KINGS HOSPITAL Colombo: LEADING LIVER TRANSPLANTATION IN SRI LANKA WITH STATE-OFTHE-ART FACILITIES

Liver transplantation, a life-saving procedure is now a reality at Kings Hospital, Colombo, thanks to the expertise of consultant liver transplant surgeon, Professor Thamara Perera. Sri Lankan surgeon Prof. Perera brings a wealth of experience from his extensive career in liver transplantation, having trained and worked in one of Europe's busiest liver transplant centers. This development marks a significant milestone in Sri Lankan healthcare, offering hope to patients with severe liver conditions. In this interview, Prof. Perera discusses the intricacies of liver failure, the transplant process, and the benefits of receiving this critical treatment in Sri Lanka.

Question: Can you tell us about your background and experience in liver transplantation?

Answer: I had my primary and secondary education, medical school, and postgraduate surgical training in Sri Lanka. In 2007, I went to the UK for specialized training in liver transplantation. I was then appointed to a consultant position in one of Europe’s busiest liver transplant centers, where I worked for over fourteen years and finally rose up to the ranks to lead the transplant program. On average my transplant centre performs approximately 250 liver transplants per year, both for adults and children. During my tenure, I gained extensive experience, performing various types of liver transplants. My particular interest was on marginal organs (poor quality liver grafts) and high-risk transplant candidates. I also mastered the surgical techniques in repeat liver transplant procedures (re-do) for example, doing a liver transplant for those who have a failed liver transplant for some reason during the follow up. In addition to my clinical work I had a very active clinical and basic science research role, and again the bulk of my research was focused on how best to utilise marginal livers, which are livers deemed unsuitable by others. My expertise in this area has allowed me to contribute to advancing liver transplant techniques and knowledge.

Question: Can you elaborate on the condition called liver failure and liver transplant operation?

Answer: There are multiple reasons for liver failure, which can happen suddenly or over a period of time. Fortunately, sudden liver failure, also known as “acute liver failure” is extremely rare as these patients only have a few hours to days to live without an emergency liver transplant. On the other hand, liver failure can result from various harmful agents like alcohol, viral diseases, excess fat deposition, or any inborn errors of one’s immune system or metabolism. Some of the causes of chronic or slow, ongoing liver damage are peculiar to different geographical regions. For example, the viral disease Hepatitis B or C disease is still common in the Far East or some of the Asian countries but in Sri Lanka we don’t see many hepatitis B or C disease. In children the causes of liver failure are much different to adults. Most of the children need liver transplant for a disease called biliary atresia, which is a problem in the bile ducts in the liver. The procedure “liver transplant”, in simple terms - refers to when a diseased liver of the patient is completely replaced by a healthy new liver.

There are very few exceptions where only a portion of the patient’s liver is removed but let’s look on what is commonly done. Overall, liver transplant procedure is lifesaving and profoundly transformative. After a successful transplant, patients often experience a remarkable improvement in their health and physical capabilities. They can engage in whatever activities they want to do that were previously impossible. The process, however, is complex and lengthy. This is an important factor that the general public and the patients should be aware of. The resource utilisation for a liver transplant procedure is massive, this is not only from the financial perspective, but also from a skilled professional involved in care, health care provider organisation, skilled staff and maintaining those skills, advanced interventions, etc. The first step of the process is to assess a patient with chronic liver failure to determine whether there is a real indication for liver transplant. A liver transplant is recommended if there is a definitive indication, defined as the risk of dying within the next 12 months being greater than the risk of dying from an operation-related complication. Given the complexity of the operation, patients should have some degree of preserved physiology or in simple terms “strength”, to cope with it. Generally when there is liver damage, other remote organs, such as the kidneys, hearts or the lungs also could be affected.

Therefore it is critical to assess the fitness and suitability of a patient as a candidate for a liver transplant. It also determines the amount of impact the patient’s body will experience. We need to determine whether the patient is fit enough for the transplant. Overall, it is resource-intensive and requires numerous investigations to determine the patient’s suitability for the procedure. Generally liver failure patients are under the care of medical specialists, more specifically hepatologists or gastroenterologists and it is their responsibility to bring up the concept of liver transplantation with the patient. As the liver is the largest solid organ in the human body, even with a marginal damage to the liver, one can go on with life because the liver has a huge capacity for repairing and regenerating.

This is called a “compensated” state. However, with long-term liver damage, some patients develop additional symptoms of de-compensation that cannot be controlled medically , and at this point, he or she requires a transplant. Medicine cannot treat a decompensated liver. It can only control symptoms and possibly slightly prolong life but it cannot provide a long-term chance of survival. When a herpetologist determines that a patient’s liver is in a decompensated state, patient should be referred to a transplant center. Typically, transplant centres operate as multidisciplinary teams that consider collective knowledge and expertise inputs before making a final decision on a candidate's suitability. Once the patient is recommended as a candidate for the transplant, then only the patient is given the advice to proceed with the operation.

The transplant operation, which is the final stage of this complex process, must proceed with a healthy donor. There are several sources of organs for transplants. In very resourceful healthcare systems, cadaveric organ donation, or organ procurement from clinically dead people, is widely accepted. Though Sri Lanka has a cadaveric donation system, it is not wellstructured or developed to provide enough organs for the large number of liver failure patients. The other option is living organ donation, in which a portion of the liver from a healthy living person is used as a graft and transplanted to a needy recipient. There are advanced surgical techniques for extracting a portion of a healthy donor's liver, avoiding any unnecessary risks associated with organ donation, and it is now a widely accepted procedure around the world. The costs associated with providing liver transplant care are enormous, perhaps one reason why it has not become a routine procedure for everyone in the state sector. In developed countries,+ of course, the State bears the costs of liver transplant operation. But for an economy like ours, providing such treatment to every patient requiring a transplant in the state sector is impractical. Therefore, many patients travel abroad at their own expense to undergo transplant surgery.

Question: What are the symptoms of liver failure?

Answer: Symptoms of liver failure can be both specific and non-specific. Early signs are often non-specific, including tiredness and lethargy due to the liver not producing enough energy. Patients may find that they are unable to do the same amount of work they used to do. Patients may also experience muscle weakness, yellowing of the eyes (jaundice), vomiting blood, tarry stools from internal bleeding, and swelling of the legs and abdomen. Non-specific symptoms include lack of sleep, drowsiness, confusion, and memory loss. These symptoms indicate the liver’s inability to perform its essential functions effectively.

Question: Is there a relationship between fatty liver and liver failure?

Answer: Fatty liver disease is a widespread problem in modern society. Initially it begins as deposition of fat droplets in the liver cells but this can progress to a much more serious condition known as non-alcoholic steato-hepatitis (NASH), in which there is an inflammatory process that begins within the liver. Simply put, the ongoing inflammation and repair process leads to the condition called cirrhosis and the damage to the liver at this stage is irreversible. Fatty liver disease is a modern-day disease linked to lifestyle factors which includes eating too much fast-food, including foods that are too oily, high in carbohydrates, or high in sugar. They also lead a sedentary lifestyle, which is defined as a lack of physical activity. Fatty liver disease, in its early stages before it progressing to NASH or cirrhosis is reversible with adhering to simple lifestyle modifications. Fatty liver disease damages the liver similarly to other conditions and can create a conducive environment for liver cancer. Even without progressing to liver failure, the underlying liver damage increases the risk of cancer, which often goes unnoticed until it is too late. If someone does not pay attention or engaged in regular surveillance program, liver cancer may occur unnoticed and it remains hidden as patient become symptomatic only at the terminal stage. Liver cancer may occur in any liver damaged with cirrhosis regardless of etiology.

Question: What is the process that has to be followed once a patient is decided to undergo a liver transplant? Answer: As previously stated, the transplant operation itself is complex, but it is only a part of a much more complex process. If a suitable candidate determined to be in need of a liver transplant and wishes to pursue a living donation route, the next step is to find a potential living organ donor. Ideally this could be a close relative. Donor assessment is another process to ensure suitability for donation of the part of liver, and this is also conducted through an assessment. Every living donor- and recipient pair should undergo psychological, and ethical reviews and finally should obtain the regulatory approval from the Ministry of Health in Sri Lanka. This process can take from several weeks to a couple of months in some cases.

Question: What facilities does Kings Hospital offer for a successful liver transplant?

Answer: At Kings Hospital, we offer living donor liver transplants, where a portion of a liver from a healthy person is transplanted to a patient. This involves performing surgeries on both the donor and recipient. We have the latest technology to carry out primary transplants and a theatre setup to accommodate these procedures. We are also in the process of opening a brand -new intensive care unit, which will be used not only for liver transplant recipients, but also to care for those undergo other hepato-biliary surgery. Our state-of-the-art facilities and equipment enable us to perform primary transplants effectively.

Question: What are the benefits of undergoing a liver transplant in Sri Lanka compared to going abroad?

Answer: There are numerous financial, emotional, and physical benefits. First, as previously stated, there are numerous assessments to be performed to determine whether the patient is fit enough to undergo the transplant. After performing them abroad, if the patient is found unfit, either too early or too late, there is a significant amount of money that must be spent on travel and lodging. Even after the transplant, it will take about three months to fully recover, and the cost of housing, food, and other expenses for the person accompanying the patient is enormous. Then there's the communication barrier. Foreign doctors mostly speak English, so imagine someone who is not fluent in the language and how he or she will ask for clarifications. When there is a language barrier, it affects the patient's recovery because he or she does not receive updates.

Furthermore, the patient is in an entirely different social setting. Some may never have flown abroad. There are no friends or relatives visiting you. Consider the mental trauma and the stress that the patient and his or her loved ones may experience in addition to the pain of the disease. As a result, having family support in the form of encouragement, care, and love is critical for the patient's recovery, particularly in situations such as a transplantation. He or she must adopt the mindset, and there are far too many factors to consider. Family and social support from the recovery period is an essential ingredient for success and that’s why some countries do not accept patients for transplantations purely for the lack of social support mechanisms in place. On that aspect, having an operation performed at a local setting benefits both the patient and their loved ones.

Question: What challenges does Sri Lanka face in liver transplantation, and how can they be addressed?

Answer: The biggest challenge is the limited number of organ donations from clinically dead individuals.

The current organ supply is hugely insufficient to meet the demand. Increasing awareness and encouraging organ donation can help address this issue and this may help more and more transplants in the State sector. Furthermore, developing a high volume transplant center is critical for handling complicated cases. This requires significant investment in resources and expertise, and the dedication of those involved in the field of transplantation is of paramount importance. This is a profession that provides more moral and psychological benefits to those who work in it than any other materialistic gain; accepting this and pursuing the specialty requires a significant personal sacrifice. A public-funded system health care system like ours may find it challenging to support such a costly endeavor to cater to the demands of each and every patient who need a liver transplant. But with strategic planning and collaboration, it is possible by teaming up with like-minded professionals. Building a sustainable and robust transplant programme will benefit many patients and improve overall healthcare standards in the country and this is an absolute current necessity given how far behind we are on a global scale.

Question: What is the key message can you give to patients hoping to undergo a liver transplant?

Answer: In Sri Lankan setting, as it is of now, early access to liver transplantation is probably the best option, because the amount of resources required to facilitate it is less. This is perhaps more economically acceptable for patients rather than waiting for a transplant when all the other organ systems in the body fall apart, and demands for much more intense support after the operation.

The lower the patient risk, then the outcomes are more likely to be better. The introduction of liver transplantation at Kings Hospital, Colombo, with state-of-the-art facilities marks a significant advancement in Sri Lankan healthcare. With the expertise of Professor Thamara Perera and a dedicated surgical and medical team, patients with severe liver conditions now have access to critical, life-saving treatment providing numerous benefits by offering treatment within the country, reducing the financial and emotional burdens on patients and their families. This groundbreaking development not only provides hope to many but also establishes a new standard for medical excellence in Sri Lanka, ensuring a healthier future for its citizens. NALEEF KITCHIL