The Medanta liver transplant team successfully performed the country’s first three-way liver transplant swap, or paired exchange, helping three patients suffering from terminal liver disease simultaneously receive liver transplants. A team of 55 doctors and nurses of Medanta, a multi-superspeciality hospital in Delhi NCR, worked together in six operating rooms for over 12 hours to complete the organ swap.
The three patients—Sanjeev Kapoor, a businessman from Madhya Pradesh, Saurabh Gupta, a businessman from Uttar Pradesh, and Aadesh Kaur, a homemaker from Delhi –were suffering from terminal liver failure, and needed urgent liver transplants. The wait for the organ of a deceased donor would have taken up to an year. However, all three of them had willing liver donors within their families, but none were a suitable match. The Medanta liver transplant team came to their rescue and performed a never-before simultaneous swap surgery.
The lead surgeons for the three transplants were Dr. AS Soin, Dr. Amit Rastogi and Dr. Prashant Bhangui.
Medanta’s chief liver transplant surgeon, Dr. Arvinder Soin, who led the team effort, said, “We introduced the concept of living donor organ swap (or paired exchange) between two recipient and donor pairs in 2009. Such exchanges help save lives of recipients whose relatives, despite being medically fit, are unable to donate due to blood group and/or liver size incompatibility. After performing 46 such two-way swaps (92 transplants) over the past 13 years, we have now successfully expanded the concept to a three-way swap chain involving three donor-recipient pairs.”
“These three transplants were performed simultaneously by operating on three donors and three recipients. A team of 55 doctors and nurses worked together in six operating rooms for over 12 hours to complete this Herculean task. While Sanjeev’s donor (his wife) was blood group compatible, her partial liver would have been too small for him. Saurabh’s donor (his wife) and Aadesh’s donor (her son) were both blood group incompatible. The paired exchange was planned in a way that all three patients received an adequate volume of a blood group compatible liver. In theory, this chain can be extended to four, five or even more donor-recipient pairs. Owing to logistic challenges of performing so many liver transplants simultaneously in one center, we are now developing protocols to collaborate and accomplish longer chains of liver exchange at 2 or 3 different centres within the same city,” he said.
Dr Amit Rastogi, senior liver transplant surgeon at Medanta, said, “Performing three liver transplants means six simultaneous liver surgeries. This is a mammoth undertaking requiring many skilled surgeons, enough trained staff and operating rooms, and a fair exchange in which all donors have equally safe surgeries. It also requires all recipients to be well matched for their severity of illness, and have equally good, expected outcomes. No wonder, this procedure has never been done before. Our success will now pave the way for increasing the living donor pool in future with more such paired exchange transplants.”
Senior transplant surgeon at Medanta Dr Prashant Bhangui said, “These operations are complex, and need all donors and patients to be optimally prepared for surgery, both medically and psychologically. If the transplants are done on successive days, there is a small possibility that one of the donors may back out of donation the next day once their family member has already received the exchange donation the previous day. Also, one of the recipients may become unfit for surgery the next day as these patients are sometimes quite critically ill before transplant.”
Dr Neeraj Saraf, senior director of Hepatology at Medanta, explained that while Sanjeev and Aadesh were both suffering from advanced liver failure with deep jaundice, water accumulation and repeated episodes of coma-like state, Saurabh had advanced liver cancer. “We thought we would lose them all as none of their donors was suitable to donate to their loved ones. All the families saw a glimmer of hope when we planned the three-way swap. However, it was a big challenge to control their infections and other complications, like kidney dysfunction, so that they could all be medically fit for surgery on the same day.”
Medanta’s Dr Nikunj Gupta, who headed the anaesthesia team, said smooth anaesthesia is vital for the success of any liver transplant. “To ensure the highest level of anaesthetic care to all six donors and recipients, we meticulously planned the staffing, timing and sequence of events with a dummy run the previous day. On the day of surgery, everything went like clockwork, with two-three members of our team in each operating room, ensuring optimal fluid, respiratory and drug management during surgery,” he said.