Are we ready for Liver transplantation in India?

I spent my holiday reading "The puzzle people", an auto biography of Dr Thomas Starzl. The provides a remarkable view about the men who made transplantation available. For the past 6 years, liver transplantation is available in India. There are centers which do an amazing volume of cases that far exceed the volumes at individual US centers.

Some months ago, I was talking to a senior surgeon who was aware of my interest in liver transplantation surgery and the efforts I am putting to treat patients with end stage liver disease. As I was telling him about the ways transplantation has given hope to people with end stage organ failure, he called me a humbug. Transplantation is for the rich, he said, a surgery where money plays the most important role. I could not disagree with him. But it set me thinking about the whole process of transplantation.

Most of the centers in India do something what we call as living related liver transplantation. It means a portion of the liver is donated by a related family member on purely altruistic reasons. The diseased liver from the patient is removed and the new liver from the donor is attached to the patient. The procedure looks relatively simple to explain. The issue is never about the technical aspects of the procedure. Liver resection is a major surgical operation with a 1% risk of death. To subject a normal person to this procedure requires thought.

Why did we adopt this procedure? Part of it stems from the way we see "death"! For a layman, death is stopping of the heart. From my interactions with patients, most of them relate this event as death. The presence of a heart beat on the monitor is considered a sign of life. The legal definition of death in the western world changed with the arrival of transplantation. 

The brain stem is the portion of the brain which contains the nerve centres which control the basic functions of the body, like breathing, heart beats and maintaining conciousness. If there is a problem in the brain stem, the person will be deeply unconcious, and it is only a matter of time before the respiration and heart beats stop. There is no recovery after brain stem damage has occured. But at that point of time, the heart beating and the breathing of the patient can be maintained by artificial means. This state is defined as "brain death". This is the legally accepted as death in the western world. It is these brain dead patients who donate their organs to be transplanted to needy patients.

Now, the legal definitions may exist, but the actual change has to come from the people. Tamilnadu, I am proud to say, took the first step in the right direction. It is the people's acceptance of "brain death", which will bring the necessary changes in organ transplantation. The transplant program in the United states was brought to life due to the sacrifices of numerous patients and doctors, who stood firm and fought many battles (in fact, Dr. Starzl has named them, Liver wars) and made this dream possible. I see this commitment missing in our people. If there is going to be a right way for people to be treated when they have end stage liver failure, the best initiative should come from the people - from you and me. 

How many of us, have donated our corneas? How often do I come across people who ask me whether blood can be purchased for their loved one? These are the simplest of transplantations. And if we cannot contribute to the pool of resources, how can we have a legitimate hand in it. The organ pool is a pie. It is a bucket of life. Unless, someone, you and me, put something in it, it is going to run out soon and we will be taking bits of living people in order to make others live. That is something terrible, especially when we might need it ourselves - tomorrow.

Public initiatives for liver transplantation must precede and continue to support the clinical work.