‘Living donor liver transplants will surpass cadaveric ones soon’

Dr K C Tan

Director of liver transplant programme at Gleneagles Hospital, Singapore, surgeon Dr K C Tan has many firsts to his credit. He has performed the first split liver transplant operation in the UK, where the donor graft was divided and transplanted into two recipients. He has also performed the first auxillary heterotopic liver graft for a patient in fulminat hepatic failure. A pair of siblings with Crigler-Najjar syndrome was successfully given orthotopic segmental grafts, the first such operation in Europe and the second in the world.
After graduating from the Medical Faculty, University of Malaya in 1978 and obtaining his fellowship of the Royal College of Surgeons of Edinburgh, Dr Tan worked as a lecturer in general and paediatric surgery for two years in the University of Malaya. He obtained advanced training in paediatric surgery in Manchester and Southampton, UK and further training in paediatric hepatabiliary surgery and liver transplant surgery in King’s College Hospital (KCH). From October 1989, after KCH was recognised and funded as the fourth liver transplant centre in the UK by the department of health, Dr Tan as in-charge of the programme, had performed over 400 liver transplant operations. Although the programme in KCH was largely adult-based, Dr Tan performed over 75 paediatric liver transplants, 45 per cent of which were liver reductions from adult liver. While working here, Dr Tan helped implement the Irish National Liver Transplant Programme in St Vincent’s Hospital, Dublin. After six years at KCH, he returned to set up private practice at Gleneagles Hospita in 1994. In his recent visit to Mumbai, Dr Tan spoke to Rita Dutta about the advantages of living donor liver transplant programme as against cadaveric one. Excerpts:

Why are you advocating living donor liver transplant (LDLT), where the life of the donor is at stake? How does LDLT score over cadaveric transplant?
The mortality rate for the donor in LDLT is one per cent and the morbidity rate is 25 to 30 per cent. However, LDLT is required because of the yawning gulf between the demand and supply of cadaveric livers.
The advantage of LDLT, firstly, is that the donor liver is in good condition as it’s mostly taken from a young person as against a cadaveric donation, which is mostly from an old one. Secondly, since the donor in living related liver transplant is mostly from somebody in the family, the rejection rate of the recipient is as low as 15 to 20 per cent as against that of cadaveric one, which is 30 per cent.

In which countries is LDLT picking up and why?
It is picking up in Japan, Singapore, Korea and Taiwan. Cadaveric donation is not so rampant in Asian countries because of religious prejudices and myths against it. Hence, LDLT is the only choice in these countries.

From which countries does Singapore get patients for LDLT and how much do you charge for the treatment?
We are getting patients from India, Pakistan, Bangladesh and Sri Lanka. Last year, we had seven patients from India. We get at least one enquiry every week. The cost of the package is Rs 70 lakh.

Will LDLT surpass cadaveric liver transplantations in near future?
Yes, very much. That is because there is not much scope for improvement in expertise in cadaveric transplant programme, with one case coming every three months. Worldwide, cadaveric liver donation programme has stopped developing and evolving after the initial three-four years; the team loses interest with less number of cases.

Why is liver transplant surgery so expensive? Is there a way to reduce the cost so that the treatment can become affordable?
As you cannot have a cheap Mercedes Benz, similarly you cannot have a cheap liver transplant surgery. The technique is so skillful, that it has to be at a certain cost. For a person who cannot afford a good liver transplant surgery and additional cost of immunosuppressants, I would advice him against surgery. It’s is better to have a good liver transplant surgery than have a bad one.

Are you in favour of commercial organ donation?
In Singapore, we have a law against unrelated organ donation. Interestingly, around two years back, the government had opened its door to unrelated donor but with emotional attachment. The ethics committee in our country is flexible regarding allowing donation from people with emotional attachment.

Who should shoulder the responsibility of screening whether a donor is related or unrelated- hospital or the government?
Making hospitals responsible for screening of a donor is equivalent to making a judge the owner of a jail. Screening should be performed by unbiased people. And hence ethics committee of the government is better than hospitals.

Can you share your experience of setting up a liver transplant programme in Ireland?
As the pioneer of paediatric liver transplant programme in the UK, I was invited by the Irish government to develop the same programme for Ireland. I had basically re-trained surgeons and nurses related to liver transplant in Ireland.

What do you think is wrong with liver transplant programme in India? What is the main cause of low success rate-is it lack of technical skill or late referral?
I don’t know why the success rate is poor in India. Indian surgeons are quite skilled. Late referral is a possibility for poor success.

What is your message to surgeons practising LDLT in India?
I would advice them to first start with paediatric living related liver before graduating to adult living related liver transplant.