REBECCA THOMAS, FORTE, BANGALORE

When four of the seven listed pediatric patients waiting for liver transplant died at St. John’s Bangalore, it became obvious that for children different strategies would have to be adopted. One patient Deepika’s parents were desperate enough to try living donor transplant, but the string of widely publicised failures of liver transplant at other centres in India was a major concern. Earlier, Dr. Mohamed Rehman, anaesthesiologist and intensivists at the St. Christopher’s Hospital Philadelphia had at a conference in Bangalore in 1997 met Dr. Philip Thomas and described their experience of starting the living donor liver transplant program in Bolivia. He was willing to organise a visit by the same team to Bangalore.  When told about Deepika in mid 1998, Dr. Rehman started organising the trip for late January 1999, and in order to maximise the benefit of the venture offered to perform three transplants over a seven day period in Bangalore.  

Even while preparing for the visit (Medical Council permission, Govt. of India clearance, raising funds etc.) the hunt for two more patients started. In keeping with the ethos of St. John’s as a teaching institution, a workshop cum CME was planned. All major centres trying to start liver transplant in India were invited to refer patients, also to come and watch the procedure and interact with the team. St. Christopher’s have the best results with pediatric liver transplants in the USA at this time, and the visiting team included anaesthetists, intensive care nurses, and a coordinator, apart from the surgeons Dr. Steven Dunn and  Dr. Adela Casas.

There was no response from other centres. In late December, St. John’s advertised in the national newspapers in an effort to directly contact waiting patients. They were four immediate responses and of them one came through with the Chinna family from Pune deciding to come for transplant.

Both Deepika Ram (age 2 yrs and 6m), and Reuel Chinna (1 yr and 10m), were suffering from biliary atresia. Apart from deep jaundice and intractable itching both had ascites, GI bleeding, and were underweight with anaemia and Hypoproteinemia. Both mothers had blood groups identical to their children and were willing to donate. The transplants were done on the 7^th and 8^th of February 1999, with the Philadelphia team doing the first and assisting at the second, Dr. Philip Thomas and Dr. Ashley D ‘Cruz were the surgeons from St. John’s.  

The mothers Shalini Ram and Diana Joel went through hepatectomy smoothly, and by the second day were out of bed and helping to look after their babies! Both children required re- exploration once – Deepika for bile leak and Reuel for a positive drain and blood culture. They rapidly recovered after this. Reuel was discharged in the fourth week. Deepika had problems with high blood pressure, mild rejection, urinary infection, and CMV reactivation. She was discharged in the fifth week after operation with a normal LFT. Both families are very happy they took their chance with liver transplant. The difference they see in their children sleeping peacefully through the night for the first time in their lives free of jaundice and itching, is very gratifying.  Both are already displaying aspects of their nature the parents never knew existed. Deepika has an extensive vocabulary and is waiting to go school. (The school she plans to attend had contributed money for her transplant). Reuel has started walking for the first time. He has returned to Pune last week.

The operation and one month post-operative costs worked out to about Rs. 3.5 lakhs with several subsidies courtesy St. John’s administration and donors from USA and India. Both families have the prospect of expensive medication and monitoring ahead, but are looking forward in hope. Deepika and Reuel and their mothers who took such a courageous step have opened a new horizon for children with biliary atresia in India.