‘Early referral is key to improve success of liver transplant’

Dr Magaral Rajasekar is credited with establishing the country’s first hepatobiliary (HPB) surgery and multiorgan transplant unit at the Indraprastha Apollo Hospitals, New Delhi, in 1996. As head of the department of HPB surgery and organ transplant, he pioneered, cadaveric and living donor liver transplantation in both adults and children in India. After completing his MBBS and Master of Surgery from University of Madras, he obtained his FRCS degree from the Royal College of Surgeons, Edinburgh and an advanced training in GI and hepato biliary surgery, laparoscopic surgery, vascular surgery and organ transplantation in the UK, subsequently. Thereafter, he obtained an MD degree at University of Newcastle, UK and pursued advanced accredited training in hepatobiliary surgery and abdominal organ transplantation at the University of Chicago Hospitals, US. In an interview with Rita Dutta, Dr Rajasekar speaks about the problems that plague liver transplant in India and suggests measures to give it a boost.

Can you share your experience of conducting liver transplant at Indraprastha Apollo Hospitals?
I made a humble beginning in January 1998 at the Indraprastha Apollo Hospitals, by carrying out the country’s first paediatric liver transplant on an 11-month-old child from a brain-dead donor whose family donated all his organs at AIIMS. Since it was an adult liver, I had reduced it to suit the child. Unfortunately, the child died from non-function of the transplanted liver after 11 days, though it had been a technical success.
It is the words of the father of this child that still keeps me inspired- “Doctor do not despair, my child was not lucky enough to benefit from your efforts, but hundreds will benefit in the future from the efforts you are making today.”
Soon after in November 1998, I carried out the first successful liver transplant on an Indian child and an adult, both of whom are doing well. I have carried out 57 liver transplants till date and the survival of the fittest patients is 85.7 per cent and that of very ill patients is 45.7 per cent.

What obstacles did you face and how did you overcome them?
In the beginning, operational delays due to government red tapism delayed the taking off of the programme for more than a year. It took our hospital 18 months to get the letter of recognition from the health ministry to start a liver transplant programme.

The lack of awareness and training among medicos and support staff was the next hurdle. Apart from the huge team of medical professionals, nurses and paramedics, a liver programme also needs excellent laboratory services, social workers, counsellors and administrative staff.

Moreover, the equipment had to be of international standards and a major part of equipment and instruments had to be imported. My work at that time entailed training the doctors, nurses and support staff, especially on post transplant ICU care, evaluate patients, counsel them on transplant, rehabilitate them, canvass and increase awareness of brain death and organ donation, and also provide grief counselling for the donor family.

I drew up protocols right from patient assessment, consent, anaesthesia and surgery protocols for the whole peri-operative period, which had to be tailormade for the Indian setting. I then carried out the surgery and took care of the patient in the ICU round-the-clock until the patient was out of danger. The list is endless. Of course, the anaesthetists then went to premier centers abroad for training.

Now, I make sure that there is an overlap of old and new doctors and staff, so that the new ones learn the processes, and having set protocols eases the situation. I have a committed and well trained team built now over these years. The obstacles for developing liver transplantation still remain at large.

I am still waging the war I began against the prevailing public ignorance, medical apathy and insensitivity to a disease, which is probably only second to coronary heart disease, on issues related to cadaver organ donation, on misunderstandings that shroud treatment options for liver cancer.

Why is Apollo charging as much as Rs 25 lakh for a liver transplant, when others are charging only around a few lakhs?
In the US, no patient is entertained even on the waitlist without a credit of USD 3,00,000 in the account, and this does not guarantee him getting a cadaver liver.

There are more Indian patients dying on the waitlists abroad, than the handful who managed to receive marginal livers (rejects from other centres) and manage to survive and return to India. A transplant abroad can cost anywhere from INR 75 lakh to INR 1.2 crore INR (all inclusive).

One of the major goals of my programme is not to cut corners, but provide patients with international quality of care. Maintaining high standards of infection control protocols in the liver ICU itself increases the cost with the high utilisation of disposables.

The high capital investment costs for the imported state of the art equipment will alone reflect heavily on the costs.
Since 70 per cent of the patients coming to my centre are already too late for transplant, they tend to have a complicated post-operative course which in turn reflects in the higher cost of management.

When others are advocating cadaver liver transplant, you have pioneered Living Related Liver Transplant (LRLT). Isn’t LRLT riskier than cadaver transplant, with the life of the donor being at stake?
I am one of the most ardent promoters of cadaver liver transplant.

Nearly 40 per cent of the patients in my series were transplanted with cadaver livers harvested from all over the country. However, the ground reality is that even in the countries where livers are freely available, the demand far outstrips the supply of organs by three times.

LRLT has become an accepted alternative to overcome organ shortage among both children and adults all over the world. In India, the scenario is nothing short of a nightmare, with 50,000 patients reaching end stage liver disease each year in India, the annual liver procurement is at best 10 in a year. That is why I pioneered the technique of adult to adult right lobe liver transplantation in south Asia, way back in 1999.

Any surgical procedure, be it minor or major, has its own inherent risks. That is true of live liver donation too. Of 5000 live donor liver transplants carried out in the world, the reported donor related mortality is 10-12.

Very few of these were directly related to the surgery, most being pulmonary embolism and other causes not directly related to liver resection. Hence there is need to restrict this practice to centres with surgeons having accredited training in liver transplants and advanced hepatobiliary surgery in hospitals with good infrastructure.

Is lack of co-ordination between surgeons, liver specialist, anaesthesiologist and immunologist a major bottleneck for liver transplantation?
The ability to co-ordinate amongst different medical specialists is a state of mind that is influenced by compulsions to achieve a common goal, equality in professional competence and institutional will to force such a behaviour. In India, there can be serious deficits in all these fronts in most institutions.

Luckily, I have managed to force an institutional compliance to meet my goals and in areas where there is deficiency in professional service, I have filled in those spaces by adapting and role play.

Why is the success rate in liver transplant low in India? What are your suggestions for improvement?
The experience of carrying out liver transplants in India is vastly different from that in the US. The patients seeking liver transplants in India are sicker since they are referred late for the transplant. Early referral is the key to improve results after liver transplant. Availability of a suitable and good quality cadaver organ also contributes immensely in improving the patient survival. Another factor which will heavily contribute to this success is good quality of medical management of patients with liver cirrhosis, as almost all patients with liver cirrhosis will be a candidate for liver transplant at some point in the natural course of the disease.

What are your suggestions for giving liver transplant a boost?
A massive coordinated effort has to be launched across India to propagate awareness for organ donation. There should be a common organ sharing system operated by an autonomous body. There should be a scientific and transparent approach to organ allotment, with blood group, time on the waitlist and severity of illness being the main criteria.

This autonomous body should also set guidelines to be followed universally for counselling, donor maintenance in the ICU to prevent damage to organs, and for organ preservation.

There should also be a network of trained transplant coordinators, who will coordinate with the donor hospital right up to the time of transplant of the organ.

Growth of liver transplantation in India is affected by ignorance of the masses, and surprisingly also the medical community at large. I have employed two processes to nullify this deleterious effect.

One to launch the country’s first free medical portal on liver disease (www.liverindia.com) and secondly, travelling to the various corners of the country to campaign for good liver health through free liver camps and medical/public education.

Many intra operative and post transplant medication had to be initially imported, and extremely expensive. Currently, many of these drugs are being manufactured here and have reduced costs. However, post transplant costs are at least INR 10,000 per month for immunosuppression. There has to be a way of making this affordable to patients.

How does one give a fillip to liver transplant in a public hospital where resource crunch is an eternal problem?
Given the gravity of the economic crunch faced by the government, I cannot fathom the idea of public hospitals starting liver transplants in a big way. It cannot be denied though that for the purpose of advancing medical education and training, there is a need to have programmes in public hospitals. The only way that liver transplant could come within the reach of the common man is by way of public-private partnerships and widening of the health insurance base.

The government can outsource certain high-tech healthcare sectors like liver transplantation, with an undertaking to offer these services to percentage of patients for free or at a reduced rate