The field of liver transplantation has undergone remarkable changes over the last three decades. The first liver transplantation in the world was performed in the year 1963. Although the first liver transplant was unsuccessful, it helped in identifying number of important issues, which needed resolution. Thus, the program was put on hold for some years and restarted with the first successful liver transplant in 1967 in United States.
The initial days of liver transplantation were very stressful and over the years the outcomes were improving slowly. After United States and UK, the liver transplant programs developed around the world and now the liver transplantation has become a routine procedure in many big transplant centers around the world. Recipients are surviving 20 or even more years with excellent quality of life. These outstanding achievements have been possible because of massive understanding of the liver transplantation procedure, its immunology along with improved perioperative care supported by the most advanced technology.
Liver transplantation is continuously expanding with improved outcomes and has also become a reality even in developing countries like ours. Having said this, liver transplantation is still considered as one of the most complicated procedure requiring the highest level of dedication and multispecialty involvement. While the focus is more on cadaveric (corpse) or brain death donation in the western world, living donor liver transplantation (LDLT), in contrast, has dominated in Asian countries. Some centers in Asia are now performing the highest number of liver transplantation in the world, majority of which are living donor liver transplantation.
Kidney transplantation had already established itself as a successful program in Nepal for more than a decade before liver transplantation started. The first successful liver transplant was performed in Nepal in December 2016. The team of surgeons from Samsung Medical Center, South Korea along with the local team at Human Organ Transplant Center (HOTC), Bhaktapur performed the first living donor liver transplantation. A 41-year-old man was transplanted a liver from his 39-year-old sister. The country’s first successful liver transplantation created a history in the field of transplantation in Nepal. However, liver transplantation couldn’t speed up as expected. When the first successful liver transplantation was performed at the HOTC, the Tribhuvan University Teaching hospital (TUTH) was also in preparation phase for the same. Over the next two and half years, the HOTC could performed only three liver transplants but importantly with successful outcomes.
Finally after many years of preparation, the TUTH was ready to perform the first liver transplantation. The TUTH is one of largest tertiary referral center in Nepal having all the clinical disciplines as well as running most of the academic programs of different specialties. Kidney transplantation, started in 2008, was already an established program of the hospital for more than a decade. The liver transplant team of Apollo Hospital, New Delhi, India along with the transplant team of TUTH performed the first living donor liver transplantation on 31st May 2019. A 33-year-old daughter donated liver to her 58-year-old father suffering from cirrhosis. The procedure and perioperative period was uneventful. The donor stayed in the Intensive Care Unit (ICU) for two days then in the post-operative ward for a week and was discharged while the recipient was discharged after three weeks of hospital stay.
It has been one year of the first successful liver transplantation at the TUTH and both donor and recipient are in regular follow-ups and in good health. The hospital transplant team had prepared for a target of doing around 10- 12 cases per year. However, due to various reasons, only four successful living donor liver transplantation were performed in the first year. After the onset of the COVID-19 pandemic, the liver transplantation program at the TUTH has been temporarily on hold with the intention to restart again as soon as the situation gets back to normalcy. The HOTC further performed one more successful living donor liver transplant making a total of four LDLTs. One unsuccessful cadaveric liver transplant was also performed at the HOTC but the details were not published. So far, the TUTH has not been able to perform any cadaveric liver or kidney transplants.
So far, a total of eight successful living donor liver transplants have been performed in the country. In both of these hospitals, liver transplants have been performed with the support of international liver transplant team. No matter how well a team is prepared and the center is equipped, it’s a worldwide practice to begin the liver transplant program with the support of team members from a very high volume centers. As it is very crucial to have an excellent outcome from the beginning for the success and sustainability of the liver transplant program, the new transplant centers always start with the support of the highly experienced team members. The TUTH has also followed the same principle and is expecting to receive continuous support from the experienced team for the next few transplants. The local transplant team is expected to completely take over and start completely doing on its own after some successful liver transplants performed with the external support. Almost all of our transplant members, be it surgeon or from other specialties have received their training from overseas. The majority of our members have received trainings from the high volume Indian centers while some have been to Australia and the United states. The training period has varied from a year-long formal fellowship to short-term training of a few months.
Besides the HOTC and the TUTH, two other hospitals have also received approval from the government to start liver transplant program. Both of them are private medical schools outside the Kathmandu Valley. However, both of them are yet to start with the first case. Up till now, there are a total of four centers in Nepal with government approval to conduct liver transplantation and two are already performing, in small numbers though. On their own, many surgeons and physicians in Nepal have managed to receive trainings in their respective filed of liver transplantation. The majority of clinicians are receiving formal training in liver transplantation from India. The sustainability of liver transplant program depends on many factors and among them, one of the most important one is having very dedicated and trained team members. The TUTH being one of the country’s largest tertiary referral center as well as a very big academic institute has an advantage of having a huge manpower support in every specialty. Despite the fact that only a small number of liver transplant procedures has been performed in Nepal, the success of these limited numbers has paved the way for a successful and sustainable liver transplantation program in Nepal in the long run. It has also overcome the disbeliefs prevailing in many that liver transplantation is not possible in Nepal.
The cost of the procedure has been an important issue regarding the liver transplantation program. Worldwide it is still considered as one of the most expensive procedure when compared to any other medical procedure. At the TUTH, the overall cost of the procedure is between Rs 2.5-3 million. In one hand, it seems to be a very expensive procedure and definitely out of reach for many citizens who desperately need transplant. While on the other hand, the procedure still turns out to be much less costlier when performed within the country than overseas. Unlike other complex and expensive medical procedures, the government is yet to provide any kind of financial support for the liver transplant recipients. Due to many obvious reasons, the commonest destinations for Nepalei patients going for liver transplant are the high volume Indian centers. Over the coming years, when liver transplant starts getting established within the country, we expect that the number of patients preferring to go overseas will drastically decrease.
The future of liver transplantation programme in Nepal seems very promising. Till date the main focus has been on the living donor liver transplantation. As the brain death donation is already legalized in Nepal, there is high possibility of developing cadaveric liver transplant in future as the safety of living donor is of utmost importance. Any untoward event to the living donor could potentially jeopardize the whole transplant program that too especially for a very young and small volume centers like ours. Besides the development of the cadaveric program in future, we are expecting some financial support to liver transplant recipients from the government similar to kidney transplants and cancer patients. This would reduce some burden to the patients and allow many potential recipients to undergo this complicated and expensive procedure. After some years of establishing the liver transplant program at the TUTH, the hospital in the long run is expecting to perform 40- 50 transplants a year and the preparations are on accordingly. Simultaneously developing liver transplant programs at other centers of the country will also help in stopping Nepali patients going abroad for the transplant. This will not only be of benefit to the patients and their relatives, but also indirectly be preventing efflux of a large sum of money overseas. Establishment of liver transplant program in any hospital also reflects the highest level of care offered to the patients of other different specialties.
(The author is Professor of Gastrointestinal and Liver Transplant Surgery, Tribhuvan University Teaching Hospital)