Liver transplantation is widely regarded as one of the most complex surgical procedures, both technically and due to the often critical condition of patients undergoing the procedure.

This intervention is primarily used to treat severe forms of cirrhosis and certain malignant liver tumors.

Dr. Michel Rayar, a prominent specialist in liver transplantation, has contributed significantly to this field, recently joining the CHU de Nice after several years at the CHU de Rennes, a well-respected center for liver surgery.

The process of liver transplantation involves surgically removing the diseased liver and implanting a healthy donor liver.

This requires connecting several major blood vessels, including the hepatic artery, the portal vein, and the hepatic veins, as well as the bile duct.

While the concept may appear straightforward, the excision of the liver is highly intricate due to the significant bleeding risks associated with the surgery.

Many patients undergoing transplantation have advanced cirrhosis, rendering them particularly susceptible to hemorrhages due to their liver's impaired ability to produce coagulation factors and often present portal hypertension, which exacerbates bleeding risk.

Recent years have seen advancements in the field, particularly with the development of machine perfusion technologies.

These devices allow for better preservation conditions for the liver, reoxygenating the organ and mitigating the detrimental effects of ischemia.

Such innovations have significantly improved transplantation outcomes.

Typically, a liver transplant operation lasts between five to six hours, including two hours for the removal of the diseased liver and two hours for the installation of the new organ, with an additional hour dedicated to ensuring proper hemostasis and closing the surgical site.

Transplants frequently occur at night, requiring surgical teams to perform under conditions of fatigue, highlighting the physical and mental endurance required for such critical operations.

The order in which organs are harvested from donors is influenced by operational needs.

Organs such as the heart and lungs are prioritized due to their limited tolerance for ischemic conditions; the liver is generally harvested before the kidneys.

As the indications for liver transplants expand, particularly in oncology, the shortfall of available grafts remains a pressing concern.

The increasing demand has placed healthcare teams under continual pressure to make difficult choices regarding patient prioritization, especially concerning alcohol-related liver diseases.

When the supply of available organs cannot meet the demand, medical teams face challenging triage decisions.

Patients awaiting transplants are placed on waiting lists and are contacted when a compatible liver becomes available.

The logistics of transplantation necessitate rapid organization, with one team retrieving the donor organ while another prepares the recipient.

Many liver transplants are performed under emergency or super-emergency conditions, with urgent cases not solely limited to cirrhotic complications.

They can also arise from acute drug overdoses, such as acetaminophen toxicity, or severe infections that result in acute liver failure.

In such scenarios, patients may require transplantation within 24 to 48 hours to have a chance of survival.

The overall activity of liver transplantation has remained stable or has seen slight increases despite challenges such as the COVID-19 pandemic, which significantly impacted surgeries by restricting procedures to life-threatening emergencies only.

Since then, the activity has rebounded, with the previous year marking a record for liver transplants from deceased donors.

In France, between 1,200 and 1,350 liver transplants are performed annually.

However, a growing concern is the increasing rate of organ donation refusals, which poses a significant barrier to meeting the rising demand for transplantation.