Liver transplantation, which replaces a diseased liver with a new one when cirrhosis worsens or liver cancer develops, is a life-saving treatment. It was long viewed as a last resort attempted only after all other treatments had failed, but advances in surgical technique and patient care have shifted thinking toward considering transplantation earlier and more actively.
Lee Jae-keun, a professor of transplantation surgery at Severance Hospital, appeared on Seoul Economic Daily TV's program "Now, Top Doctors" at 9:25 p.m. on the 5th and said liver transplantation delivers better outcomes than other treatments. "If transplantation is considered early, depending on the indication, a good prognosis can be expected," the professor said.
Liver Cancer Treated by Transplant, Addressing Liver Function at the Same Time
The main conditions requiring liver transplantation are acute liver failure, cirrhosis and liver cancer. Acute liver failure occurs when a previously healthy person suffers a sudden, sharp decline in liver function due to hepatitis A, medications, health supplements or similar causes. Severe cases accompanied by impaired consciousness can become life-threatening within a short time, and transplantation is sometimes required.
Cirrhosis has many causes. In Korea, the leading causes include viral hepatitis such as hepatitis B and C, alcohol and metabolic liver disease. The professor explained that success rates for the transplant itself do not differ greatly by cause, but managing the underlying condition after the operation is critical.
Patients with alcohol-related cirrhosis who resume drinking after a transplant can damage the newly transplanted liver. Patients with metabolic liver disease also need to manage their lifestyle, because repeated weight gain, poor diabetes control and lack of exercise can gradually deteriorate the new liver.
Transplantation is also an important option in treating liver cancer. Rather than removing only the tumor, it replaces the entire diseased liver in which the cancer arose, which means declining liver function and cirrhosis can be treated at the same time.
Not every liver cancer patient is eligible, however. In advanced cases where the cancer has invaded blood vessels or spread to other organs, the immunosuppressants used after transplantation can raise the risk of recurrence or progression, making transplantation potentially inappropriate. In early-stage liver cancer, by contrast, transplantation can be expected to deliver better long-term outcomes than other treatments, and some intermediate-stage patients may be considered for transplantation after first undergoing treatment to shrink the tumor.
Whether a liver cancer patient undergoes resection or transplantation is decided by weighing not only the size and number of tumors but also the function of the remaining liver.
"With resection, the liver left behind after surgery has to do the work, so the volume and function of the remaining liver matter," the professor said. "If liver function has declined significantly and resection is difficult, transplantation becomes an important option."
Korea a Leader in Living-Donor Transplants, With Donor Safety First
Liver transplants fall broadly into two categories: those from brain-dead donors and those from living donors. In Korea, a shortage of brain-dead organ donors, combined with major advances in living-donor surgical technique, has made living-donor transplantation widely practiced.
In a living-donor transplant, part of a healthy donor's liver is removed and transplanted into the patient. Donor safety comes first. Pre-operative tests first confirm that the donor will retain enough liver after part of it is removed, and also assess whether the removed portion is large enough for the recipient. Surgery proceeds only when both conditions are met.
Citing domestic data, the professor said the rate of severe complications among donors requiring treatment or repeat surgery was in the 1% range, that the liver recovers to more than 90% to 95% of its original size after donation, and that long-term survival among donors does not differ greatly from that of the general population.
Living-donor transplants are possible even when blood types differ. According to the professor, about one-quarter of living-donor liver transplants in Korea involve donors and recipients with different blood types. Drugs that suppress antibody formation and plasma exchange are used to lower the risk of rejection, and with appropriate treatment, outcomes comparable to blood-type-matched cases can be expected.
For transplants from brain-dead donors, by contrast, the patient's urgency matters more than time spent on the waiting list. Patients with the highest urgency, such as those in acute liver failure, receive priority, while allocation for others is ranked based on the MELD score, which reflects kidney function, bilirubin levels and blood clotting measures.
High-Difficulty Cases Once Given Up On Are Now Operable
In the operation, the diseased liver is removed, the new liver is put in place, and the hepatic vein, portal vein, hepatic artery and bile duct are reconnected. Operating time varies widely depending on the patient's condition and the complexity of the case. Transplants from brain-dead donors take an average of six to 10 hours and living-donor transplants about 10 to 12 hours, and can run longer in complicated cases.
The range of patients who can undergo surgery has widened to include those once considered unsuitable for transplantation. When the portal vein, the main blood vessel entering the liver, is blocked, surgeons may create a new pathway for blood flow and proceed with the transplant. Patients with severely impaired heart and lung function have received transplants with the support of extracorporeal membrane oxygenation (ECMO), ventilators and dialysis machines.
The professor described operating on a patient whose liver had grown by more than 10 kilograms because of a congenital disorder, making breathing and eating difficult; a patient for whom another hospital had discussed withdrawing life-sustaining treatment; and patients with simultaneous failure of multiple organs.
The professor stressed that fear of transplantation should not lead patients to miss the window for treatment.
"Operating after a patient's condition has deteriorated carries greater risk, but a transplant performed while the patient is still in good condition means a shorter recovery, fewer complications and a higher success rate," the professor said. "For patients with cirrhosis or liver cancer who need a transplant, it is important not to miss the right time."
