The first liver transplant was performed in 1963, and the patient died during surgery. Nearly 60 years later, about 8,000 liver transplant surgeries are performed in the U.S. annually, according to the American Liver Foundation. Over the past 15 years, 3% to 8% have been from live liver donations, according to Dr. Benjamin Samstein, chief of liver transplantation and HPB Surgery and associate professor of surgery at Weill Cornell Medicine in New York.

But the U.S. still needs more live liver donors, whose partial organ donations will regenerate in both donor and recipient. Dr. Samstein says patients on the United Network for Organ Sharing (UNOS) registry are at high risk of dying while waiting for a deceased donor—and their best option is a live and directed liver donation.

“If I’m having medical care, whether it’s treatment for appendicitis or chemo for cancer or a stent for a heart attack, I would like to think that the barrier to my care is not the availability of the stent or the antibiotics or the surgery for my care to be optimized,” says Dr. Samstein, who is also surgical director of the Living Donor Liver Transplant Program at New York Presbyterian. “If I need a heart stent for a heart attack, I would like for it to be available.”

Dr. Samstein has performed approximately 300 live liver transplants during his 15 years of practice. He has performed both sides of the liver donation surgery—that is, both the removal of liver from a donor and the transplantation into the recipient. From the donor side, it’s a long and complicated surgery, about five or six hours. Live liver donation has obvious advantages, but it comes with its own set of challenges.

In addition to the scarcity of donors, here’s what Dr. Samstein sees as the top challenges of live liver donation:

    • There’s a reduced margin of error in live liver donation surgery

In most surgeries involving tumor removal from an organ, surgeons have a margin of error of 1 to 2 centimeters, according to Dr. Samstein. “In living donation, because the organ has to provide life-sustaining function to two patients, the margin of error is reduced to 1 to 2 millimeters or you risk significant damage to the function of the organ,” he says.

    • Everything is half the size

When a surgeon divides the liver during the liver donation surgery, they’re cutting and sewing blood vessels that are half the normal size. The transplantation surgery into the recipient also becomes more complicated because the connections are approximately half the size.

“I like to say that every liver we sew in is tailor-made and the precision of the tailors doing that work needs to be at the highest level because we’re working with smaller vessels and connections,” Dr. Samstein says of live liver transplants.

    • Complications are not uncommon

Patients who need liver transplants often present with a complex medical history beyond liver disease. Comorbidities can include kidney disease, diabetes, loss of muscle mass or other conditions that make the healing process more challenging and makes the patient more vulnerable to infection. A severely impaired liver may be the impetus for surgery, but other conditions may complicate the healing.

    • Living donors must be valued throughout the entire process

Live liver donation involves healthy people who are undergoing a life-threatening and serious surgery for the benefit of someone else, Dr. Samstein said. “We should value that throughout the donor’s entire interaction with the healthcare system,” he said. That means ensuring that each donor has the best possible experience, he says, from evaluation, through hospitalization and post-hospital care.

    • A rising number of livers are going to the elderly

In 2000, few patients over the age of 65 and even fewer over age 70, were candidates for heart, liver or lung transplants. But programs no longer exclude potential recipients on the basis of chronological age alone.

“Our entire society values people’s lives over age 65 more than we used to,” Dr. Samstein said. That doesn’t mean older patients are automatic shoe-ins as recipients. Older patients still tend to have more comorbidities and less physiological reserves compared to their younger counterparts.

    • Living donors often underestimate the emotional experience

“People often tell me afterwards, ‘I was prepared for the incisional pain, the risk of bile leakage and infection, but the emotional experience was more than I expected,’” Dr. Samstein says. “It’s relief and gratitude and doing something heroic that brings positive energy that lasts for several days, followed by fatigue, exhaustion and an inability to sleep and get comfortable.”

He describes liver donation surgery as a very intense emotional rollercoaster: “For people who have not experienced it, it’s hard to convey what it’s like, regardless of how much informed consent you give people.”

Today’s live liver donation surgery is a far cry from the days when people thought of organ transplantation as straight out of science fiction. Dr. Samstein says medicine, like all fields, innovate and evolve over time. For liver transplants, Dr. Samstein says technological advancements include 3D imagining reconstruction, high resolution CT and MRI scans, minimally invasive surgery techniques and higher magnification loupes.

“In 1969, the idea of traveling to the moon was something that only a few people could do,” Dr. Samstein says as a comparison to when organ transplants began. “In 2021, four people with no people experience became astronauts.”

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