hospital, some tests are performed to ensure that the donor is a good match and the child is healthy enough for the transplant surgery.

The different factors that determine if a potential donor is fit to donate a liver to the child or not include:

• The donor age should be between 18 and 55 years
• The donor should be physically and mentally fit
• The blood group of the donor should be compatible with that of the child

• The surgery is performed under general anesthesia, which means that the child is made unconscious during the procedure.
• The skin over the site of surgery is cleaned using a sterile solution.
• The doctor makes an incision or cut just under the ribs on both the sides of the child’s abdomen.
• The incision goes up over the breast bone.
• The doctor then carefully separates the diseased liver from the nearby organs and structures.
• The attached arteries and veins are then clamped to stop the blood flow into the diseased liver.
• The diseased liver is then removed and the donor's liver is implanted in its place.
• The diseased or damaged liver is removed after being cut off from the blood vessels.
• The surgeon checks the liver of the donor and then implants it into the child’s body by attaching it to the child’s blood vessels.
• The blood flow to the new liver is started.
• The new liver is attached to the child’s bile ducts.
• The incision is then closed using sutures (stitches) or surgical staples.
• A drain is now placed near the incision site to reduce the swelling.
• A dressing or sterile bandage is then applied over the incision site.
• The surgery takes approximately 10 to 12 hours to complete.

1. The following are the post-procedure steps following a paediatric liver transplant:
2. The child is kept in the pediatric intensive care unit (PICU) after the procedure.
3. The child will be shifted to a normal hospital room in a few days.
4. The child will stay in the hospital for two to three weeks after the surgery.
5. Once the child goes home, several follow-up appointments with the doctor are needed to ensure that the transplanted liver is working well.
6. Initially, the follow-up visits are scheduled every week. The frequency of follow-ups decreases with time. Eventually, lab tests are recommended every two to three months to check if the new liver is functioning well.
7. Anti-rejection medications, also known as immunosuppressants are prescribed. These medications help in preventing the rejection of the transplanted liver by the body’s immune or disease-fighting system and need to be taken lifelong.
8. The immunosuppressants may make the child more susceptible to infections, especially in the first few days after the surgery. It is advisable to keep the child away from sick people and wash the child’s and caretaker’s hands frequently to prevent infection.
9. Most children having a liver transplant go on to live a healthy, normal life.
10. The child is encouraged to exercise regularly, eat well, and get plenty of rest to keep the new liver healthy.

Watch for symptoms of infection or rejection in your child and contact the doctor immediately if you notice any of the following transplants:

• Fever
• Tiredness
• Vomiting
• Coughing
• Weight loss
• Jaundice
• Loss of appetite
• Diarrhea
• Stomach pains

The following are the risks associated with a paediatric liver transplant:

• Infection
• Bleeding
• Blood clot formation
• Allergic reaction to the anesthetic agent used
• Rejection of the transplanted liver by the body’s immune or disease-fighting system
• Complications due to anti-rejection medications, like cancer
• Blocked blood vessels 
• Leakage of bile
• Blocked bile ducts
• Recurrent liver disease
• Transplanted liver not working for a short period after surgery
• Death

The cost of paediatric transplant in India varies depending on the condition of the patient, the type of procedure being performed, and the health status of the patient.
The cost varies among different doctors in different hospitals. Usually, a paediatric liver transplant cost in India varies between INR 10,00,000 to INR 32,00,000.