What to Expect During and After a Liver Transplant

Liver transplantation offers hope for individuals with primary liver cancer and end stage liver disease. The process, however, is complex. It requires meticulous preparation, skilled surgical expertise and comprehensive long-term care with experts in liver disease.

By understanding what to expect during and after the transplant, patients and their caregivers can navigate the journey with more clarity.

Liver transplant surgery is a major operation, lasting more than six hours. During this time, patients are placed under general anesthesia to ensure they remain unconscious and pain-free. The entire procedure can be divided into the following key steps:

1. Prior to the surgery, surgeons will insert several tubes into the patient’s body to help manage bodily functions. These include:

• Intravenous (IV) lines — Inserted into the arm, neck, or thigh to deliver fluids, medications, and monitor blood pressure.
• Mechanical ventilator — A tube placed through the mouth into the windpipe to assist with breathing.
• Abdominal drainage tubes — To remove excess blood and fluid from around the liver.
• Nasogastric tube — A tube from the nose to the stomach to drain secretions.
• Bladder catheter — To drain urine during the procedure.

2. As the liver has a rich blood supply, the risk of bleeding during the surgery is high. Therefore, surgeons take extra care when handling tissues and blood vessels around the liver to avoid massive bleeding. Nevertheless, the surgical team is prepared for the possibility of a blood transfusion if needed. Requiring transfusion of blood or blood products is fairly common in liver transplant surgery.

3. The surgeon makes a large incision (about 6-12 inches long) across the abdomen to access the liver. They then remove the damaged liver by carefully detaching it from the surrounding blood vessels and bile ducts. The new liver is attached to these blood vessels and bile ducts before the incision is closed. The patient is then transferred to intensive care for close monitoring.

Immediately after surgery, patients are taken to an intensive care unit (ICU) where they are monitored closely for several days. Typically, patients stay in the ICU for two to three days, but this period may be extended if the liver function takes longer to return to normal or there are other complications post-surgery. During this time, the cancer care team checks for complications and assess liver function through regular blood tests.

Stable patients can gradually have their tubes removed and be transferred to a recovery unit. The hospital stay may last between one to three weeks, depending on recovery progress. The average length of stay after a liver transplant is 7-10 days.

During this time, as part of the recovery process:

• Patients begin reintroducing liquids and soft foods to their diet as bowel function returns.
• The large abdominal incision requires careful pain management — with IV pain relief gradually replaced by oral medication.
• The care team continues to monitor liver function through blood tests.
• Medications are adjusted as needed.
• Exercise tolerance is assessed.

Immunosuppressants

One of the most crucial aspects of post-transplant care is the use of immunosuppressant medications. These drugs are usually needed for life unless the patient develops operational tolerance, but this is quite rare. They usually start in the operating theatre and continue after the surgery.

The common initial regimen consists of a triple combination of immunosuppressants from these three classes:

• Corticosteroids - mimic hormones that regulate immune systems by suppressing inflammation and inhibiting certain immune responses
• Antimetabolite agents, a type of monoclonal antibody that disrupts the way cells use nutrients and build themselves.
• Calcineurin inhibitors - A class of drugs that prevents the immune system from overreacting or attacking the body’s own tissues. Also used to treat autoimmune diseases

Dosages are typically high during the first three months after surgery but are gradually reduced based on the individual's response. Although these medication adjustments are personalized, most patients usually reach a maintenance regimen within six months post-transplant.

These drugs prevent the immune system from attacking the new liver, which may be perceived as foreign. However, by suppressing the overall immune system, there is also an increased risk of tumor recurrence in patients who have a history of liver cancer. Therefore, finding the effective minimum dosage to prevent liver rejection while minimizing this risk is essential.

Immunosuppressive medications come with significant risks of drug interactions. Many common medications, including over-the-counter drugs, herbal supplements and prescription drugs, can interact with immunosuppressants. For this reason, it is essential for patients to consult their doctors before starting any medication.

Understanding the liver transplant process, potential complications and recovery expectations can help patients and their families to make informed decisions and feel more in control of their journey. Throughout this process, your medical team will be there to provide the care and guidance you need.