Comprehensive Liver Services
We offer complete (360 degree) care in liver disease and transplantation, being equipped with the latest and the best in facilities. We house equipments and facilities required to deliver the most comprehensive program aiming at results that are truly exemplary. We have the 'state of the art' Liver & Multi Organ Transplant intensive care units, operation theatres, and aim to ensure that liver transplants are a smooth and safe process for all.Various surgical tools to enable safe & bloodless liver surgery including the cavitron ultrasonic surgical aspirator, argon laser coagulation etc are all used. 320 slice CT scanner, highly integrated interventional radiology support and other ancillary supporting departments make this program fully comprehensive team based care. Our pre and post transplant coordinators, social workers, dietitians and physiotherapists complete the care with a human touch. Our patients and their families are in touch even after their liver disease has been cured successfully and a complex transplant has been successfully performed. Our “Comprehensive Liver Team”do provide a multi-disciplinary, highly skilled state of-the-art service to patients, supported by cutting-edge medical technology and infrastructure.
We provide an integrated, multidisciplinary service which includes: Live Donor Liver Transplantation and Deceased Donor Liver Transplantation
Assessing patients’ suitability for Transplantation
This can be undertaken as an inpatient or an outpatient and includes imaging, blood and lung function tests, cardiac assessment and clinical review. It is supervised by a dedicated transplant Hepatologist. Eligibility for the waiting list is decided after a multidisciplinary meeting of surgeons, hepatologists, anaesthetists, intensive care physicians, specialist transplant nurses (transplant coordinators) and social workers.
Comprehensive education and support for all patients on the waiting list
Patients meet all members of our team and are closely linked to a transplant coordinator while we are caring for them. They attend a specialist consent clinic where a consultant surgeon explains the transplant process and obtains the patient’s consent for the operation.
Transplant surgery with aftercare
When a suitable organ becomes available it is allocated to the most appropriate patient on the waiting list. We ask them to come to PVS Memorial Hospital Kochi as soon as possible to be assessed before they go to theatre. After surgery all patients stay on the Liver Intensive Care Unit (LICU) for 24-48 hours and then go to HDU for further care. Subsequent care for the next two weeks before discharge will be in the new block IP room.
Post-transplant care and follow-up
Newly transplanted patients are seen in clinic at least once a week; the interval between clinic appointments is gradually extended and established patients are seen every four - six months. The team offers help and advice outside of these appointments. All patients take anti-rejection (immunosuppressant) drugs long term and are monitored regularly to minimise any side-effects.
We offer a number of standard and more innovative techniques, such as:
- Split liver transplantation, where the left part of the liver is transplanted into a child and the right to an adult
- Living donor liver transplantation, where a segment of adult liver istransplanted into a child or another adult
- Auxiliary liver transplantation, where a liver graft is transplanted alongside part of the patient's own organ.
Why it’s done.
End stage liver diseases – usually cirrhosis or development of tumors (HCC) in the cirrhotic liver. Recurrent gastrointestinal bleeding and development of fluid buildup in the abdomen, fatigue and weight loss are reasons to consider transplant. Frequent hospitalization, spontaneous infections requiring multiple antibiotics and kidney impairment make surgery costly and risky. Better not to delay transplant to this stage. A liver transplant may not be recommended if you have an infection outside the liver, a medical condition that poses a problem or if you are an active substance abuser. More information is available by request on PVS Hospitals policy regarding liver transplants for patients with alcoholic liver disease. People who have certain cancers — such as metastatic carcinoma and cancer of the bile ducts called cholangiocarcinoma — or have certain severe heart or lung conditions are not considered candidates for liver transplant.
End-Stage Liver Damage.
Because the liver has so many functions, a number of different diseases and conditions can result in liver failure.
Congenital Liver Damage or Cirrhosis.
Congenital or acquired end-stage liver damage, called cirrhosis, can be due to various factors such as nutritional deficiencies, poisons including alcohol or previous inflammation. These causes of liver damage include:
- Primary biliary cirrhosis, in which the bile becomes inflamed and destroyed.
- Secondary biliary cirrhosis resulting from prolonged bile duct obstruction.
- Chronic active hepatitis, a long-term inflammation caused by the Hepatitis virus.
- Cirrhosis of unknown origin or cryptogenic.
Autoimmune cirrhosis in which the body's defensive mechanism against infection fights against itself.Inflammation of the bile ducts resulting in hardening of the tissue or sclerosing cholangitis.Biliary atresia, birth defects in which the bile ducts fail to develop or develop abnormally.
Physical and Chemical Changes.
Liver-based disorders due to physical and chemical or metabolic changes in the body include:
Tyrosinemia, a disease of tyrosine metabolism Galactosemia, an enzyme deficiency in childrenPrimary oxalosis, overproduction of oxalic acidGlycogen storage diseaseAlpha-1-antitrypsin deficiency, an inhibitor of the enzyme trypsinWilson's disease, an increase in copper absorption,Protoporphyria, a disturbance of porphyrin metabolis Hemochromatosis, a disturbance of iron metabolism
Other conditions that can result in liver damage are:
- Budd-Chiari Syndrome, a blockage of the veins draining from the liver.
- Some liver cancers such as hepatoma (HCC) and hepatoblastoma.
Fast appearing or fulminant liver failure. Fulminant liver failure can occur during acute viral hepatitis, in reaction to mushroom poisoning or as a reaction to overdoses of medication such as acetaminophen.
Is it Safe or Risky ?.
This is major surgery requiring total removal of the diseased liver. In the presence of poor coagulation and reduced platelet count this can be a major undertaking. However, patients with cirrhosis, if they are not smokers or diabetic, have good cardiac reserve and can withstand this operation. If the donor liver is good and starts working immediately (as is usually seen with live donors), the patient’s condition dramatically improves.
Anti rejection medicines are required lifelong. The number of medicines and the doses are maximum in the first year and require close monitoring. After this, with modern transplant medicine the side effects are minimal and patients lead a normal life with minimum increased susceptibility to infections and very good quality of life. Within a year or so the medications are fewer to take as well from a rejection perspective.
How to assess if I meet criteria?.
Calculate your Model for End stage Liver Disease (MELD) score. This is easily possible on the internet by searching for ‘MELD Calculator’ and putting in the values of Billirubin, INR, Creatinine and Sodium. These tests should be done every 3 months in patients with cirrhosis. In addition Ultrasound scan must be done every 6 months to look for development of tumor (HCC). When MELD is over 12 or if there is suspicion of HCC it is time to consider Liver Transplant. Development of “Ascites” (fluid in the abdomen) and “SBP” (Spontaneous infection in the Fluid) are serious complications that result in a life expectancy worse than most cancers today. Avoid smoking and regular exercise – walking briskly for 20-30 minutes every alternate day or preferably every day is the best way to keep fit and get the best outcome of transplant. Diet with adequate protein and calories is critical to maintain muscle mass and strength. The ”Comprehensive Liver Team” at PVS will guide you to these preparations.
What can you expect after Liver Transplantation?.
One to 2 weeks in ICU and 3-4 weeks in hospital. Over 85% of patients survive after transplant in 2 years time and over 55 to 60% live through ten years or more. These are patients who without transplant usually succumb to their illness or complications in months. Since re-transplant is usually not an option for a poor quality graft, careful selection of a deceased donor organ, or having a good live donor (less than 45 Yrs ideally) is the critical factor for success.
Hepato-Pancreatico-Biliary Surgery (HPB)
In addition to liver transplantation , complex non-transplant liver, pancreas and biliary surgery is done for hepato-pancreato-biliary disease in both adults and children. PVS hospitals is also a high volume referral centre for all types of liver lumps, bile duct cancer, pancreatic andperiampullary cancers, cysts and blocks. Both minimally invasive (laparoscopic HPB surgery) and open surgery is done as per indications and need. Further ongoing care happens in a Multidisciplinary setup and follow up by surgeons, HPB physicians, interventional radiologist and oncologist.
What we do.
We provide all-round care for people with liver, pancreatic, biliary and gall bladder disorders. Our team offers specialist investigations and care for conditions such as:
- Primary liver cancer: hepatocellular carcinoma (HCC)
- Benign liver tumours: focal nodular hyperplasia (FNH), adenoma, haemangiomabiliarycystadenoma
- Primary biliary cancers: cholangiocarcinoma and gallbladder cancer primary pancreatic cancer
- Secondary liver tumours from a colorectal, breast or other primary chronic and acute pancreatitis, complex benign hepato-biliary and pancreatic conditions.
- NeuroEndocrineTumours (NET)- comprehensive MDT on NET tumours
Treatments include:liver, pancreatic and biliary resectionpercutaneous radio-frequency ablation of primary and secondary liver tumourspercutaneous chemo-embolisation for primary liver tumourspercutaneous bland embolisation for liver tumoursendoscopic radio-frequency ablation for biliary tumoursSelective Internal Radiation Therapy (SIRT) for primary or secondary liver tumours subject to individual patient fundingsorafenib for primary liver cancer - hepatocellular carcinoma (HCC) Patients are assessed and reviewed by our consultants at PVS HPB clinics. Systemic chemotherapy and/or radiotherapy (outsourced)is provided at PVS as needed. Patients with neuroendocrine tumours are treated by our NETS service.
Multi Organ Transplantation
Multi Organ Transplantation Unit.
The multi-organ transplant unit combines the expertise of specialists in multiple transplants and related disciplines. PVS Memorial hospital is now poised to participate in and provide leadership in the future growth of transplantation in Kerala, providing hope for patients in need of whole and split (DDLT or LDLT) organ liver transplant, pancreas , kidney , and combined organ transplants.
Liver Transplant , simultaneous liver-kidney transplant.
Many patients have associated renal failure with end stage liver disease, necessitating combined Liver & Kidney Transplantation. The need for multi organ transplant, like simultaneous liver- kidney transplant, is becoming more common. Our department has the experience to meet this challenge of the futurewithtransplant team trained in world-renowned centers for multi-organ transplantation in UK (Freeman Hospital &Addenbrookes; Hospital), South Korea
Pancreas transplant and pancreas kidney transplant
Diabetes is a common scourge of our population, which ultimately results in a damaged kidney. Now with the onset of pancreas and simultaneous kidney transplant, curative treatment can be offered to those afflicted.
A pancreas transplant is an operation to treat diabetes by replacing the need for insulin with a healthy insulin-producing pancreas from a donor who has recently died. The pancreas is an organ in the abdomen that produces both digestive juices and hormones, such as insulin, that help the body break down food and turn it into energy. A pancreas transplant is sometimes recommended as a treatment for people with insulin-treated diabetes, such as type 1 diabetes, who are unable to produce their own insulin.
Why pancreas transplants are carried out?.
A pancreas transplant allows people with type 1 diabetes to produce insulin again. It is not a routine treatment because it carries significant risks, and treatment with insulin injections is often effective. A pancreas transplant is usually only considered if: You also have severe kidney disease – a pancreas transplant may be carried out at the same time as a kidney transplant. In these casesyou have severe episodes of dangerously low blood sugar levels (hypoglycaemia) that occur without warning and aren't controlled with insulin The multi-organ transplant team, will need to have a detailed assessment to check whether you're healthy enough to have one, before being placed on a waiting list.
What happens during a pancreas transplant?.
A pancreas transplant needs to be carried out as soon as possible after a donor pancreas becomes available.The procedure is performed under general anaesthetic, where you're asleep.A cut (incision) is made along your tummy. The donor pancreas – and donor kidney, if you're having a kidney transplant at the same time – is then placed inside, and attached to nearby blood vessels and your bowel. The new pancreas should start producing insulin straight away. Your old damaged pancreas will be left in place and will continue to produce important digestive juices after the transplant.
Recovering from a pancreas transplant.
You'll usually need to stay in hospital for around two or three weeks after a pancreas transplant. Most people are able to get back to their normal activities within a few months. Your transplant team can give you advice about how long you may need to avoid certain activities during your recovery. You'll need to have regular check-ups with your transplant team after the transplant. You'll also need to take medications called immunosuppressants for the rest of your life. Without these medicines, your body will recognise your new pancreas as foreign and attack it – this is known as rejection.
Risks of a pancreas transplant
A pancreas transplant is a complex and risky procedure. Possible complications include:the immune system recognising the transplanted pancreas as foreign and attacking it (rejection), blood clots forming in the blood vessels supplying the donor pancreas (thrombosis), short-lived inflammation of the pancreas (pancreatitis), usually just after transplantationside effects from the immunosuppressant medication, such as an increased chance of catching certain infections, developing high blood pressure, and weakened bones (osteoporosis)Many of these problems are treatable, although sometimes it may be necessary to remove the donor pancreas.
Outlook for a pancreas transplant
The outlook for people with a pancreas transplant is usually good: Most people live for many years, or even decades, after a pancreas transplant – 97% will live at least a year afterwards, and almost 90% will live at least five years. For people who had a pancreas and kidney transplant together – around 85% of donor pancreases are still working after one year, and around 75% are still working after five years. For people who just had a pancreas transplant – around 65% of donor pancreases are still working after one year, and around 45% are still working after five years.
Dialysis access surgery
We also offer an excellent dialysis access surgical service for patient requiring hemodialysis, with routine use of early puncture arteriovenous access grafts in addition to naturally created arteriovenous fistulae, thus offering patients the flexibility to choose from a variety of options.
Small bowel transplant and multi visceral transplant
Intestinal diseases where nutrition is inadequate and needs to be maintained with costly and risky TPN can be cured with intestinal transplant and if necessary intestinal + liver transplant. (License for pancreas and small bowel transplant awaited)
Doctors in Multi Organ Transplantation
MS, DNB, MCh (SGE), FEBS (Transplant Surgery) , M Phil (Cambridge), FRCS(Eng), CCT (UK)
Dr. Shaji Ponnambathayil
MBBS, MS, FMAS, DNB (GI surgery),
Fellowship in Transplantation Surgery (UK), Senior Consultant in HPB surgery, GI surgery and Multi organ transplantation.