Building a Liver Transplant Programme in a Resource-Constrained Setting

The first check is whether the background liver is cirrhotic or, from vertical hepatitis B or C transmission, essentially normal; a normal liver allows extended resection with portal vein embolisation to grow the future remnant. On a cirrhotic background, the priority is ruling out disease outside the liver, then grading any portal vein invasion from VP1 (a segmental branch) to VP4 (the main portal vein). Patients with VP1 or VP2 involvement and no extrahepatic disease can still be offered transplant, upfront or after downstaging with TACE, sometimes combined with SBRT for a portal vein tumour thrombus, aiming for 12 weeks of stable disease.

Non-cirrhotic HCC is uncommon in Dr. George's own caseload, around 5 patients in every 100 he sees, but for exactly this group his unit is far more aggressive: extended resections, portal vein embolisation, and even ALPPS, a staged hepatectomy, are all options, because a normal liver can lose as much as 80 percent of its volume and still regenerate enough function from what remains.

HCC has a characteristic imaging signature, so biopsy is reserved for genuine diagnostic dilemmas. An arterially enhancing lesion with venous washout on a properly phased triphasic CT is treated as diagnostic in around 95 percent of cases; MRI is used when the CT is inconclusive. Around 40 percent of HCC patients have an elevated AFP, meaning 60 percent do not, so diagnosis relies on radiology rather than tumour markers.

No. Dr. George has operated on perihilar cholangiocarcinoma patients with bilirubin as high as 30 to 35. Surgical practice has also evolved: where extended resections once left only the left lateral section or right posterior sector achievable, his unit now more often does a left- or right-with-caudate resection with extended bile duct resection, preserving more liver parenchyma. Preoperative biliary drainage, usually percutaneous (PTBD) rather than endoscopic nasobiliary drainage, is reserved for patients with cholangitis or those planned for portal vein embolisation.

Alpha-fetoprotein is the marker primarily elevated in hepatocellular carcinoma. CA19-9 comes primarily from the biliary system and can rise somewhat in cirrhotic patients, but not to a high degree, so it remains the more specific marker for cholangiocarcinoma.

Even within India, transplant remains rare in the government hospital system, offered at only a handful of centres. Growth in capacity has come almost entirely from the private sector, reflecting that government health systems often have other, more urgent priorities that require less infrastructure and cost to address first.

Transplant has historically been a surgeon-driven undertaking, but radiology, anaesthesia, critical care and hepatology can just as easily become the bottleneck if they are not equally invested. Building a programme requires all of these specialties to be committed to offering the service, not just the surgical team.

A programme needs a strong interventional radiology service, CT and MRI capable of proper phasic imaging, and an apheresis machine for ABO-incompatible transplants, alongside full institutional backing, since transplant demands far more time and effort than routine gastrointestinal or hepatobiliary surgery.

The first seven patients in India's early transplant programme did not survive. Today, mortality is treated as an unexpected event rather than a norm. Roughly 5 to 7 patients in every 100 transplants may not survive, but the large majority go home, a shift attributed to skill transfer and institutional patience rather than a lower bar for acceptable outcomes.