India’s First Three-way Swap Liver Transplant At Medanta Saves Three Lives

In a rare feat, the Medanta Liver Transplant Team successfully performed the country’s first three-way liver transplant swap, or paired exchange, in which three patients suffering from terminal liver disease simultaneously received life-saving liver transplants. The lead surgeons for the three transplants were Dr AS Soin, Dr Amit Rastogi and Dr Prashant Bhangui, respectively. 

This three-way swap is a tale of how three complete strangers, Sanjeev Kapoor, a businessman from Madhya Pradesh, Saurabh Gupta, a businessman from Uttar Pradesh, and Aadesh Kaur, a homemaker from Delhi, shared common destinies. They were all ill with terminal liver failure, each needing an urgent liver transplant to survive but too unwell to wait for an organ on the deceased donor list which could have taken up to a year. The three patients had willing liver donors within their families, but none were a suitable match. They had all given up hope till the Medanta Liver Transplant Team planned this never-before simultaneous swap surgery that gave all three another shot at life. 

Medanta’s Chief Liver Transplant Surgeon, Dr Arvinder Soin, who led this formidable team effort, said, “We introduced the concept of living donor organ swap (or paired exchange) between two recipient and donor pairs in 2009. Such exchanges help save lives of recipients whose relatives, despite being medically fit, are unable to donate due to blood group and/or liver size incompatibility. After performing 46 such two-way swaps (92 transplants) over the past 13 years, we have now successfully expanded the concept to a three-way swap chain involving three donor-recipient pairs."

These three transplants were performed simultaneously by operating on three donors and three recipients. A team of 55 doctors and nurses worked together in six operating rooms for over 12 hours to complete this Herculean task. While Sanjeev’s donor (his wife) was blood group compatible, her partial liver would have been too small for him. On the other hand, Saurabh’s donor (his wife) and Aadesh’s donor (her son) were both blood group incompatible. The paired exchange was planned in a way that all three patients received an adequate volume of a blood group compatible liver, Dr Soin stated.

Speaking to BW Healthcare World Dr Soin highlighting the government's role said that the government needs to relook at some rules of its Human Organ Donation Transplant Act which prohibits anyone other than a family member from becoming a swapping donor, "I believe that this can at least be expanded to the extended family like cousins. And the second says that Indian and foreign nationals cannot participate in the same swap operation, modifications in these parts of the law will certainly increase the donor pool and save more lives." he said.

Dr Soin added that in theory, this chain can be extended to four, five or even more donor-recipient pairs. Owing to logistic challenges of performing so many liver transplants simultaneously in one center, we are now developing protocols to collaborate and accomplish longer chains of liver exchange at 2 or 3 different centres within the same city. 

Dr Soin explained "Hospitals will need to agree on common protocols, we are planning to partner with 4-5 large hospitals which have a certain degree of experience, a certain number of surgeons, standards, equipment and clinical expertise. We have already started putting forward proposals to many hospitals and going forward these hospitals will be partnering with us."

Performing three liver transplants means six simultaneous liver surgeries. This is a mammoth undertaking requiring many skilled surgeons, enough trained staff and operating rooms, and a fair exchange in which all donors have equally safe surgeries. It also requires all recipients to be well matched for their severity of illness, and have equally good, expected outcomes. No wonder, this procedure has never been done before. Our success will now pave the way for increasing the living donor pool in future with more such paired exchange transplants, enumerated Dr Amit Rastogi, senior liver transplant surgeon at Medanta.

Explaining why the three transplants (six operations) were done simultaneously, senior transplant surgeon at Medanta Dr Prashant Bhangui said, “These operations are complex, and need all donors and patients to be optimally prepared for surgery, both medically and psychologically. If the transplants are done on successive days, there is a small possibility that one of the donors may back out of donation the next day once their family member has already received the exchange donation the previous day. Also, one of the recipients may become unfit for surgery the next day as these patients is sometimes quite critically ill before transplant.” 

Dr Neeraj Saraf, Senior Director of Hepatology at Medanta, explained that while Sanjeev and Aadesh were both suffering from advanced liver failure with deep jaundice, water accumulation and repeated episodes of coma-like state, Saurabh had advanced liver cancer. “We thought we would lose them all as none of their donors was suitable to donate to their loved ones. All the families saw a glimmer of hope when we planned the three-way swap. However, it was a big challenge to control their infections and other complications, like kidney dysfunction, so that they could all be medically fit for surgery on the same day,” Dr Saraf said. 

Medanta’s Dr Nikunj Gupta, who headed the anaesthesia team, said that smooth anaesthesia is vital for the success of any liver transplant. “To ensure the highest level of anaesthetic care to all six donors and recipients, we meticulously planned the staffing, timing and sequence of events with a dummy run the previous day. On the day of surgery, everything went like clockwork, with 2-3 members of our team in each operating room, ensuring optimal fluid, respiratory and drug management during surgery,” he said.

Congratulating the Liver Team, Dr Naresh Trehan, Chairman and Managing Director, Medanta, said, “This historic achievement has been made possible by the close multidisciplinary effort of various senior superspecialists, and strict treatment and operating protocols being practised at Medanta. After this pioneering effort, we now plan to expand our paired exchange programmes for liver and kidney further so we can offer life-saving transplants to more and more people.”