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A donated liver is being transferred from London to Queen Elizabeth Hospital in Birmingham, in the north of England.
It was against the clock. Time is critical
“The liver is being deprived of oxygen, with every minute that passes, more liver cells are dying and the risks of that liver not working after the transplant increase,” says surgeon Richard Laing.
The specialist is carrying out one of the clinical trials that are done in the hospital, in which doctors use cutting-edge techniques in humans for the first time to combat conditions that are usually fatal.
The organ that is on the way would normally have been rejected , since it comes from a middle-aged donor who died of a heart attack outside the hospital.
Laing hopes to prove that many of the rejected livers are, in fact, viable for transplants.
Every year hundreds of millions of surgeries are performed in the world, but few of us know what happens behind the doors of the operating room.
The Queen Elizabeth Hospital, one of the largest surgical units in England, opened those doors to the BBC, giving you privileged access to this pioneering procedure.
Laing’s essay seeks a solution to one of the greatest health crises: liver disease.
Due to a Western diet, obesity is a big problem and is one of the biggest causes of liver disease.
C ada more patients waiting for liver transplants that saved their lives .
Surgeons only use livers of sufficient quality for a safe transplant, so that each year hundreds are rejected for being considered two very high risk .
Meanwhile the waiting list of patients who are on the verge of death grows .
“This trial has the potential to help many patients, but it’s a high-risk test,” Laing tells the BBC.
“In and of itself, organ transplants are risky, and what we are doing is taking the livers that have been rejected by everyone and trying to put them in the patients … it is distressing .”
When it arrives, the donor’s liver will connect to a machine that is the key piece in this clinical trial .
Through a process called perfusion , it will restore the liver to its best possible functional state, giving the team the opportunity to assess whether it is healthy enough for a successful transplant.
“This machine mimics the conditions that a liver would experience inside the human body, so you give it blood, oxygen, nutrients, all at the normal body temperature.”
“Thus, the liver starts to function, and not only does it work, but there is also a certain degree of reconditioning, so that the liver can begin to repair itself ,” explains Laing.
“The machine allows us to take a liver that is considered inadequate and to test if it will work after being transplanted.”
That is the risk that both the Laing team and the patient waiting for the transplant are taking.
Connie has suffered from rare liver disease for decades and is the third time that she has been operated at Queen Elizabeth Hospital for that cause.
“First I had a hemorrhage and I had emergency surgery and when they finished, they found out I had liver cancer and they saved me again, now I need a new liver.”
“The last two years have not been more than doctors, doctors, doctors, doctors, the disease has consumed absolutely my whole life.”
For Connie, the possibility of receiving a transplant quickly overcomes the anxiety that can be produced by being part of an experimental treatment .
The donor’s liver is about to arrive for the first stage of the test.
There is an air of anticipation: “Will it work, it will not work? There are some livers that even if we put them in the machine they simply do not work”.
The one that could be Connie’s “has more fat than we think, it’s not the most attractive liver.”
But whether it works or not will only be known after the test .
“We connect it to the device and, throughout the perfusion, we will begin to see several readings that will indicate whether the liver is useful or not.”
During the next four hours, the liver must pass a series of tests that will determine if it is healthy enough to transplant.
Only time will tell
Richard Laing has been monitoring the liver of a donor who wants to use the transplant test during the last few hours.
One of the main functions of the liver is to convert lactate, an acid produced by muscle activity, into glucose.
A lactate reading of 2.5 or less indicates that the liver is working well enough.
“It’s 2.6. Fantastic!” The liver is very close to meeting the criteria.
Shortly after, the result is 2.1.
He passed the tests, but this is only the beginning .
The question now is whether the liver will continue to function after being transplanted.
The moment of truth
Because she enrolled in the trial, Connie will receive the transplant she needs quickly. But everyone is aware of the price that she could pay.
“With any clinical trial, there is a degree of risk, but what is at stake is enormous with this test,” says Laing.
“If we can not do what we propose, for us, as doctors, it’s really disappointing, but for patients, it could be devastating .”
“In the worst case, they can die.”
“Clinical trials would not be possible if there were not patients who were brave enough to participate, risking their own health in many cases, and even their lives,” Laing adds.
“We have a duty to really take care of these patients as much as possible, make the conditions as safe as possible and really try to make them go well.”
In the operating room, Connie’s life will be in the hands of transplant surgeon Thamara Perera.
In the last seven years he has performed hundreds of transplants.
“Transplant surgery is not a very popular field because it requires a lot of hard work, but there are so many patients on the waiting list for transplants that I do not want to stop doing it,” says Perera.
He adds that there are rewarding aspects: “I can see the transformation, I really feel that I have done something as a patient and that it has a new life, which is what makes this work worthwhile “.
Regarding this clinical trial, Laing says that “there comes a time when you have made all the preparations, you just have to take that leap of faith and move on to the next stage, and hope it works”.
The leap of faith
The main surgical challenge is to connect Connie’s new liver as quickly as possible. Thamara Perera is about to remove Connie’s diseased liver and replace it with the revived and rehabilitated organ.
” The surgery itself is extremely complicated , because there is an organ that is sick, but in any case is receiving two liters of blood per minute,” says Laing.
Using an electrosurgical pencil, Perera needs to carefully separate Connie’s liver from the surrounding tissue in her abdomen.
The liver is attached to the main blood vessels , including the arteries that supply blood from the heart and the portal vein that carries blood to the liver from the stomach and intestines.
All must be disconnected with immense care and will have to be reconnected to the donated liver.
“If you do not do it right, the consequences happen in front of your eyes.”
Connie’s liver has been removed.
The donor’s organ has to be disconnected from the oxygen and blood supply of the machine.
The clock does not stop.
“Time is critical, because every second the liver passes out of the machine, it suffers a degree of damage that can lead to a failure and a new emergency transplant,” says Perera.
The organ is being rapidly prepared but time runs and the cells die; moments later arrives at the Perera operating room.
Perera has just 13 minutes to connect it to Connie’s blood vessels.
It begins with the portal vein, which administers 75% of the liver’s blood supply .
“It’s one of the most complex operations, you have to have a mental design in your head.”
The portal vein is a thin and thin structure, susceptible to tearing during the operation.
The integrity of these vessels is important for liver survival.
The portal vein is connected.
With blood now flowing through the donor’s organ, Connie’s body could have an adverse reaction to such an important procedure.
This is the period in which the patient can become unstable. Sometimes the changes are powerful enough to stop the heart.
Now, the surgeon goes to the most delicate stage : plumbing in the network of hepatic arteries that helps supply oxygenated blood to the liver.
They are very fine sutures, and you have to do it in the best possible way so that no blood clot or damage occurs in the blood vessel.
“If a clot develops in the hepatic artery, it will harm the liver,” Perera tells the BBC.
“If it breaks a blood vessel, the bleeding is enough to kill a patient in 30 seconds.”
“One of my teachers told me, when I became a surgeon: ‘God has given you power, it’s a privilege, make sure every patient goes home safe and sound,'” Perera recalls.
With all the blood vessels attached, Perera has one final task: to connect the bile duct that supplies the digestive system with the fluid we need to digest fats.
“Once you know that everything has gone well, it’s a huge relief.”
The operation ends on time.
Now we have to wait to see if Connie’s new liver continues to work.
“This is a clinical trial, there are no certainties, we will keep crossing our fingers to do well.”
The ultimate goal is to increase the number of donor livers available to patients who will die without them.
– Good morning, Connie. How are you?
– Excited and ready to go home. Could not be happier. Without that machine, I would not have received this liver. I’m waiting for a future. I think those two words, ” a future “, say it all.
In ten years, the use of these machines for organs will probably be in common use.
For now, “see a person who enrolls in the trial and receives one of these livers, and examine it a month later and see that his life has changed drastically … it ‘s great! ” Exclaimed surgeon Richard Laing.
“Improving people’s lives is an absolutely fantastic feeling …
You really can not ask for much more than that . “