I am a hepatopancreatobiliary surgeon, which we briefly call HPB surgeon. In fact, in my professional career, my interest in liver transplantation has overtaken my focus on HPB surgery.
It may seem strange to praise an organ, but my companion of 34 years fully deserves it. Unfortunately, I cannot say the same for the pancreas, with which I have a similar relationship. While the pancreas is unpredictable and temperamental, the liver is a predictable, loyal and a resilient organ.
If it has impressed me this much, the Stone Age hunters must have also been struck by this large, blood-filled organ when they first saw it. In ancient times, the liver was believed to be the center of the soul within the body. In Babylon and ancient Egypt, soothsayers would make prophecies by examining the liver. They would look at the liver of a sacrificed animal and predict the future based on the spots and marks on it, diagnose diseases, and whisper the outcomes of wars into the ears of their rulers. This interest in the liver lasted until the early 17th century when William Harvey described the heart and circulatory system. The liver, having been stripped of its spiritual power, ceded its place to the heart.
During our residency, the liver was presented as an “untouchable” organ. In the 1950s, the French anatomist and surgeon Couinaud demonstrated that the liver has eight independent sections, each with its own blood supply and bile drainage system. This allowed surgeons to slice the liver like a cake, and hepatectomies and segmentectomies became common. With the advancements in liver transplantation, which gained momentum in the 1980s, liver transplants, first from cadavers and later from living donors, became a reality. The liver, packed in ice, was flown from one center to another. In living-donor transplants, the liver was split on one table and transplanted into another patient on another table. Tremendous advancements were made not only in liver transplantation but also in conventional liver surgery, including cancer treatments. Surgeries that were once deemed impossible due to insufficient liver volume have become feasible by enhancing the remaining portion through regeneration. Surgeons have even gone so far as to remove the cancerous liver, clean it in a cold, bloodless environment, and then reattach it after tumor removal. Technological advances and the courage of pioneering surgeons played a significant role in this progress, but the liver’s resilient, regenerative nature cannot be overlooked. Is there any other organ in our body capable of such feats?
Now, let’s return to the present and consider the liver’s attributes through the lens of modern medicine:
1. When you search the internet, you’ll find that the liver has over 500 functions. We can quickly list around 8-10 of its vital roles. I won’t go into them in detail, but I would like to emphasize the connection between these functions and the liver’s location in the body. The liver receives blood through two different channels, and the blood it processes is sent directly to the heart for pumping. The first type of blood comes directly from the heart and is oxygenated. This is vital for liver cells. The second blood flow comes from the intestines, carrying nutrients from the food and drinks we consume. The liver processes these nutrients, turning them into usable forms (proteins, sugars, fats, etc.) for the body. However, this blood does not only bring good things to the liver; it also carries bacteria, toxins, alcohol, drugs, and pesticides, which the liver must filter. The liver’s performance is impacted by the type, quantity, and duration of these harmful substances. Additionally, viruses like hepatitis can settle in the liver cells and cause long-term structural damage, leading to a decrease in its production capacity.
2. We are still far from creating a bio-mechanical “thing” that can take on the liver’s complex list of tasks. Unlike kidney failure, where we have dialysis machines, there is no hemodialysis machine for liver failure.
3. The liver’s regenerative ability is astounding, making it the only organ in the body capable of such regeneration. Its strong cell renewal cycle also protects it from the effects of aging, to the point where we can say it almost “does not age.” Notable examples of this come from liver transplants, where livers from elderly donors have continued to function for many years in young recipients.
If we had to remove 80% of a high-quality liver, the remaining 20%, although initially strained, would meet the body’s vital metabolic needs. This 20% portion would regenerate within 4-6 weeks to nearly its original size (though not its original shape). However, if less than 20% remains, signs of liver failure begin to appear. The liver will no longer be able to perform its essential functions, leading to fluid accumulation in the abdomen, impaired brain function, kidney failure, decreased albumin production, and an increased tendency to bleed. In such cases, we could lose the patient early on.
The phrase “20% of the liver is enough” obviously applies to high-quality, undamaged livers. Unfortunaly, HPB surgeons today mostly operate on damaged, lower-quality livers. As liver cells become damaged and decrease in number, the liver’s quality and performance also decline. As quality declines, the amount of liver left behind after surgery must increase. For example, at least 30% of a fatty liver (steatosis) and at least 40% of a cirrhotic liver must remain for the liver to continue functioning and keep the patient alive.
If 20% of an organ is enough to sustain life, we can say we all are born with four spare livers. It’s like having four lives in a video game. Hepatitis viruses, alcohol, or poor diet gradually deplete these four lives over the years. The most important factor in this process is the continuous nature of the damage. When the liver is repeatedly attacked without the chance to repair its walls properly, the result may be a rough, makeshift repair. Over time, the liver hardens, shrinks, and becomes nodular. This structural damage is called fibrosis, and in advanced stages, cirrhosis manifests with all its troubling symptoms. By then, we’ve missed the last exit before the bridge and find ourselves having already crossed it.
Every year, approximately 1 million new cases of liver cancer are diagnosed worldwide. When we talk about liver cancer, we are referring to cancers originating in the liver itself. Around 90% of these develop on a cirrhotic background, meaning 90% of them are of our own making. By damaging the liver to the point of cirrhosis, aren’t we essentially giving it the idea of developing cancer? Can we really blame the liver? It is probably the one organ that will still be trying to keep you alive, even when everyone else has left. Even after all the damage it has endured over the years, the liver remains your faithful companion.
Doesn’t such a loyal organ deserve this little bit of praise?
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Prof. Dr. Sedat Karademir
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