Child liver transplant: A medical first in Lanka
Colombo North Teaching Hospital (CNTH), Ragama, carries out first successful liver transplant in Sri Lanka for a child from a living donor
Nail- biting tension, for they were pushed to the edge by worry. There was, however, simply no time for emotion, for riveted was the multi-disciplinary team’s focus on the slip of a girl, just nine years old, on the operating table before them.
Her tender life was in their hands and it was “touch-and-go” at a crucial point not only during the marathon trailblazing surgery but also on Day 0 soon after the operation.
On Wednesday (July 22) though when the Sunday Times meets some of the team members for a three- hour wide-ranging interview, they are relaxed and smiling, joking how their first proper meal after the 15-hour marathon was bread, parippu (dhal) and seeni sambol, while the little one, when allowed food firstly savoured a chocolate biscuit.
……… And in another section, wide are the smiles of a mother who hugs her daughter whose bed in the ICU is festooned with balloons with a large teddy bear at her feet, while far away in the northern peninsula, the other members of this humble family – a father and son – are overjoyed.
The first successful liver transplant for a child and that too from a living donor has been performed in Sri Lanka on July 14 at the Colombo North Teaching Hospital (CNTH), Ragama, without much fanfare but overcoming many a challenge.
The child-recipient is S. Kishanu and it is her own mother S. Rasika (38) who donated part of her liver to pull her back from the jaws of death.
As the CNTH Organ Transplant Team looks ahead at ensuring a sustainable transplant programme for adults and children, it is a double celebration in their journey – the successful paediatric liver transplant is a major milestone, as coincidentally they mark their 50th transplant.
The pathway to both cadaveric and living-donor transplants had been charted by visionaries such as Prof. Janaka de Silva, Prof. Kemal Deen and Prof. Ranil Fernando of the Faculty of Medicine, University of Kelaniya, back in the late 1990s. Strewn with ups and downs, the programme had finally got on course in 2011.
The July 14 paediatric liver transplant has been ‘unique’ in more ways than one – for wide and varied have been the unstinting support the transplant team got from their hospital under the leadership of Director Dr. Shelton Perera; other hospitals and donors. Surgical instruments and anaesthetic equipment had been collected from within the hospital and borrowed from without.
The team refers with much appreciation to Hemas Hospital, Wattala, the management of which without any hesitation acceded to a request to give one of their precious ICU beds for eight long days, without charging a cent and seeking “nothing” in return.
Then there were also three doctors, seeing the plight of this family from Jaffna, with no kith and kin network at Ragama, who used their good offices to collect Rs. 600,000 for them to rent a small place close to the hospital and also for the “unseen” costs of their travel, food, clothes, medicines and some laboratory tests that needed to be done from outside.
For the children and parents of Sri Lanka, no news can be better. Before the red-letter day of July 14, if a child was diagnosed with end-stage liver disease, the only option was for the parents to go around with a begging bowl and sell whatever of value they had to collect the huge sum of money needed to take the child abroad or heartrendingly watch the child die.
The tale of this paediatric liver transplant begins when Kishanu “on a chance” was referred to Consultant HepatoPancreato-Biliary Surgeon Prof. Rohan Siriwardana, two months ago by the Jaffna Teaching Hospital (JTH). Late last year, the family had gone to JTH as Kishanu was not gaining weight. A battery of tests found that she had a serious issue with her liver.
Dr. V. Thusyanthan and Dr. K. Arulmoli of the JTH who had trained at the CNTH and were aware of the adult liver transplant programme had approached their Director and suggested that Kishanu be sent to the CNTH.
When faced by the hopelessness of the family, Prof. Siriwardana had sought an assessment from Consultant Paediatrician Dr. Meranthi Fernando.
“I assessed Kishanu’s liver condition – whether she could undergo a transplant; whether there were any contraindications and complications against such a transplant and whether the child was stable for such major surgery,” says Dr. Fernando.
The cause of her chronic liver disease was probably due to metabolic liver disease. In many cases, the cause may never be determined, it is understood, and the team is awaiting test results to see whether there is a genetic factor involved.
What was heartbreakingly clear to Dr. Fernando was that the child was critically ill, showing signs of progressive deterioration. Her abdomen was distended due to fluid collection and the yellowing of her eyes had deepened. She had lost her appetite and there was nutritional deficiency. The vital functions of the liver which included albumin synthesis and blood-clotting regulation were hindered.
“There was no doubt that Kishanu was dying,” she says and the only option was a transplant.
The decision was then made by Prof. Siriwardana to go ahead with the transplant and the team got activated. Even though they had not done a paediatric transplant before – it was a first for them – they had skill and experience in adult living donor transplants. They also had on board Dr. Meranthi Fernando who had a special interest and training in liver disease and liver transplantation in children and had just returned from the United Kingdom and Consultant HepatoPancreato-Biliary Surgeon Dr. Suchintha Tillakaratne who had trained in both paediatric and adult transplantation.
They told Kishanu’s parents the truth – that the team had not attempted such a transplant before and that the child could die despite their best efforts. The parents were willing to take the risk because the child was going to die anyway without a transplant.
Would it be a liver from a cadaver or a living donor? Kishanu’s mother was healthy and seemed to fit the bill as a donor and she was more than happy to donate part of her liver to her beloved daughter.
The blood groups and liver size matched but to be on the safe side in case something went wrong, the team looked for a “backup” and found another matching liver in Kishanu’s aunt ( mother’s sister), V. Sumithra (40).
Permission was also sought and granted by the Director- General of Health Services, Dr. Anil Jasinghe to go ahead.
It was like a military-style operation….. going through scenarios of before-and-after transplant and fine-tuning the details.
“We rehearsed for two days before the transplant, going into meticulous detail of where each instrument and monitoring machine would be kept, how the lights would be and where each person on the team would be positioned,” smiles Prof. Siriwardana, explaining that they photographed everything as well.
Consultant Anaesthetist Dr. Bhaagya Gunetilleke points out that as the biggest danger to a transplant patient comes from infection, the operating theatres were swabbed and all the instruments sterilized thoroughly.
“The post-operative period is crucial and we don’t have a dedicated ICU for transplant patients. Possible infection in the six-bed ICU at the hospital could cause deadly consequences. This is why we sought the assistance of Hemas Hospital,” he adds.
We see Kishanu on Wednesday (July 22) back at CNTH – her beautiful smile, the gift for all those involved in this pioneering transplantation.
(Please see related stories on the transplantation procedure on our website
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