President Maithrapala Sirisena’s call on Wednesday, to improve the overall delivery and quality of health care in the country for all Lankans , could not have been better timed.
In a country where health is given the highest priority and stands unique in almost all health indices relating to mother and child mortality and eradication of many common communicable diseases such as, polio, diphtheria and measles, the promise given by no less than the head of the state, is no doubt encouraging to a country facing new challenges in the health sector.
Summoning a meeting of health officials in all districts, his message to them was clear: “ Strengthen your services and deliver quality medical care to all patients under your purview. Identify the needs, strengths and weaknesses and fill the gaps ”.
One of the current and most pressing needs of patients with severe health impacts today, is organ transplant. The number of patients which has steadily grown in recent years for this life saving surgery, from data collected in the waiting lists of hospitals having the resources to perform such surgery, bears evidence of this sad fact. Despite the fact that such patients have other options e.g. dialysis in the case of renal failure among patients severely affected by chronic diabetes, it has been scientifically and medically proved that replacing a damaged organ with a new organ from a healthy donor is a far better choice.
“With a perfect match to their damaged organ, replacement through transplant surgery will improve their quality of life and their life span. Instead of having to undergo the ordeal of frequent dialysis, they can now lead a normal life, eat normal diets while adhering to the medication regimen prescribed to them”, says Consultant Physician, Ragama Teaching Hospital, Colombo North, Professor Arjuna De Silva.
The Ragama Hospital is no stranger to organ transplant surgery. In recent years it has acted as a beacon of hope to a growing number of patients with compromised livers.
Starting on this trail blazing path from May 2011, the hospital has carved a niche for itself in the annals of ‘firsts’ in our medical history in the field of Liver organ transplant. According to hospital data, the first such transplant was in May 2011 when doctors performed its first donor recipient exchange between a mother and a daughter. The mother, (51), UKG Menika’s liver was given to her daughter, Niroshi 21, whose liver had been badly damaged.
“This was even before the hospital had formally established its Hepatobiliary and Liver transplant Unit in 2012. We have to be grateful to Prof Janaka de Silva who was a foremost pioneer in Hepatobiliary and Liver transplant”, Prof.De Silva told the Sunday Observer in a telephone interview.
Since then the hospital has performed transplants with thirteen deceased donor livers . According to hospital sources, the success rate for these surgeries is 70%. .
Explaining the two methods of donor liver transplants, Prof. De Silva said, “ There are two methods we use. 1) Where a living donor could donate a liver to another. 2) Cadaveric liver transplant where the liver from a brain dead person is extricated and replanted in another whose liver is badly damaged.
Asked to give an example, he said, “ Road accidents are very common in Sri Lanka. Most people who die from them, according to hospital and Police reports are young and also healthy but have suffered from cerebral haemorrhage (internal bleeding of the brain).
These livers and other organs can be transplanted in a person who is in need of such organs and whose life depends on life supporting machines, if the brain dead person’s organs are transplanted in their bodies, in time.
The time duration is thus a crucial factor and requires team effort and hundred percent dedication”.
He said, live donor transplant has been found to be a daunting and challenging ordeal for the donor as well. Why? “ Because one has to part with a substantial portion of a normally 100 % healthy liver. There is also a 0.2%-0.5% risk of the donor dying as well, though this is rare”.
Both surgeries are very complex. About 30% of recipients can have complications which revolve around the duration of surgery, during which an infection could set in, post surgery. The other types of complications are related mostly to bile ducts.
Rejection of the liver could also be possible as it is a totally new and foreign organ which has been transplanted . This is the time period when infections could set in as the patient’s immuno suppression is low. Fortunately, we have medicines to suppress rejection”, he said. ´Drawing comparisons with other organ transplants, he added, “Unlike kidney transplants, liver transplants can be treated easily.”
Asked how soon a patient could be discharged, he said, “ This is a very long surgical procedure that we are talking about, lasting 12-15 hours. The first six months are most critical and the patient has to be conscious of adhering to strict dietary habits . On no account must he/she allow germs to get into their system due to their low immune system. However, after six months it improves along with their dye”.
Gaps
Responding to questions on survival rates and the quality of life after a liver transplant, he says confidently, “If the surgery is successful the recipient could have a long survival rate”.
The number of patients referred for transplant assessment is around 120 per year, and the number of patients listed (i.e. having completed work and are ready for deceased donor transplant whenever a liver was available) was 4-5 patients from each blood group.
The selection method however is not one hundred percent fool proof , it seems.
According to unnamed sources not all patients were eligible for transplant and in fact, were unsuitable for such surgery. In other instances the hospital also faced constraints of resources, including, nursing staff, lab technicians, etc.
To clear some of these issues we asked Prof. Arjuna if there were any specific guidelines for the eligibility of a recipient of a kidney transplant.
“ They have to be less than 60 years old, and ideally not over 55 years. Elderly persons are not allowed to get a transplant. That means, while a father can donate his kidney to a child, a grandparent will not be allowed to do so”. Age apart, we asked if pre-existing conditions other than chronic kidney disease were considered when selecting a person with a serious kidney ailment. “ The examining physicians will look into all these problems and only operate those patients after a careful assessment of their current health status and the ability to undergo surgery with minimum complications arising from such pre-existing conditions”, he said.
Abuse of organ donations
Recent evidence of persons ( mainly from other countries) , engaging in illegally selling donated organs to be used by patients in need of organ transplants, has become a huge issue, posing many ethical and legal implications. Prof De Silva has a suggestion to overcome or reduce these risks.
He said, “Living recipients of an organ transplant, should only accept organs from proven relatives or friends. This would minimize the risk of becoming victims of an illegal racket in organ trading”.
Overcoming obstacles to organ donation
Asked how the many constraints facing surgeons in organ transplantation could be overcome , Prof. De Silva had this to say: “ We need to encourage our own people to voluntarily donate their organs as is done in other countries, where such consent is even included in the driving licence. This would not be too difficult in a Buddhist country where such an act will be considered a meritorious deed.”
Quoting a news report he said that the parents of a youth from Bibile, K.Y. Lakshan Pramodya 19, of Dewaketiya who was pronounced brain dead at the Ampara Hospital following a road accident, had donated the boy’s two kidneys to be transplanted on two kidney patients in Kilinochchi and Kurunegala. Lakshan’s parents have been reported to have said that they are “extremely happy to have committed this meritorious act in the name of their beloved son.”
Eye bank
Citing an example he said, the Eye donation bank started by Dr Hudson Silva has spread its influence beyond expectations, inspiring even international communities to donate their corneas. So, we already have an excellent model to work on. If people are encouraged to donate not just one part of their body but their entire body parts, both, for medical research as well as for organ transplantation, our mounting waiting lists for organ transplants will be much less,” he pointed out.
Meanwhile, on July 20 this year, the Colombo North Ragama Teaching Hospital’s Hepatobiliary and Liver Transplant Unit recorded another first. The path breaking operation was performed on a 59 year old school teacher, Hemamali Amaraskera, who was gifted with a brand new liver from a brain dead donor. The medical team comprised, Consultant Gastroentereologist and Hepatologist Dr Madunil Nriella, Dr Anuratha Kajendran, Dr Vithya Rishikesavan, Dr Achini Withanachchi, Prof. Arjuna de Silva and Prof. Janaka de Silva.
The surgical team consisted of, Consultant Gastroenterologicl and Hepatobiliary surgeon Dr Rohan Siriwardana , and Dr Suchintha Tilekaratne working closely with NHSL’s Dr Ruwan Dissanayake and Maligawatte Hospital’s Dr Nalaka Gunawansa.
Now, five months after she discovered what was ailing her, the patient is reportedly doing well.
Explaining the procedure, and the role of the liver which although the human body’s largest internal organ, is still little understood, Prof. de Silva said that extricating the donor –liver from all its connections required several skills as it is joined to many parts of the body.
If the liver was brought from another institution, time was an important factor, as the time the liver had to be kept on ice was of critical importance, before it is linked to the key structures of the recipient, such as, the hepatic vein, the portal vein, the hepatic artery and the bile duct. He also noted that blood loss was a major worry in such an operation for the anaesthetist, who would have to anaesthetise the patient and maintain stable blood pressure and keep her ventilated and pain free.
Liver re-section – a new forward step
Prof. De Silva said, apart from liver transplants, liver re-section was anther advanced area that had been introduced to Sri Lanka recently. “This is one of the primary options being offered to patients with liver cancer”, he noted. Explaining further, he said, “ There could be a primary cancer that starts in the liver and becomes secondary when it reaches the colon or any other organ and spreads to the liver. What we do is, remove that part of the liver surgically.
The liver has a very good capacity to regenerate as it is the only organ in the body which could rebuild itself with a 20% capacity – provided it is healthy. The liver is divided into eight segments with the aid of an operative ultra scan. Blood vessels and tumour sites are marked using new instruments called CUSA which enable the surgery to be done with ease”, he said.
Drawbacks
However, the lack of donors for the long waiting list of patients whose lives teeter on the edge of a life supporting machine, is a huge problem. As Prof. De Silva notes, “The Ragama Hospital is the only one currently doing this kind of surgery. A liver transplant requires a team of forty people per patient including operating staff, nursing staff and minor employees.
The cost factor for a similar surgery in Singapore is around Rs 25 million and in India, between Rs12-15 million. So, most patients had no options. But, now this is being offered to them at much reduced prices of around Rs 5-6 million and is free for all in patients at state hospitals. But the acute shortge of livers for this surgery poses a major constraint.
“ As we now have the infra structure, and a good team of doctors, we can overcome the immediate constrains if we could increase our supply of liver to meet the ever increasing demand”, Prof. De Silva believes.