Indian surgeon's feat

Dr. Mohammed Rela, who successfully transplanted a liver into a five-day-old infant in London last year, says that it is only a matter of time before liver transplants become commonplace in India.

IN his well-cut dark blue suit, Dr. Mohammed Rela looks more like a successful young banker or stock-broker than a surgeon who spends six to seven hours a day operating on one of the most complex organs in the human body, the liver. Tamil Nadu-born Dr. Rela completed his basic medical education at Stanley Medical College, Chennai. He came to Britain in 1986 with an M.S. degree, took his FRCS, and stayed on. Today, he is one of the best-known liver surgeons in the United Kingdom.

Dr. Rela came to public attention last December when it was announced that he had transplanted a liver into a five-day-old baby girl, the youngest patient to undergo such an operation.

Baby Baebhen (meaning "melodious" in Gaelic) Schutke was born in Dublin in July last to an Irish mother and German father. Two days after her birth, she was diagnosed as having a rare inherited condition known as neo-natal haemochromatosis, which causes iron to build up in the liver. She was rushed to King's College Hospital in London. A suitable donor, a 10-year-old boy who had died in an accident, was found almost immediately. Dr. Rela and his team then began a gruelling eight-hour process of first paring down the donor liver (a 10-year-old's liver is too large to fit into a baby's abdomen) to one-eighth of its normal size and then transplanting it. It took six hours to connect up the tiny blood vessels linking the new liver.

Today the baby, eight months old, is doing well, and there is every chance of her growing up normally without any medical support. Dr. Rela commented: "The liver is now adapting to her body and is growing normally. She will not need another transplant when she is older."

Liver transplants are among the most complex of surgical operations. Dr. Rela has over 500 operations to his credit, including 15 on children under three months of age. Dr. Rela describes a liver transplant as "probably the most difficult operation" for both patients and doctors. "I would say it is five to ten times more difficult than heart surgery."

Dr. Rela started his career in general surgery before coming to King's College Hospital six years ago. The liver unit at King's College was a leading centre for transplantation, and this area of surgery naturally aroused his interest. After an arduous period of apprenticeship (his tasks as a junior included flying out to different parts of the country to collect organs for transplantation), Dr. Rela established himself as a skilled surgeon.

Dr. Rela's origins perhaps make it inevitable that the conversation with him must shift to the state of medicine in India, particularly the question of why liver transplants have not really caught on in India despite the demand for such transplants. Given the high incidence of Hepatitis-B and Hepatitis-C in the country, Dr. Rela is in no doubt that a large number of people are in need of transplant operations. While the poorer ones just die, those who can afford the operation go abroad. A transplant at King's College costs the equivalent of Rs. 50 lakhs, Dr. Rela points out.

Why do doctors in India not perform this complex surgery? A trifle wary about airing his views, he blames the hierarchical organisation of medicine in India for the absence of such a medical practice. "A successful transplant in India will generate a lot of publicity. Naturally, the people who want to perform the surgery are the senior doctors, doctors who do not have the time to go abroad and get trained." On the other hand, young doctors with the requisite training will probably not get a chance because they are considered junior. There are young doctors in India who spent one or two years abroad training, "but have not been able to do anything once they got back", according to him.

This, Dr. Rela points out, is not the only difficulty in initiating liver transplants in India. It is not enough for surgeons alone to get trained in transplanting techniques. Supporting personnel, such as physicians and anaesthetists, also require specialist training. "You need back-up because it is team work. You have to train a whole team." When Ireland wanted to start a liver transplant programme, they sent a whole team for training, Dr. Rela said.

Trained back-up staff were essential to ensure a reasonable survival rate after transplantation, or even to ensure that patients did not die on the operating table. "The surgeons might be capable of performing the operation, but somebody else might kill them (the patients) while they are performing the operation...It's training for everybody, not just the individual."

Dr. Rela estimated that it would take at least a year for a surgeon to get trained, and three to six months to train support staff. This was more than most hospitals in India were willing to invest. "It's a big investment, but they want results without actually investing."

When liver transplants do catch on in India, Dr. Rela indicated, one must not expect a high success rate almost immediately. For, a hospital such as King's College was able to ensure a high rate of post-operative survival only after decades of hard work to build up expertise and skills. This was in spite of the technology available at the hospital, he pointed out.

Dr. Rela is sure that it is only a matter of time before liver transplants became commonplace in India. "I have absolutely no doubt that the technology will reach India."