Advances in Living Donor Liver Transplantation

Podcast Transcript

Dr. Scott Steele: Butts & Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end. Hi again, everyone, and welcome to another episode of Butts & Guts. I'm your host, Scott Steele, president of main campus and colorectal surgeon here in the Cleveland Clinic in beautiful Cleveland, Ohio. And today I'm very pleased to talk about a topic we haven't talked about recently and that is living donor liver transplant. Going to focus on innovation, robotics in the future and I'm very pleased to welcome our expert, Dr. Alejandro Pita, who's the director of Living Donor Liver Transplantation in Cleveland Clinic's Transplant Center. Alejandro, welcome to Butts & Guts.

Dr. Alejandro Pita: Thank you so much for having me. Pleasure to be here.

Dr. Scott Steele: So we always like to start out a little bit about your background. So for our listeners, can you tell us a little bit about where you're from, where'd you train and how did it come to the point that you're here at the Cleveland Clinic?

Dr. Alejandro Pita: Absolutely. So I'm originally from Cuba. I was born and raised in Havana. I moved to the United States after finishing high school. I did both my undergraduate and medical training at the University of Miami, and then I headed to LA for general surgery training at USC. After that, I moved to Cleveland for my fellowship in abdominal transplantation and hepatobiliary surgery at the Cleveland Clinic. Then my family and I really fell in love with the city. We've been here ever since. Incredibly fortunate to practice as a liver transplant surgeon here at the Cleveland Clinic and be a part of such an outstanding institution.

Dr. Scott Steele: Well, we are super excited that you're here. And so let's start off this episode by explaining at a high level what a living donor liver transplant is and how is it different from getting a liver transplant, for example, from someone who is deceased? And what are the benefits to that?

Dr. Alejandro Pita: Living donor liver transplant is a procedure where a healthy person donates a portion of their liver to somebody who needs a transplant. This is different from a deceased donor transplant where the entire liver comes from somebody who has passed away and has chosen to be an organ donor. So there are many advantages to a living donation, but I would say the biggest advantage will be timing. Instead of waiting for months or sometimes even years on the deceased donor wait list, we are able to plan the transplant at a convenient time for both the donor and the recipient, oftentimes before a patient becomes critically ill.

So the ability to intervene earlier frequently leads to better outcomes, shorter hospital stays, improved long-term survival and also because the liver segment comes from a very carefully selected, healthy donor, the quality of the graft is consistently excellent, which really further contributes to better outcomes compared with deceased donor liver transplant. Living donation also expands the available organ supply, which reduces mortality in patients on the transplant waiting list.

Dr. Scott Steele: So what are some of the diseases that might lead to a liver transplant and what symptoms or tests indicate that a liver transplant is needed?

Dr. Alejandro Pita: Liver transplantation is most commonly needed for end-stage liver disease, which can result from conditions like bio-hepatitis, alcohol-related liver disease, non-alcoholic fatty liver disease, or also known as metabolic associated steatotic liver disease, things like autoimmune liver diseases, genetic disorders, or even different types of liver cancer. Recently, the indications for liver transplant have been expanding in certain areas such as transplant oncology, where transplant can be used to treat some other cancers that have metastasized to the liver, such as the case of cancers of the colon and the rectum, for example.

And some of the symptoms of end-stage liver disease usually include fatigue, jaundice, fluid buildup in the abdomen that oftentimes requires draining, confusion, GI bleeding, also sometimes severe itching. So we rely on a combination of symptoms and lab tests, imaging and scoring systems like the MELD score, which helps us quantify how sick the liver is and allow us to predict short-term survival without a transplant. I would say, however, liver disease can affect other organs in the body and even patients with low MELD scores can sometimes be in desperate in need of a liver transplant and that's another reason why living donation is so important, because it can help a whole lot of these patients with low MELD scores or with malignancies.

Dr. Scott Steele: So let's put this into a little bit of perspective. So how many liver transplants are typically needed per year in the United States? And how many, for that matter, are typically performed each year in the United States and are there enough donors to meet that demand?

Dr. Alejandro Pita: Yeah. Last year, more than 12,000 patients underwent liver transplant in the US. The annual number of transplants has been increasing by approximately a thousand every year. But despite the increase in number, the reality is that demand still far exceeds the supply and only a fraction of the thousands of patients that need a liver transplant actually end up receiving one. As a result, people continue to die on the waiting list every year and this is a big problem. And living donor liver transplant is one of the most effective ways of closing that gap and giving patients access to lifesaving surgery sooner rather than later.

Dr. Scott Steele: So Alejandro, with that many patients that are on the transplant list, and obviously we don't want to see any one of them pass while on that transplant list, what factors can basically impact qualifications to get on the list or the overall success for surgery?

Dr. Alejandro Pita: Eligibility for liver transplantation depends on several factors, most often including the severity of liver disease, other medical conditions, particularly cardiopulmonary comorbidities, nutritional status, physical status, social support and overall the patient's ability to tolerate a major surgery. So the success is also influenced by timing. So patients who undergo transplant before they become critically ill tend to do a lot better and that's one of the major advantages of living donation.

Dr. Scott Steele: So how long is the recovery period for both the donor as well as the recipient?

Dr. Alejandro Pita: I'd say for most donors, they're in the hospital for about four to seven days and many return to normal daily activities within four to eight weeks, depending on their job demands. Recipients usually spend about one to two weeks in the hospital, followed by several months of closed outpatient follow-up. Most recipients who undergo liver transplant are back to a good quality of life within three to six months or so, although recovery really varies by individual, especially about how sick they were prior to undergoing transplant.

Dr. Scott Steele: Okay. So I'm out there and I'm listening to this podcast and I say, "Maybe I want to be a living donor." So who can be a living liver donor? And what is the part of the evaluation process to become that living donor and how long can this take?

Dr. Alejandro Pita: That's a great question. Living donors are typically healthy adults who may be a family member of the recipient, also maybe a friend, someone from the community or altruistic donors, meaning a donor who wants to donate to somebody they don't even know just for the sake of helping somebody in need. So anyone between the ages 18 and 60 years old can be a potential donor in our program. The evaluation is very thorough and focuses first and foremost on the safety of the donor.

It typically includes blood tests, imaging, cardiac evaluation, psychological assessments and meetings with several people, including independent donor advocate. So this process typically takes about three to four weeks, but the timing of the transplant ultimately depends on both the donor and recipient factors. So as soon as both the donor and recipient evaluation have been completed and the recipient is waitlisted, the transplant can then proceed as a scheduled case.

Dr. Scott Steele: Does the donor have to be a living related donor or what does it mean for a donor to be a good match for the recipient? In other words, can a donor still proceed with donation if they're not a quote unquote appropriate match?

Dr. Alejandro Pita: Yeah, a good match typically means a compatible blood type, but it also involves other factors such as appropriate liver size, favorable anatomy, to ensure the safety really of both the donor and the recipient. So we encourage all potential donors to undergo an evaluation even if the blood type may not initially appear compatible, as there are sometimes ways to make living donations still possible. So if someone isn't a match for a specific recipient, they still may be able to donate through paired donation, which means donating to another recipient, allowing their loved one to receive a compatible liver from someone else.

Dr. Scott Steele: Truth or myth, truth or myth. After part of the liver is donated, the remaining liver naturally grows back to its original size?

Dr. Alejandro Pita: This is mostly truth, perhaps with an important nuance, but the liver is a remarkable organ and it has the ability to regenerate to normal size in both a donor and the recipient, usually growing to near its original size within six to eight weeks or so. However, unlike a lizard's tail after it falls off, the liver doesn't regrow back to its exact original shape. Instead, the remaining portion grows larger, restoring its mass and function. So both donor and recipient ultimately will have a full-size functioning liver.

Dr. Scott Steele: So walk me through, what can a patient expect when visiting you or someone on your team here at the Cleveland Clinic Liver Transplant Program? Can you walk us through a little bit about their journey? Who are they meeting with? What is this all about?

Dr. Alejandro Pita: Yeah. Initially, a potential donor will fill out a simple questionnaire on a Cleveland Clinic living donor website or calling our living donor office to state their interest in becoming a donor. Our living donor coordinator will then schedule a series of blood tests, imaging of the liver and cardiac testing if necessary. Typically, over the course of one to two weeks, the testing will be done and the donor will meet the hepatologist, the transplant surgeon, social workers and other members of the evaluation team and once the evaluation has been completed, the results are thoroughly reviewed and discussed among the team to ensure it will be safe for the donor to proceed with donation.

Dr. Scott Steele: So let's talk a little bit about the surgical options for the living donor liver transplantation. Are there minimally invasive approaches to this, and if so, what are the benefits of having that minimally invasive donation?

Dr. Alejandro Pita: Yeah, minimally invasive hepatectomy is an excellent option for a donor who wants to donate a portion of their liver. We use small incisions with laparoscopic or robotic assisted tools rather than a large open incision, which is still the standard for most living donor centers in the United States. At Cleveland Clinic, we have done all living donor surgeries using a minimally invasive approach since the end of 2019, initially through laparoscopic hepatectomy and then we transitioned to the robotic-assisted approach last year.

So there are many benefits, including smaller scars with improved cosmetic results, less postoperative pain, shorter hospital stay, which is typically around four to five days, lower risk of wound complications, such as infections or hernias, and a much quicker return to normal activities. Overall, minimally invasive donation prioritizes donor safety and comfort without compromising the success of the transplant.

Dr. Scott Steele: So now let's look at it at the other side. Can you talk a little bit about the robotic assisted transplantation? Is this an option for both the living donor and a deceased donor transplant? And if so, can you give us a little bit about the benefits of that transplant and how do you decide if it is indeed the best option?

Dr. Alejandro Pita: Absolutely. Robot-assisted transplantation is a very innovative cutting-edge approach to liver transplantation. So similarly to the living donor for very selected recipients, the fully robotic approach can be used to complete the liver transplant operation. So this is an option for both living donors and deceased donor recipients, but only a handful of centers in the US and very few programs in the world are currently used in this approach. So, fortunately, the Cleveland Clinic is one of those centers to offer this state-of-the-art modality in liver transplant recipients.

Although due to the complexity of the operation and certain recipient factors, not all recipients are considered appropriate candidates for the robotic approach. But for those who are potential candidates, the use of advanced robotic tools that are fully controlled by the transplant surgeon such as articulated instruments and 3D visualization with remarkable magnification really allow for the operation to be performed in a minimally invasive way. So the benefits, again, are similar to the donor, includes less tissue trauma, lower interoperative blood loss, much smaller incisions that do not divide muscle. So there is less postoperative pain, shorter hospital stay and faster recovery.

Dr. Scott Steele: That's fantastic. So let's take a look ahead into the future. So what's on the horizon as far as research into living donor liver transplantation that will essentially help provide better outcomes and quality of life for both donors as well as recipients?

Dr. Alejandro Pita: Yeah, it's really exciting to see what's coming in the future for living donor liver transplant. There's a lot of work being done in expanding access through national networks, such as donor registries and pair exchange programs to help donors and recipient find better matches. Regarding the surgical advances, particularly robotic assisted procedures, more and more centers in the US are gaining a lot of interest in incorporating some of these techniques, which will improve access and contribute to better outcomes in both donors and recipients.

Expanding the use of living donation in transplant oncology is increasingly providing lifesaving opportunities for many patients with primary and metastatic cancers to deliver such as colon cancer and there's a lot of research being done in that area. Also, artificial intelligence and machine learning are being used to improve transplant planning and decision-making, talking about things like predicting transplant viability or long-term outcomes and also the development of data-driven personalized care pathways with advanced computational models, which soon will be able to detect complications earlier and also provide avenues for optimal recovery.

Dr. Scott Steele: So now it's time for our quick hitters, a chance to get to know our guests a little bit better. So first of all, salt or sweet?

Dr. Alejandro Pita: Both. Maybe slightly more salt, but definitely both.

Dr. Scott Steele: Amen. What was your first car?

Dr. Alejandro Pita: My first car was a 2003 Subaru Baja.

Dr. Scott Steele: Fantastic. And if you had one ability to have a superpower of any kind, what would that superpower be?

Dr. Alejandro Pita: I would say teleporting. I think it would be amazing to travel the world without having to go through airports and deal with long flights.

Dr. Scott Steele: Yeah, that'd be fantastic. And finally, if you could go back in time, maybe to the time when you were about to enter medical school, what would be a piece of advice that you would give to yourself?

Dr. Alejandro Pita: Yeah, I would say don't be shy to challenge the way things have always been done. Have the courage to do things differently, take smart risks and the future may open doors to new things that you can't even see yet.

Dr. Scott Steele: That's fantastic. So give us a final take-home message for our listeners regarding this living donor liver transplant.

Dr. Alejandro Pita: Living donation is really a remarkable gift. It's a gift of hope. So with today's surgical advances, living donors can safely give a piece of themselves, and with that, they can change somebody's life forever.

Dr. Scott Steele: Fantastic. So for more information on Cleveland Clinic's Living Donor Liver Transplant Program, please visit clevelandclinic.org/livingdonation. That's clevelandclinic.org/livingdonation. You can also call the program at 216.444.1976. That's 216.444.1976. Dr. Pita, thanks so much for joining us on Butts & Guts.

Dr. Alejandro Pita: Thank you so much for having me.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.