 Good afternoon, everyone. My name is Dr. Shalindra Lalwani and I am the head of the Department of Liver Transplant and Astrology in Manipal Hospital, Delhi. Liver is the largest organ of the body and it's situated in the right upper quadrant of the abdomen just behind the ribs. Its weight is 1.2 to 1.5 kg and it performs more than 500 different liver functions in the body. It has a natural regeneration capacity due to hepatocyte functions and due to repeated exposure to toxins it can cause liver damage and it can lead to chronic liver failure. End stage liver disease is defined when patients have abnormal liver function who develop decompensation or complications and in end stage liver disease scar tissue is regularly replaced the normal liver until unless they have regenerative capacity. And end stage liver disease is considered to be synonymous with chronic liver failure sometime. End stage liver disease is the 12th leading cause of death for adults in the US and in 2004 around 27000 deaths were reported in the US which were actually 1.1% of the total deaths. In India we need 27000 transplant per year for end stage liver disease but currently we are only doing 1400 transplants in a year in the whole country. If you see causes of liver cirrhosis globally there is a lot of difference between Eastern and Western countries. If you see in Eastern countries the leading cause is hepatitis B virus related chronic liver disease and in Western countries it is hepatitis C virus related chronic liver disease. But in last 10 years there has been change in the etiology of this chronic liver failure in India. Right now if you see alcoholic liver disease is the most common cause but non-alcoholic fatty liver disease is coming as epidemic for the chronic liver disease. And in Western countries also because of obesity NAFLD is actually on rising trends. Viral hepatitis can be caused by different type of viruses from A, B, C, V, E. A and E usually causes acute liver failure, B, C normally causes chronic liver dysfunction. The root of transmission for A and E is bichoral root and for root for transmission for B and C is normally submucosal or percutaneous root. Hepatitis B and C can be treated and treatment is very effective and cure is possible if detected on time. Alcohol is again the leading cause of chronic liver disease nowadays. Alcohol abuses are very common under the in the low socioeconomic and high socioeconomic status. Quantity quality sometimes differs. Alcohol can affect liver in various way. It can cause a status, it can cause repeated hepatitis and this repeated episode of hepatitis can go to cirrhosis. These statuses and hepatitis stages are reversible if alcohol is stopped on time. Obesity again can cause chronic liver disease in long term. If you see in obese patient around 5 to 8% patients will have ultimately cirrhosis. Early symptoms are jaundice, anorexia, fatigue and vomiting. Late symptoms are asitis when there is fluid in the tummy. It can give rise to bloody vomiting. It can give rise to edema or there is unconsciousness or forgetfulness. These are the late symptoms. When cirrhosis is associated with decompensation, patients can have infectious like water in tummy and this water can get infected which is called as spontaneous bacterial peritonitis. Patients can have chronic hepatitis and syplopathy. Patients can have recurrent GI, which means G blood and vomiting or in stool. They can have chronic hepatorenal syndrome or hepatopulmonary syndrome in which because of liver disease, kidneys or lungs are affected. So what is the prognosis in patients who develop decompensation? If any decompensated patients have symptoms like jaundice and syplopathy, asitis or varicill, hemorrhage. The average life span is 2 years. So if you can calculate that if some patient is having asitis in his tummy, out of 100 patients, only 50% patient will survive after 1 year. If they have hepatopulmonary syndrome, their average survival is 10 months. If they have spontaneous bacterial peritonitis, their average survival is 9 months. If they have hepatorenal syndrome, depending on types of hepatorenal syndrome, their survival average is 6 weeks to 6 months. So to know the prediction of mortality in these patients, there are two scores which is commonly used. One is child to be scored. Second is model for and stage liver disease. In living donor liver transplant, we mostly use this child to be scoring system. It depends on the 5 parameters and syplopathy, asitis, albumin, bilirubin and INR. If patient is having a score of more than 10, that is the indication for liver transplantation and these patients should be referred to transplant center for transplantation. Another score is med, which includes three parameters only, that is serum bilirubin, INR and serum creatinine. And the score of 14 or more, they are being referred to transplant centers for transplants. And in western countries, this is the criteria they use for disease donor liver transplant listing. So coming to liver transplant, first transplant was performed by Sir Thomas Sturgeon in US in 1963. First successful full transplant was done by the same fellow in 1967. But it was in 1918, when cyclosporin was discovered and result of transplant started improving. And in 1980, again, the development of University of Wisconsin solution, which is used for graft preservation. These were the two landmark research which actually gave the boost to the liver transplant. After 1980, if you see, survival was better than 1970s. So in early 1980s, the liver transplant became the clinical reality in 1983. It became the definitive therapy for end-stage liver disease. So liver transplant disease is a life-saving procedure for end-stage liver disease. Liver failure can be of acute or chronic. Currently, one-year patient's survival is around 85 to 90 percent and five-year's survival rate is around 75 percent. These are the famous personalities like Steve Jobs. He developed pancreatic cancer and he intervened Wipel's procedure for that. But later on, he developed neuroendocrinal secondaries in the liver. So he intervened liver transplantation for neuroendocrinal secondaries. But later on, he died after transplant. Second one is Barcelona defender Eric, who intervened liver distinction in 2011 for liver cancer. But in 2012, he again developed recurrence for then he intervened liver transplantation in 2012. So in last 40 years, if you see, liver transplantation has evolved from an experimental procedure to the definitive treatment option for patients with acute and chronic liver disease. This is the survival rate. If you see, 10-year's survival is around 60 to 80 percent in between 60 to 80 percent. If you see, living donor liver transplant survival is better than disease donor liver transplant. You can see the blue brick. In India, the transplant numbers are gradually increasing. You can see in 2014, numbers were highest. That was around 1400. And from 2014 to 2020, there has been no major increase in the, because every center has the capacity of doing limited liver transplants only. So right now, if you see in 2019, in India, it was around 14, 150 transplants were done. So when patients should be referred to the transplant center, the patients who are too well should not be transplanted. Likewise, the patient is too sick. He also should not be transplanted because these patients will have poor outcome. Thus liver transplantation should be performed when the patient's survival chances are highest. Source of graft can be disease donor liver transplant or living donor liver transplant. In disease donor transplant, two types of donors are available. One is brain dead and after brain dead, one is after cardiac death. But results of donation after cardiac death, if you do, transplants are inferior. Living donor transplant advantages, you can choose the donor with better graft. Living donor liver transplants, we take different type of lobes, right lobe, left lobe, left lateral segment and posterior sectoral graft depending on the liver volume and the weight of the recipient. In disease donor, we normally remove the whole liver of the recipient patient and we implant the complete liver from the brain dead donor in the recipient. In living donor liver transplant, we usually take half or 60% of the liver depending on the age and weight of the recipient. And we implant this half of the liver after the explanation of the complete liver from the recipient. These are few indications when patients having cirrhosis and redevelopment complication in form of hepatic encephalopathy, increasing acytase, recurrent varicellate, spontaneous bacterial peritonitis, or he's having some side effects of liver disease like Hepatopulmonary syndrome, Hepatorena syndrome, development of liver cancer and cirrhotic liver, which is very common. If we develop muscle resting or he'll have increased osteopenia, these are the indications for liver transplant and chronic liver disease. These are few more indications in which patient will have metabolic liver disease and liver transplant is the only treatment in patients with like Wilson disease, Glycogenesuric disease, ureocycle disorder, citrolynemia type, and few other indications are polycystic liver disease and Bud-Kerry syndrome. Bud-Kerry syndrome is very common in the Gulf countries. These are few absolute or relative contraindications, absolute contraindications are extrapetive malignancy, active alcoholism, active substance abuse, and non-compliance. Relative contraindications are putopulmonary hypertension, large FCC and HIV is no more contraindication nowadays because initially we used to have Milan's criteria for transplantation in a petrocellular carcinoma, but that criteria has been changed by different centers and now there is no size limit actually for transplantation in petrocellular carcinoma. And we are doing regularly transplants in HIV patients also. We ourselves have some experience of doing transplants in HIV patients if the disease is not that worse. Fulminant hepatic failure is another cause which give very good results with liver transplant. And fulminant hepatic failure is called as when basically patient develop rapidly develop encephalopathy, jaundice, and coagulopathy when there is no pre-existing chronic liver disease. Once these patients will meet the King's College criteria, they should undergo liver transplant and mortality is 90% without transplant in these patients, and success of transplant in these patients is around 85 to 90%. Mortality causes are mainly liver failure, sepsis, and multi-organ failure in these acute hepatic failure. So at LDLT, we have some advantages like you can take ideal donor, you can see the graft quality, there is time to prepare the recipient, so we can be optimized. You can schedule the case electively. So if you want to get it done early as you can get it early, if you can wait for some time, you can wait for some time also. And there is relative short cold steam and time because you can actually plan these surgeries donor and donor and recipient. So how we select the donor? Donor ideally should be between 18 to 55 years of age. They should be related voluntary donor. There should be no major comorbidity. If they are smokers or taking contraceptive pills, they should be abstinent for 6 weeks prior to surgery. In Indian patients, we take cutoff VMI of less than 27, but we take 30 cutoff VMI per Middle East patient when they have remnant of 30% or above. Liver attenuation index of more than 5 is acceptable. Less than that, we have to do liver biopsy and depending on the liver biopsy result, we accept or reject these donor. There should be compatible blood group matching definitely. If donor is O, then he can donate to recipient of blood group O, A, B or AB. He is the universal donor. If donor's blood group is A, he can donate to A or AB. If donor's blood group is B, he can donate to B or AB. If donor's blood group is AB, he can only donate to AB blood group recipient. Donor should be providing a graft of adequate size, which is usually determined on the CT volumetry. And donor should undergo a thorough medical and psychological evaluation. If he is psychologically and medically fit, then only he can donate his liver. He should understand the risk of surgery fully. If we don't have AB or compatible donor. So we can go ahead with AB or incompatible transplant also, but results are a bit inferior as compared to AB or compatible transplant, but still the success rate is reasonably good. If the volume of one donor is not sufficient for recipient, then we can take two different lobes from two donors and that can be implanted in the single recipient. So these are the basically methods by which we can actually transplant the patient who don't have the suitable donor because of volume or matching blood group. Recent advance, if you see there is a great advancement in the CT softwares actually. With that, we can actually assess the volume and anatomy of the liver, which actually help us to assess the suitability of the donor in terms of volume as well as anatomy of the donor. You can see how multiple pictures are these, which can tell you which vein is draining with segment of liver. There can be a lot of anatomical variation of hepatic arteries. Previously, if you see 10 years back, we used to reject few donors because of this arterial anatomical variation, but nowadays it's very rare that because of this anatomical variation we are rejecting any donor. Similar things happened with the portal vein. Previously, we used to reject the donor who was having two portal veins, but nowadays we are accepting two portal veins. We are only rejecting type D anatomy in which actually the opposite segment is supplied by the opposite portal vein. Similarly, anatomical variations are common in biliratory, but in today's era, there is no contraindication of doing liver transplant because of anatomical variation of the bilirinary. Similarly, hepatic veins previously we used to reject the donors with multiple hepatic veins. Now, we have actually reconstructed the eight veins also. So it's a very difficult situation, but now it is possible. So this is one of the basically advancement because of technical advancement, innovation. This you can see the implantation. We have used PTFE graphs. This is another technology which we have developed in the last five, seven years. We don't use because sometimes veins are not available from the graph. So now we have started using this PTFE graph for venous reconstruction. After the transplant, the patient is shifted to ICU and his liver functions are actually being monitored regularly. His febrinozine level usually in the next three days, there is gradual normalization of AST and ALT, bilirupin and brothrombin time. There is early elevation of liver enzymes always, which is followed by quick normalization in three to five days. These patients will tend to have thrombocytopenia after the transplant, but after one week, usually in second week, it started rising. We do normally ultrasound Doppler till five days in ICU once patient is out of ICU, we stop doing it. We normally start immunosuppression from the day of surgery only. And in the next seven days, we start monitoring these immunosuppression drug levels also. Transplant can have few complications like early complications are primary graft failure, muscular complications, infections and acute rejection. But most of these are treatable except the primary graft failure. That means retransplant, otherwise other complications can be managed in most of the cases. Late complications are infection, chronic rejection, biliric complications, post-transplant, lymphoperative, proliferative disorders. But if detected on time, most of these can be managed except post-transplant lymphoperative disorders. So these are the common questions actually most of the people ask what is the risk to the liver donor. So right tippectomy is a complex procedure. Wound pain is quite common, but for that we are actually putting epidural, so that is being taken care of. Psychological trauma is there in case of recipient death. If recipient get discharged, donor is always happy and they have less psychological trauma. If you see overall risk is around 0.5 to 0.5, 0.1 to 0.5 percent. Minor complication risk around 2 to 4 percent. This is second question that when can donor resume their work after the surgery. So normally donor is discharged within 7 to 10 days. Donor can resume his normal activity within 3 to 4 weeks and resume his jobs within 6 weeks time. There is no special precaution donor has to take care after about 4 to 6 weeks. And hey, he can live a normal life thereafter. So most of the complications in donors if at all happens is in the early post-operative period. And 99% of these complications are managed by smaller procedures like doing aspirating the fluid or putting the PCD. So what is the actually outcome of survival, success of this transplant procedure? So the survival rate at around 1 year if you see is around 89% and at 5 years 75 to 80% patients will be alive if you do 100 transplants. These are few technical innovations which we are doing now regularly. This is doable low transplant in which actually one donor is not sufficient for the recipient because of volume issues. So we take two different lobes from two different donors. So this is the dual low transplant. You can see right lobe and left lobe we have implanted in the recipient. This another technical innovation which we have done when we are doing pediatric transplant. If you see this left lobe graft, left lateral lobe graft is actually too huge for a 1 year old or 5, 6 months old child. So what we have done, we have reduced that graft because larger is the graft. If the graft is larger, total vein flow is not that great. Then this graft ultimately will get necrosis. So we have reduced this graft and this is the final picture after the reduction of the graft. And you can see this much we have reduced while taking the graft from the donor. And this is after implantation and this is the final picture of the graft in the small kid which was I think around it was 5 to 6 month old child only. Recently we have gained the experience in minimally invasive donor surgery. It was started in 2002 actually, but it became reality in 2012 or 13 only. We have started this doing around 3 years back. Initially we were doing laparoscopic assisted donor apatecary only. And then we upgraded us to pure laparoscopic left in a lateral donor apatecary for pedagogical treatment. And now we are doing robotic right donor apatecary also. But the problem with the robotic donor apatecary it will cost around 4000 to 5000 dollars extra to the patient. You can see this donor robotic labor section is being performed by us. Again this robotic donor apatecary in non donor apatecary actually. Again similarly we are doing the transaction by the robotic surgery. This is the use of interoperative ultrasound to mark the transaction line in the donor apatecary. We are actually believers in cosmetic donor apatecary. You can see the scar is comparatively less if you see the recipients scar that is used. So previously people what they were doing that they were doing this, giving the same incision as this recipient is having. But now you can see we have reduced the scar size very significantly. This is the mongolian donor who is a supermodel in her own country and she donated her right low for her mother. Now you can really identify this car if you can see it very, very deeply. He is another donor who became the bodybuilder. So you can see the drastic change in his body. This is the experience of our team. We have experience of over a decade. Our team has done more than 1800 transplants out of them. 90% are adult and we are having reasonably very good experience of a pediatric transplant that is around 10%. Overall success rate is around 95% and our survival and emergency transplants for acute liver failure is 92% and one year survival is around 89%. In chronic liver disease, our one year survival is 92% and three year survival is 88%. We have done 17 combined liver kidney transplants also and we have done five dual low transplants. That is the big achievement. I think that is the probably we are the third or fourth center in the world who has done five dual low liver transplants. Most of the people are not that experts in doing dual low transplants. We have done four swap series. These are our achievements. If you see pediatric liver transplants we have done in less than 10 kg weight child. We have done the smallest way with child transplant also. And we have done liver transplant in the child who was having hemiparesis. It was first in India, this kind of transplants and that kid is doing well after even six years. Hemiparesis is also the tool. We have done five dual low transplants in which we take, as I told you that we take two grafts from two different donors and we transplant it in one recipient. We have done retransplant also in a child which is a very difficult thing to perform. We have done living donor liver transplant in a strongly positive cross-match patient which usually is not being done by other centers. And the success rate in this transplant is very low but we have done two transplants in strongly positive cross-match patient. And even after four or five years of transplant they are doing very well. We have done ABO incompatible transplant. Definitely as I said results of ABO incompatible transplant is not as equal as a compatible transplant. We have done transplant in HIV positive patients and I think that was the second in India which we did I think three, four years back and the patient is doing well. Transplant, we have done transplant removal of cardiac tumor simultaneously which was the first transplant of that kind in the world. So to summarize liver transplant is a good management option for end stage liver disease and complication rates are low and we have a very good success rate. Risk of donor to risk to donor is minimal. Transplant will improve the quality of life and prolong disease peace survival. And with technical advancement there are only few contraindications nowadays. If there is any question I will be happy to answer. I think first question is that does cousin marriages in Gulf countries one of the cause of liver transplant or disease? Yes, but it usually happens in the children's not in others because this can say goodness marries is actually a cause of many genetic disease. Second question is what is the prognosis of donor. So as I told you in the presentation the risk for donor is around 0.1 to 0.5%. So if you see success rate is 99.5%. This is small risk is always there when you are actually traveling somewhere or you are crossing the road. So it's like that only. I think there is another question actually what type of disease you get actually once you marry two cousins. So these are actually metabolic disorders which I told you many Wilson's disease. Like any genetic disorders they can have. There is one more question I think in case of no related donor is available for a patient. What can be done in these cases? So one option as I told you is ABO incompatible. They have donor in the family but blood growth is not matching. Second option is if they have no suitable donor means because of volume issue if they are having some problem. So we can take two graphs as I told you and we can do a low transplants. Third option is they don't have any donor in the family then actually it's a difficult situation for them then they can register for the disease donor liver transplant at our center. Once the graft is available but that is available only for Indian patients not for foreigners because it's because of basically restrictions in some law. Another option is they can actually it's up to the committee actually but they can actually find a donor in nearby relatives or in friends who are actually attached with them for more than 10 years. Then committee can review the case and if they found that there is no problem in doing this then only we can actually do. So it's very difficult situation actually. So first option is they can register for disease donor liver transplant. And second option is they can actually apply with the unrelated donor but it should be at least emotionally related because sometime what happens if it is emotionally related and they are actually living together or like a relative since many years and they have some evidence for that. The committee considered these type of cases also but that depends on the committee itself because once committee is clear we will do transplants only after that. So it's not that easy thing. If there is any further question you can actually contact our marketing team or you can find my number on the Google search and you can message me or call me for any query or questions if you are having in your mind. So thank you all for listening and so we will finish this session now.