About 1 week recovery time for liver donors under 50 after surgery
Anticancer effects of the new immunosuppressive drugs
Professor Ju Man-ki, Departmentof Surgery, Gangnam Severance Hospital

The best treatment for End-stage Liver Disease is a liver transplant. However, the liver transplant is a surgical procedure that replaces diseased liver with a healthy liver from a deceased donor or a portion of a healthy liver from a living donor. It demands high technical skill level because of intricate vascular architecture in the liver as well as needs more than 10 hours of surgery time. This is why liver transplantation is called one of the hardest transplants.

Thanks to advances in technology, these days laparoscopic surgery is more popular than laparotomy in liver transplant. However, it is said that laparoscopic surgery is a pleasure to a patient but a pain to a surgeon. It means it is good for the patient as much as that, but tricky for the surgeon.

I met Professor Ju Man-ki (48), a surgeon of Gangnam Severance Hospital. He is a highly experienced surgeon who has performed over 500 liver and renal transplant operations since 2005. Professor Ju said, “Although 70% of the liver is removed from a living donor , which accounts for 80% of liver transplantation, the liver regenerates quickly and is back essentially to what it was prior to surgery within a week when the donor is under 50, therefore, liver donors don’t need to worry too much.” He also said, “More people have a liver transplant with advanced liver diseases such as hepatitis C, nonalcoholic fatty liver, or autoimmune liver disease than because of hepatitis B.”

- Why is a liver transplantation necessary?

“Although 70% of the liver functions are damaged, most patients don't have any subjective symptoms. This is the reason why the liver is known as a silent organ. When symptoms such as swelling and jaundice bec ome apparent, 70% of your liver functions will already be damaged. The only treatment for such end-stage liver disease is a liver transplant.

Adult patients need a liver transplant in case of cirrhosis, acute hepatic insufficiency, or liver cancer. Liver transplantation will be performed for patients with advanced liver cirrhosis who may not live over 1 year without a liver transplant, patients with acute hepatic insufficiency who may die in a couple of weeks due to acute liver damage resulting from toxic substances or hepatitis viruses, or patients with hepatoma who don't have any other treatment options. Children patients need liver transplantation when they suffer from congenital biliary atresia, acute hepatic insufficiency, or metabolic liver hypofunction that harmful substances are accumulated in the liver due to the congenital lack of hepatic metabolic enzymes.

Recently, many senior patients have been getting liver transplant operations. Last year, a 79-year-old patient received a liver transplant operation at Gangnam Severance Hospital. Patients over 70 with healthy heart and lung conditions may get liver transplants without any problems. The success rate of a liver transplant has greatly increased to 97% (the success rate here means the chance of dying within a month after surgery).”

- Is it available to donate the liver with blood group mismatched donors?

“A liver transplant among different blood types opened a breakthrough stage in this area. Unlike previous ABO-compatible liver transplant, patients will get injection with an antibody formation inhibitor (Rituximab) and total plasma exchange will be performed before transplant. Patients with end-stage liver cirrhosis or liver cancer who couldn’t have a transplant due to mismatched blood types now have a chance to be treated.

The problem is that brain-dead donors sharply reduced recently due to the discontinuance of life-sustaining treatment. As a result, liver transplant from brain-dead donors greatly decreased to 200 to 300 cases per year. So, there is a big increase in people on the liver transplantation waiting list. In 2016, the number of brain- dead donors reached a peak of 573 cases. However, it decreased to 515 cases in 2017 and to 449 cases last year. As brain-dead donors reduced, the number of patients on Korea’s organ transplantation waiting list reached 34,423 (as of 2017, Center for Korean Network for Organ Sharing, Korea Centers for Disease Control and Prevention). It is a shame as a surgeon who performs liver transplantation.”

- I heard that patients should take immunosuppressant for liver transplantation.

“Organ transplantation means that a healthy organ comes into your body. However, your body reacts as if a fist-sized colony of germs come into your body. It’s a kind of immune reactions, so-called a rejection. To prevent such rejection reactions, you should take immunosuppressive drugs from the moment of transplantation. Not only do immunosuppressive drugs prevent rejection reactions, but also inhibit your entire immune system. Therefore, you become very vulnerable to infection. Recently, a small dose of different immunosuppressive drugs is mixed to reduce other side effects.

Those who take immunosuppressant are three times more likely to risk getting cancer than those who don’t. Therefore, you need regular checkups to monitor the onset of cancer. It is recommended to visit your doctor once a month for the first six months after organ transplantation, and once every two months after that. In addition, you should take a general medical checkup once a year to monitor your comprehensive health conditions as well as the transplanted organ.

Fortunately, patients who had a liver transplant due to liver cancer can be insured for the new class of immunosuppressive drugs (mTOR inhibitors) since last year by the National Health Insurance. Not only do these immunosuppressive drugs inhibit the immune system, but also have anticancer effects. Furthermore, the more weight you gain after a transplant, the more metabolites will be generated. It may put stresses on the transplanted organ. So, it is very important to maintain a healthy weight.”

- What do you want to say to patients with liver disease?

“It is surprisingly easy to keep your liver healthy. Do not drink too much, but have regular checkups and listen to your doctor. If patients with hepatitis viruses drink too much or abuse their livers, most of them get liver cirrhosis. 80% of the toxic substances in alcohol are detoxified by the liver. If the liver is not able to handle it, it may lead to liver cancer as well as liver damage. Although you have hepatitis, you can keep your liver healthy if you manage well. However, many people don’t know yet about liver diseases well. Hepatitis B and hepatitis C may easily lead to chronic hepatitis, and 30 to 40% of those will develop cirrhosis or liver cancer.”