Liver Transplant Center

Kaohsiung Chang Gung Memorial Hospital

Chao-Long Chen, Superintendent

The first liver transplantation in Taiwan was performed on March 23, 1984 at the Linkou Chang Gung Memorial Hospital. This case was the first successful liver transplant (extended survival) in Asia. This was also the first case of organ procurement from a brain-dead cadaver donor at a time when brain death was not yet approved in Taiwan. This event stimulated extensive discussion and debate in the medical community until a consensus was finally reached when the Medical Association of the Republic of China issued a statement recognizing brain death as death in October of the same year. Thereafter, the Human Organ Transplant Act was passed in Congress in 1987 and Taiwan became the first nation in Asia to legalize brain death.

Chang Gung Memorial Hospital has caught the attention of neighboring countries on the achievement of liver transplantation. Dr. Hideo Kawarasaki of the University of Tokyo and I conceived of the possibility of liver transplantation from a live donor in 1988 when living donor liver transplantation had not yet become a clinical reality. We then decided to collaborate in setting up an animal model and the transplant team of the University of Tokyo visited our hospital for six times in 1988-89 to work on this project. This cooperation facilitated the clinical development of living donor liver transplantation in both University of Tokyo and Chang Gung Memorial Hospital. In 1990, Professor Masatoshi Makuuchi of National Shinshu University invited me to supervise their first living donor liver transplant operation. The patient became the longest surviving liver transplant patient in Japan.

Sufficient support and collaboration from related disciplines are necessary to successfully carry out liver transplantation. Consequently, the development of a liver transplant program can bring along progress in related disciplines. During liver transplantation surgery, venous return flow to the heart from the inferior vena cava is interrupted when the entire liver is removed brought about by crossclamping of the inferior vena cava. In the so-called “anhepatic phase”, causes drastic changes in hemodynamics and metabolism, creating unprecedented challenges for anesthesiologists. These new problems and challenges in anesthetic management in a complex operation such as liver transplantation have provided the impetus for enhancing technology in anesthesiology. Another indispensable service is diagnostic radiology. Liver transplantation, especially living donor liver transplantation, is a highly sophisticated operation, which requires precision in liver imaging including demonstration of vascular and biliary branching patterns and volume measurements. The development of liver transplantation, therefore, demands the production of high-quality images that allow accurate interpretation. Moreover, liver transplantation also brings about unique pathological changes in the human body due to rejection, infection, etc., so that new issues and challenges in differential diagnoses are created for pathologists. All these phenomena associated with transplantation serve as stimuli to bring about advancement in research and service in medical science. For these reasons liver transplantation must be developed in the setting of a medical center to allow specialists from related disciplines to fully develop in an environment of healthy interaction in working together to achieve a common goal.

The liver transplantation program initiated in Linkou and Keelung was later moved to Kaohsiung where it benefited from the addition of new members to the team: surgeon Yaw-Sen Chen, radiologist Yu-Fan Cheng, anesthesiologists Bruno Jawan and Hak-Kim Cheung and pathologist Fu-Liu Hsing. By fostering continuing education and interaction through regular meetings and seminars, the multidisciplinary core group was gradually consolidated and harmonious working relationships were established. On March 8, 1993, the first liver transplantation in Southern Taiwan was performed at Kaohsiung Chang Gung Memorial Hospital.

After continuous clinical simulation and animal experimentation, the first living donor liver transplantation in Taiwan was performed on June 17, 1994. Living donor liver transplantation brought about a new era in the management of advanced liver disease. In the past, patients with end-stage liver disease were struggling at the brink of death while waiting for cadaveric liver grafts. Unfortunately, they often died after a seemingly endless period of waiting, because cadaveric donation is very limited in this country. The development of living donor liver transplantation now gives the patient the opportunity to receive a high-quality liver graft through the donation from relatives. The patient’s previous passive role of helpless waiting comes to an end when he or she benefits from a relative’s voluntary donation.

As the skills in living donor liver transplantation grew mature, the transplant team went on to perform Asia’s first split liver transplantation in May 1997. Split liver transplantation involves the division of a cadaveric liver into two parts, and the hemigrafts are transplanted into two separate recipients. This procedure is tantamount to doubling the supply of liver grafts. Major liver transplant centers in Asia have also started split liver transplantation: the University of Singapore (1997), Seoul University (1998), Kyoto University (1999) and the University of Hong Kong (2000).

In January 1999, we performed the first adult-to-adult living donor liver transplantation in Taiwan. The development of the adult living donor liver transplantation has made it possible to donate as much as nearly 70% of the liver without detriment to the health of the donor. Henceforth the recipients have come to include not only children but adults as well. The indications have, likewise, been extended to end-stage liver disease in adults, primarily hepatitis B related liver cirrhosis with or without hepatoma, which is highly prevalent in Taiwan.

In 1997, the liver transplant program obtained a large program project grant from the National Health Research Institutes entitled “Living Donor Liver Transplantation”. With this funding, we were able to establish a liver transplant research center integrating both basic and clinical research. The basic science arm now consists of transplant cellular immunology laboratory, transplant molecular biology laboratory, transplant protein chemistry laboratory, experimental surgery laboratory, specific pathogen free animal laboratory, and bioartificial liver laboratory. It is hoped that more progress could be achieved through the integration of basic and clinical research.

The “First International Living Donor Liver Transplantation Symposium” was hosted by Kaohsiung Chang Gung Memorial Hospital, on January 6-7, 1996. The conference was revived in 2000 in Seoul and since then became an annual Asian international event. The succeeding meetings were held in Hong Kong in 2001 and again in Kaohsiung in 2002. Our hospital thus became the founding institute of this academic conference. With its growing achievement in liver transplantation and as the busiest liver transplant center in Taiwan, Kaohsiung Chang Gung Memorial Hospital has joined Kyoto University, University of Tokyo, Ulsan University in Korea and University of Hong Kong as the five major liver transplantation centers in Asia.

In 1996, six members of the liver transplant team from Kaohsiung Chang Gung Memorial Hospital were invited by the National Kidney and Transplantation Institute in Manila to perform the first living donor liver transplantation in the Philippines. In 2001, fourteen members were invited by the Peking University to perform the first pediatric right lobe living donor liver transplant in China. In 2002, thirteen members were again invited by the Beijing Union Hospital to perform the first adult living donor liver transplantation in Beijing. With respect to international education and training, besides offering learning opportunities to short-term visitors from foreign centers, our hospital has also been providing 1-2 year training for surgical fellows from Japanese universities annually. We also accept qualified surgeons from Southeast Asia for fellowship training on a longer-term basis.

In April 2000, myself, Dr. Yaw-Sen Chen and Dr. Chih-Chi Wang performed three liver transplant surgeries simultaneously. The three patients were all discharged from hospital a month later. This amounts to saying that in our hospital, as a result of greater experience, three teams can now perform liver transplantation simultaneously through collaboration and cooperation. Living donor liver transplantation has also become a routine operation in our center, being performed on a weekly basis for elective cases. The number of cases that have been performed amount to nearly eighty percent of total number in the whole country to date, and our survival record remains among the highest in the world.