August 16, 2010

Liver transplants must be started in Kuwait

Updated on: 16/08/2010

Miami University team to train local doctors

Dr Hussein Hayati is a liver, pancreas and organ transplantation specialist. Along with his team of surgeons and hospital officials, he is working on starting liver transplantation in Kuwait; a process he says is much needed in the country.

Fortunately, he and his team are on the verge of finalizing an agreement with an American team from the university of Miami and a liver transplant unit has been established at the Amiri Hospital currently catering to cancer surgeries and surgical diseases related to the liver, pancreas and the biliary system. These surgeries have also only begun to be performed in Kuwait.

“Kuwait is in need of liver transplantation and we have the facilities to establish this system and if we work hard on deceased donation, we can do 15 to 20 if not more liver transplantation a year. This may reduce the number of people going outside and reduce the costs. A liver transplantation can cost a person a minimum of one million dollars abroad. Liver transplantation will be free of charge here; the expenses will be for the investigations only,” said Dr Hayati.

He added that liver transplantation, procedures are necessary as currently doctors are loosing patients who could have been saved, especially young patients who are nationals and non-nationals.

Q: What does liver transplantation consist of?

A: Liver transplantation is like any other organ transplantation,transferring an organ or organ tissue from a donor to a recipient. It is done in two ways, either you take the liver from a deceased person or brain-dead person or you take it from a living donor who could be a relative or someone with matching criteria.

The diseased liver of the recipient could also be replaced by a piece of liver from the donor. We connect this piece of liver to the recipient and with time the liver grows into almost the size of the liver that he or she needs.

Q: What is the criteria for being a recipient or a donor?

A: Liver transplant is done on those who have liver cirrhosis or liver failure. Liver cirrhosis is the end result for any chronic disease that affects the liver. The most common liver diseases are viruses; we have Hepatitis C and Hepatitis B. They cause chronic illnesses and inflammation which will result is cirrhosis, which means the liver tissue will be replaced by fibrous tissue that is inactive.

There are other causes of chronic liver illness such as alcohol consumption, which is the second common cause for liver failure in the world. Then we have hereditary causes and congenital causes. Either you have enzymatic deficiencies or metabolism problems which these days affect children. However, the most common causes are Hepatitis and alcohol.

Q: What are the most commonly used techniques for liver transplantation?

A: Liver transplantation is done surgically, either transplanting a complete liver or a piece of liver. The techniques for both surgeries are the common. However, if you take the liver from a liver donor it is more time consuming and needs a lot of work because you will end up with two rooms, one for the donor and one for the recipient.

The donor will be under anesthesia and a team will work on him or her to take a piece of liver. Sometimes you need a small piece and sometimes you need a bigger piece. The bigger piece is taken from the right lobe of the liver in adults. In pediatrics, we can take segments. The liver has eight segments and these segments are divided into two lobes anatomically.

That’s why I mentioned piece of liver, cause it could be for a child, they take a segment or two segments of the liver. But if it is an adult, they take either the left or right side, but usually the right side.

The techniques of surgery are slightly different when a piece of liver from a live donor is taken because surgeons will be dealing with smaller liver tissue as well as smaller vessels and ducts that need to be connected. It is more time consuming, if liver is taken from a live donor.

Q: How successful is the live donor liver transplant surgery? How long does it take the recipient and the donor to recover?

A: Usually fit donors with no medical problems are chosen for the surgery, so that you don’t end up with problems during the anesthesia or after the surgery. Their hospital sty is usually five to seven days and then they are discharged. After that it takes three months for the liver to reform and grow to normal size, plus or minus ten percent, and it will appear that no surgery was ever performed.

The situation for the recipient is different and he will take more time to recover because the recipient has taken in a foreign organ to his system or body. He will end up taking medication to reduce his immunity, called immuno-suppressive medication. He will be taking four kinds of medication and then he will be discharged with three kinds which are, with time, withdrawn slowly. If the transplant is from a live donor, the liver will also grow to about normal size.

If a whole liver is transplanted, the recovery time and medications will be the same but the surgery itself is less complicated. The surgeon will be dealing with large structures, bigger vessels and ducts that drain the biliary system, so it is easier to connect the organ to the body.

The life expectancy of a liver transplant recipient depends on the cause of the liver cirrhosis or liver failure. It is divided into viral and non-viral. Viral diseases are Hepatitis B and Hepatitis C. Non-viral causes are alcohol, hereditary problems, congenital problems or enzymatic deficiencies, which is a congenital problem.

Recipients with non-viral liver failure have the best outcome than recipients with viral problems. That is because viruses can come back again when immunity is low and cause damage to the transplanted liver. That is why with the non-viral, we are talking about 95 percent, one year survival and we call it graft survival. It can reach to almost 80 percent, five year survival and ten years you can go to 70 percent.

Recipients with viral disease also divided into two categories; the ones with Hepatitis B and the ones with Hepatitis C. Hepatitis C is the worst because we do not have the proper anti-viral to counteract the effects of the virus.

After the first year of the transplant, there is a 60 percent chance the virus will reoccur. But the amount of damage varies, for some people within three months the liver is completely damaged and they need a re-transplantation. Some people can last for three, four or five years even without any problem.

On the contrary, we have certain antibodies and anti-viral for Hepatitis B. That is why the outcome for Hepatitis B is much better than Hepatitis C. The recurrence of Hepatitis B after transplantation in the transplanted liver is 11 percent. There used to be an 80 percent chance of recurrence, but due to the discover of the anti-viral and antibodies that are included in the treatment regiment, it lowered the chance of recurrence.

Q: Has liver transplantation ever been done in Kuwait?

A: Liver transplantation has not been done yet in Kuwait. We are on the verge of finalizing an agreement with an American team at the University of Miami. We already approached the team and they have visited Kuwait, but we are just waiting for the final agreement.

The team evaluated the facilities in Kuwait and has pointed out that we should start a liver transplant and liver surgery unit at the Amiri Hospital because, according to their evaluation, the Amiri Hospital has the best facilities such as a new ICU and new operating room to avoid infections in these kinds of cases.

Also, we have Al-Thunayan Gestural and Intestinal Center nearby so if we need intervention by endoscopies it is available.

It has been agreed upon by the heads of departments to locate that unite there and the services have already been opened up, but right now we are only doing specialized cancer surgery and operating on surgical diseases related to the liver, pancreas and the biliary system.

These surgeries have only begun to be performed in Kuwait. We have started doing them around a year ago but now we have a specialized place and a team and we are training the ICU and nursing staff to get used to these kinds of cases. We are getting transfers so far from three or four hospitals, excluding Mubarak Hospital.

We are performing one surgery a week because it is not a very common problem but the problem is still there and we are still new and people are still getting used to us. For example, we don’t get transfers for private hospitals, so we need to build a good reputation.

We have the support of the Ministry of Health because we have ministerial decree to establish the unit and to establish the referral system from other hospitals to this unit. So all these specialty surgeries related to the liver, pancreas and the biliary system are done in our unit.

Q: When do you expect liver transplantation to begin in Kuwait?

A: It depends when we get the agreement. There are certain financial issues not finalized yet, but hopefully by the end of this year or early next year.

Q: How necessary is liver transplantation in Kuwait?

A: It is very necessary and we need it. We are loosing patients and especially young patients who are nationals and non-nationals. The non-nationals have Hepatitis C more frequently and the nationals get Hepatitis B often and there are some cases of cirrhosis of an unknown origin, but it is non-viral and non-alcoholic, it can happen like that because there is an entity called idiopathic, we don’t know the cause. There is a small percentage of alcohol related cases as well.

Kuwait is in need of liver transplantation and we have the facilities to establish this system and if we work hard on deceased donation, we can do 15 to 20 if not more transplantation a year. This may reduce the number of people going outside and this may also reduce the cost. A liver transplantation can cost a person a minimum of one million dollars abroad. Liver transplantation will be free of charge here; the expenses will be for the investigations only.

If the services are provided here, it will reduce the costs and it will be much more effective because we are losing young patients. Recently, only in the l last month, we lost an 18-year-old girl to chemical hepatitis. She took more herbal medication and she developed liver failure. She was put into intensive care and we rushed to send her abroad but we didn’t have enough time. She passed away before we were able to send her abroad.

If we had the liver transplant service here, we could have managed to rescue her. There were also similar cases like this one, we have another 28-year-old lady last year, a mother with three children, who took a medication for TB and had a bad reaction that ended with liver failure. We couldn’t save her live.

So the service has to be established and the MoH is working hard on that. They realized that we needed this. They have the expertise in all different specialties but it is just a matter or organization, plus they wanted an outside experienced team to come here so they will gain the trust of the people.

To be honest, there is a lack of trust in the medical services in Kuwait because of awareness problems and political issues. That is why the Minister of Health Dr Hilal Al-Sayer, made an excellent move by bringing in teams for the chest hospital, the cancer center and the transplant center because these are the three main areas we have not built upon in Kuwait. He provided the teams here so that there will be no excuse for going abroad.

Q: Do you have compiled donor list for liver transplantation?

A: We don’t have a donor list; we should have a recipient list according to blood group because evaluating a person consumes a lot of time and money. We cannot do that unless we reach an agreement and have a starting date. If this process takes longer, I have to evaluate the patient again because his status will change with time.

So if we reach an agreement and decide on a starting date, then we can arrange a list of people who are fit for transplants two months prior by contacting all the centers in Kuwait that deal with liver cirrhosis.

We already have 5,000 people with donation cards and their names are registered in Kuwait Society of Organ Transplantation but we are still working on the deceased donation list.

Any program in the world starts with deceased donation, because it is less complicated than living donation. You have to establish a good deceased donation program before you start a living donor program in case the living donors develop problems themselves or living donor transplantation surgeries go wrong.

Dr Mostafa Al-Mousawi is the head of the organ procurement department which started working toward this program in June and is developing a good system. Now we get a good number of reports from the ICUs, it is just that we need to convince the families to donate.

For example, someone who has had an accident and he is comatose in the ICU. We cannot take consent from him; we have to take consent from his family who may even not be in the country.

So the system is being established, it has been there for a long time and is the best system in the Gulf, but we had some drawbacks due to problems with the transplant coordinators. That is why we are sort of re-evaluating the system and the MOH promised to give us more facilities and to establish more teams.

The American team for liver transplantation will include not only surgeons, but physicians, anesthetists, radiologists and coordinators as well who will train out local coordinators. We will have an agreement to send our Kuwaiti coordinators to Miami to be trained and the non-Kuwaitis will be trained here by the Miami team.

So we will have coordinators with different nationalities to communicate with the families from all over the world, such as Egypt, Syria, India and Bangladesh.

Q: Have there been any unique surgeries done so far for the first time in the Gulf?

A: All what we are doing now is new in the Arabian Gulf and we did one case which was not done before in the ME, but these are not done frequently. We do surgeries for cancer of the liver, pancreas, gal bladder and biliary system or tumor and benign conditions that need surgery.

So far we did eight big surgeries since we started in June. We get referrals from different hospitals and some don’t need surgical intervention for the time being.

The case that we did that was unique is called ‘Synchronous Resection’ where we performed two surgeries at the same time on one patient. This patient had cancer of the colon that has spread to the liver. These surgeries are not frequently done because you need special situations and a dedicated and educated patient that can be aware of the risks.

You also need a two-team approach, a team that can handle the colon cancer and a team which can handle the liver, which was our team. When we evaluated the patient, who is 43 years old, we discovered that she had colon cancer and at the same time she had a big metastatic spread of the tumour to the liver. We decided to do the surgery and the patient had a smooth recovery and she was discharged home by day eight.

It is not the surgeries that matter it is the services that you have around. We had excellent ICU care at the Amiri Hospital, the team was superb. The nursing staff in the operating room was excellent as well. You cannot work alone; you need other services to support you and the patient. I hope in the future we get more referrals from different hospitals.

By: Nihal Sharaf
 
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