Medanta Press Release

Press Release: January 17 , 2012

World’s First Liver Transplant Chain saves 3 children:
Medanta Liver Team creates history by performing “Swap and Domino Liver Transplant” operations simultaneously


They could only survive if 6 operations – 3 on the dying children, 2 on their family donors and 1 bench surgery - were all done simultaneously in 6 Operation theatres.
Against all odds, the surgeons toiled non-stop for 20 hours and accomplished the feat on 25 Dec – Christmas Eve, 2011………..
Dr A.S. Soin, Chief Liver Transplant surgeon led the team of surgeons, that pulled off the most intricate chain of liver operations.
Dr Neelam Mohan, Chief Pediatric Hepatologist, led the team of physicians for these challenging cases management.
Only a month ago, toddlers Tejasree, Anees and Ansa were 3 strangers united by the common destiny for need of liver transplant to survive. None of them had any suitable donors within the family for liver transplantation. While Anees had no donor at all, Tejasree and Ansa had mismatched donors. However, the Medanta Liver Transplant Team, in a historical feat, conducted a chain of liver transplant operations on the 3 kids simultaneously on Christmas Day last year and saved their lives. These are the most complex transplants undertaken so far by the team.
According to Dr. A.S. Soin, Chairman and Chief Surgeon of the Medanta Liver Institute, who led the team, all the 3 kids were registered in Medanta’s alternative liver donor program. In this unique program, database is maintained of recipients who do not have matching family
donors. “ They are given innovative options such as swap or donor liver exchange, domino, which is the use of liver removed from one transplantee to transplant another; cadaveric donor, split liver and ABO-incompatible donor organs ,as and when they become available”, explained Soin.
Elaborating on the medical condition of the kids, Dr Neelam Mohan, Director of Pediatric Gastroenterology and Hepatology, said that 3 year old Tejasree was suffering from a rare metabolic disorder called Maple Syrup urine Disease that resulted in accumulation of certain amino acids (end products of protein) in her body and causing recurrent toxicity to the brain. This happened as she lacked the enzyme that detoxifies these. Normally, this enzyme is present in many tissues of the body including the liver. A new liver would give Tejasree enough enzyme to cure the problem. Also, since her own liver was otherwise normal, it could in turn be used to save some other child who needed a transplant for a different reason. Two year old Ansa and one year old Anees were the other two children in the chain. Both were suffering from biliary atresia and liver failure which would have been fatal. While Tejasree and Ansa had mismatched family donors, Anees did not have any suitable donor. “After preliminary tests, we realized that if Tejasree and Ansa exchanged their donor livers, and Tejasree’s liver in turn went to Anees, we could pull it off and save all three, exclaimed Dr Mohan.
Recounting the challenges and the scene of the surgery, Dr Soin said, “We were essentially confronted with daunting task of carrying out this chain of 6 liver operations, each linked to another, all at the same time. This needed complex liver surgery, coordinated between 6 operating rooms with clockwork precision sustained over 20 hours – something that had never been previously accomplished. We planned it quite like a rocket launch – with prior allocation of time- and target-bound responsibilities to the individual team members. We were constrained by Tejasree, since we did not want her to be fasting for too long before the new liver was put in her as this could precipitate neurological crisis in view of her MSUD status. We first started with Tejasree, her donor and Anees’s operations. Once we made the requisite progress, Ansa’s and her donor’s surgeries started another 1 and 2 hours later. While Tejasree was receiving her transplant, her own liver was removed and taken to the 6th OT for bench surgery to make it suitable for transplant.
Eventually, after 22 fine joints (anastomoses) between blood vessels and bile ducts (normal liver transplant has 4-5), and several dashes and phone calls between the 6 OTs, all operations were accomplished successfully, just before midnight. The rocket had been successfully launched and Santa managed to give the kids their Christmas gifts just in the nick of time, said the emotional Dr. Soin.
Dr Vijay Vohra, Chairman of Liver Anesthesia and Critical Care, said that during this long surgery, maintaining the right balance and dose of 8-10 intravenous medicines and monitoring nearly 30 vital blood parameters is a challenge in any small child. Since all 3 kids were 10-12 kg in weight, the chain operation was challenging thrice as much.
Commenting on the patients’ recovery, Dr Neelam Mohan said, “Postoperatively, the care in the first week for the three children was extremely challenging. Fortunately all three transplanted livers were taken up well by their recipients, and all 5 patients – 3 recipients and 2 donors made an excellent recovery”. Thanks to their special bond, the 3 families have now united into a single big happy family, as they see visions of their little ones growing into happy adults, she said.
Congratulating the parents and the liver team on the successful chain of liver transplants, Dr Naresh Trehan, Chairman and Managing Director, Medanta-The Medicity, said that this achievement is the result of a rare amalgam of world class medical expertise, infrastructure, equipment, blood bank and lab support, thus setting a new global benchmark in multidisciplinary tertiary care.
The Medanta Liver Institute