By future medicine
The girl is also one of the youngest to undergo portal vein stenting
Doctors from VPS Lakeshore Hospital, Kochi, have recently carried out a successful liver transplant surgery on a six-month-old baby girl from Lakshadweep. The baby had been suffering from biliary atresia which demanded an early liver transplant.
The surgery was performed by the Comprehensive Liver Care team of VPS Lakeshore amid several hurdles, including the COVID-19 pandemic and travel restrictions from Lakshadweep. The child’s mother was the donor, and the baby is one of the youngest to undergo a liver
transplant in Kerala.
The baby had symptoms of jaundice, including yellow eyes and dark urine, shortly after her birth, and was diagnosed with biliary atresia.
Biliary atresia is a congenital condition that occurs when the bile ducts inside or outside the liver do not develop normally.
This causes blockage in the tubes (ducts) that carry bile from the liver to the gallbladder. Biliary atresia is found in almost 1 in 70,000 newborns. Children with biliary atresia will have jaundice right from birth and it does not clear.
“Jaundice in children is quite common. Out of every 10 children born, 1 child will have jaundice. There may be many reasons for these children to have jaundice. But most of the time, the jaundice will clear within two weeks after birth. But some of these children, like those who have got biliary atresia and other problems of the liver, will continue to have it. This will require a paediatric liver expert to make a proper and early diagnosis so as to provide necessary intervention,” says Dr Abhishek Yadav, Chief Liver Transplant Surgeon and Director of Comprehensive Liver Care Institute, VPS Lakeshore Hospital.
Apart from liver transplantation, the Kasai procedure is another surgery that can be done for such children. But a Kasai surgery should be done within 60 days of the child’s birth. If it is extended beyond 60 days, the results will not be good. Even if it is done within 60 days, the success rate of this operation is only 30-40%. “So, if we are doing it in 100 children, only 30 operations will be successful, and the rest will eventually require a liver transplant,” said Dr Yadav.
The child had already undergone a Kasai procedure at around 46 days of age at a different hospital. But even after the operation, the child did not recover completely. Her jaundice was persistent, and she had water retention in her abdomen. The baby was underdeveloped, her body weighed only 5.5 kg at 6 months of age (at which age, it normally should be 8 or 9 kgs). The child also had infections in the blood because the body’s immunity was being compromised. As her condition was worsening rapidly due to recurrent infections, an expedited liver transplantation was the only possible cure for her.
Liver transplants in babies are a challenging and difficult procedure, especially in babies who are so small. In addition, there were additional hurdles that these surgeons had to overcome.
The first hurdle was the very small and undeveloped portal vein – the main blood supply to the liver. The team overcame this problem by modifying a stent originally designed for stenting neck vessels in adults and placed it inside the child’s portal vein during the surgery. The second problem was a variation in the hepatic veins of the mother, which was overcome by using a piece of blood vessel harvested from a brain-dead donor at Trivandrum.
Though rejection is common in adults after transplantation, the chances of rejection are much less in children, especially in case the liver is taken from a parent.
“These children, who have a liver transplant, would have to take immunosuppressants for a period of 3 years. Generally, after 2-3 years, we can reduce the use of immunosuppressants, and I will say about 30-40% of our paediatric patients who had transplantation can be off immunosuppressants or at a very low dose of immunosuppression after 5 years. Some 40-50% of them can completely stop immunosuppressants after this period, especially in children who receive organs from their parents, because of the similar genetic composition,” adds Dr Yadav.
The child would have a completely normal life from then on. If the transplant is done in adults because of liver cirrhosis, or hepatitis B or hepatitis C infection, and the infection comes back subsequently, the new liver gets affected, the condition gets more complicated and impacts the survival rate.
”But in children with conditions like biliary atresia, serious complications like organ rejection are rare and can be managed if they occur,” says Dr Yadav.
The child may also be one of the smallest to undergo a portal vein stenting, a procedure which is only available in 2 or 3 centres across the country. VPS Lakeshore hospital also claims to be one of the few centres in the world to have a success rate of over 90% in paediatric liver transplantation. So far, nearly 30 children have undergone such transplants in the hospital.
Along with Dr Yadav, Dr Navaneethan Subrahmanian, Dr Fadal Veerankutty, Dr Dharav Kheradia, Dr Nita George and a team of over 25 doctors and support staff from the departments of critical care, paediatrics, GI surgery, gastroenterology, radiology were involved in the care of the baby. Both the child and mother are reportedly doing well after discharge from the hospital.
Tags: case study, Dr. Abhishek yadav, Kochi VPS, Lakeshore Hospital