Mumbai doctors use low-cost improvisation to ensure successful liver transplant

Mumbai: A ‘desi jugaad’ or a cost-saving improvisation in a city hospital’s operation theatre saved a 63-year-old Uttar Pradesh farmer during a liver transplant.Doctors operating on the farmer, Suryakant Singh (name changed), used a heart-lung machine — found in most Indian hospitals as cardiac problems are commonplace here — to pump oxygenated blood, nutrients and medications through the donated liver to keep it functioning well before implantation. Dedicated liver perfusion machines, costing more than double the most expensive heart-lung machines, are regularly used in the West.An international manufacturer lent a few liver perfusion machines to Indian hospitals in a pilot project a few years ago, but its use reportedly added Rs 7 lakh per liver transplant, on top of an average transplant cost of Rs 20 lakh across India (the company then withdrew the machines). In contrast, when doctors of S L Raheja Hospital in Mahim used the heart-lung machine for Singh, Rs 50,000 was added to the bill.Not all transplants need a special machine to “maintain” retrieved livers, but Singh’s medical history made it important. Battling liver failure since 2010, Singh was recently diagnosed with hepatocellular carcinoma, a type of liver cancer, and his kidneys too were getting affected. He shifted from Benares to his sister’s home in Mulund 18 months ago for medical reasons, and registered for a cadaveric liver transplant at S L Raheja almost nine months ago as no one in his family could be a match.“His health became so delicate that he needed hospitalisation every week to drain out the fluid accumulated in his abdomen,” said his sister.Liver transplant surgeon Dr Vikram Raut, who operated on Singh on April 3, said the patient was critical when they heard from transplant coordinating authorities about the availability of a “marginal liver” from a brain-dead donor in another hospital. This donor had a fatty liver, diabetes and a high body mass index, making his liver “marginal”.“If our patient was younger, in his forties, then we would have used such a marginal liver without any worry, but giving Singh such a liver would have meant higher risk for complications,” said Dr Raut. The key was to ensure that the liver retrieved from the donor didn’t worsen when kept in cold storage, as is the protocol.As coordination and distribution of a brain-dead patient’s organs takes time, the Raheja doctors could brainstorm and decided to use the heart-lung machine, called the cardiopulmonary bypass machine.“By using the cardiopulmonary bypass machine for five hours, we provided continuous oxygenated blood flow to the liver. The lactate clearance (the body’s ability to remove excess lactic acid from the blood and improve oxygenation) also improved, and there was bile production as well,” said Dr Raut.The Raheja team has already submitted a research paper on Singh’s case to an international medical journal. “The heart-lung machine has been used in some countries for other organs, but we didn’t find any reference for the liver,” said the doctor.Dr Ravi Mohanka, liver surgeon with H N Reliance Hospital, said, “In our country, we cannot use dedicated normothermic machines for liver perfusion because of the costs that run into lakhs. Hence, such innovations are the need of the hour.”At present, India focuses on brain-dead patients for organ donations, but as and when Donation after Circulatory Death (DCD) picks up in India, such machines would be needed, he added.Another senior doctor said that before accepting such innovations, “we need to develop proper protocols for liver perfusion. A detailed study about settings of the heart-lung machine for liver perfusion should be standardised.”As for Singh, he is happy that there is no more fluid accumulation. “I am having four eggs a day as the doctor has asked me to improve my weight and muscles, which got wasted in the last few years,” said Singh.