New Laparoscopic Procedure for Live Donor Liver Transplant Makes Donation Easier

It wasn’t until after his liver transplant that Felix Pon’s personality began to shine. His rare liver disease left him bright yellow, itchy, depleted, and hardly able to smile. He’s making up for it today by greeting everyone he meets with a wide grin and a happy hello.

“It was like a veil was lifted after his liver transplant. His good-natured, friendly personality came out,” says his mom, Katie Gilmer Pon.

Felix is special in that he is the first infant to receive a live-donor liver transplant with an organ that was removed laparoscopically from an adult donor. Stanford Medicine Children’s Health is the first hospital to perform the procedure on the West Coast. Katie gave up a small segment of her liver to save her son.

“The surgery was successful beyond our wildest dreams,” says Andrew Bonham, MD, surgical director of the Live Donor Liver Transplant Program and Pediatric Intestinal Transplant Program at Stanford Children’s Health and associate professor of surgery at Stanford Medicine. “We’re used to complications in liver surgeries, so I’m quite happy this went off without a hitch.”

The advantage of the laparoscopic procedure is that donors spend less time in the hospital, recover more quickly with less pain, and avoid the scarring of a major open surgery. It demands six small incisions instead of one large incision, which the usual open surgery requires. Katie was well enough to visit Felix at his bedside the day after the surgery.

“Laparoscopic living donor surgeries are common in Korea and other Far East countries, but in the United States, only a handful of medical centers perform the procedure, which is complex and technically challenging,” says Kazunari Sasaki, MD, a clinical associate professor of surgery and new member of the liver transplant team.

Dr. Sasaki was recruited to Stanford because of his extensive experience with laparoscopic donor organ retrieval, which requires two surgeons to ensure patient safety. Stanford Children’s Health has been performing live donor transplants for more than 20 years. Having a minimally invasive option for potential donors is exciting.

Felix was born with biliary atresia, a rare liver disease that affects tubes in the liver called bile ducts. It often leads to liver damage and liver cirrhosis, which can be fatal if not treated. Biliary atresia is the most common reason for liver transplants in infants. It causes jaundice, a buildup of bilirubin, which is the yellow substance that normally passes through the liver. Jaundice causes yellow eyes and yellow, itchy skin.

“A few days before his 1-month wellness appointment, Katie noticed that his eyes looked yellow. She brought it up with the pediatrician, and Felix had a Kasai procedure the next week,” says Evan Pon, Felix’s dad.

Felix received the Kasai procedure at his local hospital in Portland, Oregon. A part of his intestine was brought up to the liver to create a channel for bile to escape. The Kasai is usually the first treatment for babies with biliary atresia.

“We knew the Kasai probably wouldn’t work long term and that he would need a liver transplant. But the living donor procedure is daunting to think about. We had to talk ourselves into it, but once we did, there was relief and we wanted to move forward,” Evan adds.

Felix was sick, but not sick enough to be high on the transplant list. Nationally, the average wait time for a liver transplant is 8.7 months, according to figures from the United Network for Organ Sharing. Stanford Children’s Health, which has one of the busiest liver transplant programs in the country, has a better record, with an average wait time of 2.8 months.

“With a living donor, the procedure can be planned when the recipient is not seriously ill and thus more likely to do well,” Dr. Bonham says. “The liver is the only organ that can regenerate, with donors fully recovering within about six weeks. But living donors still face risks.”

The family chose the living donor option because Felix was low to medium on the donor wait list, which could have meant a longer wait for him and a higher potential for dangerous complications as time went on. First, Evan was evaluated as a living donor, but he was not a good match. That left Katie, who didn’t hesitate.

On the day of the procedure, the surgical team—including three physicians, two anesthesiologists, and specialized nurses—gathered in an operating room to retrieve a portion of Katie’s liver. To perform the laparoscopic living liver donor surgery, they inserted surgical tools with a tiny light and camera attached. The camera provides a three-dimensional view of the donor’s anatomy, making it easier for the physicians to navigate inside.

“The use of a 3-D camera in laparoscopy speeds up the operation and produces better results,” Dr. Sasaki says.

Dr. Bonham has performed many laparoscopic surgeries on patients with liver tumors and cysts, but operating on a person with a healthy liver presents unique challenges. You have to maintain blood flow to keep the donor’s liver alive, so the blood vessels must be preserved. In the end, the surgeons removed just 15 percent of Katie’s liver, extracting the tissue through a 3.5-inch skin incision along her bikini line.

The fresh organ was flushed with preservative, placed in a bucket of ice, and delivered to a neighboring operating room where baby Felix was waiting. A separate team of surgeons, led by Carlos Esquivel, MD, PhD, director of the Pediatric Liver Transplant Program, and Amy Gallo, MD, surgical director of the Pediatric Kidney Transplant Program, sewed the liver in place. They watched it come to life, as it turned a healthy pink and began producing bile.

The couple chose Stanford Children’s Health because of its reputation, and also because Evan’s parents live in nearby Sunnyvale, making it convenient. They also appreciate that the Liver Transplant Program has an outreach program in Portland, one of several locations in the West. That means Felix can receive follow-up care close to home throughout his life.

“We felt good about choosing Stanford. We knew we would get great care,” Evan says. “We were impressed by all of the doctors and nurses.”

Within a few weeks, Katie’s pain subsided. For the first month she felt sapped of energy as her liver regrew to its original volume. Having help from family who served as caregivers for Katie, Felix, and his older brother, Kieran, was necessary and appreciated. It’s been three months since the transplant, and both mom and baby are fully recovered.

“Felix’s liver numbers are great. He’s coming off of some immune suppression medicines, and he’s gaining weight and hitting milestones,” Katie says.

Dr. Bonham hopes the prospect of a laparoscopic procedure will be an incentive for more people to donate liver tissue. People are back to normal fairly quickly, with minimal scars and, most important, with the satisfaction that they gave a child a chance at a full life.