Who is concerned?

A liver transplant is a surgical procedure that involves replacing an irreversibly diseased liver with a healthy liver from a donor. Candidates for liver transplantation are selected after a long series of specific examinations. Once a person is deemed fit to undergo the operation, they are placed on a waiting list and called as soon as a liver becomes available to replace their diseased one. For various reasons, the liver may be damaged and no longer fulfill its functions. This condition is called severe liver failure and can have several origins. Cirrhosis (or hepatic cirrhosis), which is the process during which liver cells (hepatocytes) die and are replaced by scar or fibrous tissue, is a common cause. Cirrhosis caused by hepatitis C is the most common indication for liver transplant cirrhosis.

Other pathologies may require a liver transplant, including:

• Primary or primitive liver cancer, when it is limited to the liver itself and cannot be treated by other methods (liver cancer transplant);
• Cirrhosis caused by alcohol abuse;
• Biliary tract diseases, which can cause liver failure if bile returns to the liver, leading to cirrhosis;
• Certain hereditary diseases, such as Wilson's disease, in which dangerous levels of copper accumulate in the body, and hemochromatosis, in which the liver is overwhelmed by iron and severe liver damage also occurs;

Less common causes of cirrhosis include:

• Cystic fibrosis;
• Liver cancer;
• Hemochromatosis
• Biliary atresia;
• Wilson's disease;
• Sclerosing cholangitis;
• Acute and chronic liver failure;

Depending on the speed of onset of liver failure symptoms, we distinguish:

• Acute liver failure: It appears suddenly and evolves in a very short time with even dramatic effects. This is a rare event, usually occurring following poisoning with paracetamol (a common analgesic) or other substances;
• Chronic liver failure: It develops slowly and can take several months, or even several years, to severely damage the liver. This is the most frequent form of liver failure;

Most cancers that originate outside the liver and metastasize to the liver cannot be treated by transplantation. Similarly, tumors that originate in the liver and spread to other organs cannot be treated by transplantation. Transplantation of a hepatocellular carcinoma (tumor originating in the liver), if performed at an early stage and when the disease is confined to the liver, can be extremely effective.

Where does the transplanted liver come from?

The donor can be a recently deceased person or a living person: in the latter case (living donor liver transplant), the donation is only partial, but, given the organ's regenerative capacity, it can be just as effective.

How to prepare for the procedure?

The assessment that takes place before the liver transplant consists of a set of tests (blood and instrumental, some of which are invasive) and specialized examinations aimed at determining the characteristics of the liver disease and the functionality of the different organs in order to rule out the presence of contraindications to liver transplantation.

The duration of the pre-transplantation assessment is on average three months; it can be shorter in some cases (if the patient has already undergone some of the required examinations) or longer (if it is necessary to perform other examinations in addition to routine examinations).

At the end of the assessment, after the anesthesiological and surgical evaluation of the transplantation, the patient's candidacy is discussed at the weekly multidisciplinary meeting of the liver transplantation team, which is followed by the patient's inclusion on the waiting list or the reasoned rejection of the candidacy.

• ECG and blood tests, tuberculin test;
• Chest X-ray, skull X-ray, dental overview;
• Echocardiogram with measurement of pulmonary pressures;
• Spirometry;
• Abdominal CT scan with vascular reconstruction;
• Oesophagogastroduodenoscopy;
• Total colonoscopy;
• Specialized examinations (pneumological, psychological or others depending on the clinical situation);

The assessment is therefore an evaluation with a view to a possible liver transplant, but it does not constitute a guarantee of inclusion on the waiting list, nor therefore a guarantee of the performance of the transplantation.

Liver transplant waiting times are variable (from a few weeks to a few months) and cannot be established with accuracy:

• The patient's blood group, due to a question of blood compatibility. Some blood groups are rarer than others, which has a significant impact on the availability of transplantable organs;
• A similar size between the donor and the recipient, due to the proportion of internal organs;
• The position on the waiting list is determined by the MILD and Child-Pugh scores. The severity and seriousness of the clinical condition determine the priority of the transplantation beyond the time spent on the list;

How is the procedure performed?

Removing the diseased liver

The surgeon first makes an incision in the patient's abdomen to access the abdominal cavity; he then isolates the diseased liver from its connections with the blood vessels and biliary ducts. He then proceeds to the removal and replacement of the hepatic organ.

Grafing the healthy liver

The operation on the donor involves incising the abdomen and removing one of the two lobes of the liver: the larger right lobe is reserved for adult or normally built patients, while the smaller left lobe is reserved for young patients (generally children) or small people. The procedure on the recipient is exactly the same as in the case of transplants from deceased donors.