Although none of the editors of InsideSurgery.com are participating in his care, we have noted reports that Apple Founder and Chairman Steve Jobs received a liver transplant earlier this spring.
Fortune magazine is reporting that he received the transplant in Tennessee and is said to be recovering well. Jobs began a well-publicized job leave earlier this year for medical issues that were later deemed “more complex” than originally believed.
Jobs received surgical treatment in 1994 for an insulinoma of the pancreas.
Liver transplantation is a highly complex surgical procedure and management that is done by surgeons who commonly make this procedure the focus of their careers. Patients undergoing liver transplantation go through three phases of treatment.
Pre-transplantation and Listing
Liver transplantation in the United States is performed under a hybrid “public/private” arrangement between the United Network for Organ Sharing (UNOS) and individual transplant centers. UNOS is the agency that has been awarded exclusive jurisdiction by the federal government in deciding which patients on the transplant waiting lists receive available organs and tissue.
Liver transplant programs require considerable hospital financial and personnel resources. It is generally acknowledged that these operations are best performed by centers who perform large volumes of the procedure by professionals who devote themselves largely to this procedure and patient population.
Individual centers have broad leeway in deciding which patients to place on the waiting list for transplantation. Each center has their own exclusion criteria and protocols for evaluating prospective patients.
Most patients who receive a liver transplant are classified as having either chronic or fulminant (i.e., rapid) liver failure. A small percentage of patients receive a liver transplant to remove a liver containing a malignancy or to correct an underlying physiological defect when they are not in frank liver failure.
Generally, patient evaluation for liver transplant include a detailed history and physical, a financial means test, and an evaluation of likely compliance with the lifelong regimen needed to maintain the viability of the graft.
It is important to determine that the patient has enough physiological reserve to withstand the rigors of the operation and following regimen of immunosuppression.
A diligent search for the reason for liver failure and remaining liver reserve is made. Lab tests commonly drawn include serologies for hepatitis and HIV, blood type, liver function tests, Ebstein Barr virus (EBV), cytomegavirus (CMV), complete blood count, albumin, ammonia, serum electolytes, and urine and blood drug tests.
Other tests performed include computed tomography of the abdomen and pelvis, magnetic resonance imaging, electrocardiogram, and cardiac stress tests.
The most common etiologies in the United States include alcohol and substance abuse and infection with the hepatitis C virus. In cases of substance abuse, many (but not all) centers require a period of abstinence before the patient is entered onto the waiting list.
After a patient is deemed acceptable for transplantation a MELD score is calculated for them and is used as an indicator of severity of liver disease. The variables used in determining the MELD score are age, serum bilirubin, serum creatinine, and INR (internationation normalized ratio, a measure of coagulopathy or “thinned blood”.)
The Liver Transplant Surgical Procedure
Immunosuppression and Post-transplant Period