Could you share your journey to becoming an Hepato Pancreato Biliary and Liver Transplant (HPBLT) surgeon, and what it took to reach where you are today? What inspired you to pursue this specialty?
I wanted to be a surgeon right from the start. In the late 1990s, HPB surgery was emerging as a new specialty, and liver transplantation was just beginning to gain momentum in the country. I was interested in surgery, and this was a unique field. I chose hepatobiliary surgery and transplantation because of its complexity and my interest in operating on the liver.
I completed my undergraduate studies at Annamalai and my postgraduate training in Thanjavur before moving to England. There, I trained in hepatobiliary transplantation for around two years. After returning to India, I worked as a registrar and subsequently completed my DNB in Surgical Gastroenterology. Following that, I pursued a fellowship in liver transplantation. It is a programme that covers abdominal organ transplantation, including the liver, kidney, and intestine. That is how I became a transplant surgeon.
How was your experience in England different from that in India?
In India, medical practice tends to be more decentralized, allowing professionals with the appropriate training to establish private practices. In contrast, England’s system is more structured and government regulated. For example, to perform HPB surgery, one must work in a designated center, which results in higher caseloads and broader exposure. Consultant positions are also limited, as there are only seven HPB centers, meaning independent practice requires securing a consultant role at one of these institutions.
To all the students who wish to follow a similar career path, what qualities would you say are required?
You need to be passionate and have the endurance to work long hours. A liver transplant typically takes around ten hours, whereas a kidney transplant can be completed in three to four hours. Intestinal transplants take even longer because the entire intestine must be removed and carefully dissected before it is replaced.
You also need to stay on top of the patient's progress at all times, so you must remain vigilant. It is a labour-intensive specialty. Among all transplant procedures, I believe liver transplantation is the most technically demanding and requires the longest operating hours. Heart transplantation is technically simpler in terms of vascular anastomosis because the blood vessels are larger. In liver transplantation, the blood vessels are much smaller, particularly in living-donor procedures. The bile duct is also very small, so technical precision is essential. You need excellent hand-eye coordination and strong skills in both vascular and general surgery. Removing the diseased liver is a major procedure in itself because portal hypertension causes extensive dilation of the blood vessels, making the operation more prone to bleeding.
Given that you have over a decade of experience in the field of HPBLT surgery, where do you see this field heading over the next decade?
The future of this field is exciting because robotics has become an integral part of surgery. Surgeons have already begun performing robotic liver transplantation, including robotic implantation. In the coming years, treatment for every illness will become increasingly individualised and personalised. However, transplantation will remain the mainstay for treating advanced liver disease. We replace a failed organ much like we replace lost blood through transfusion. Technical innovations such as robotics, laparoscopy, and other minimally invasive procedures will continue to reduce surgical trauma. In oncology, transplantation also has an important role in treating malignancies such as hepatocellular carcinoma and cholangiocarcinoma.
Stem cell research is advancing rapidly in Western countries, and we have also established a stem cell laboratory in our hospital. Regenerative therapy is still in the pipeline, but it is likely to play an important role in treating early-stage diseases and certain blood cancers in the future.
Is there a patient whose story shaped your perspective and stayed with you throughout your career?
When I was a DNB registrar, I treated an 18-year-old girl who had consumed rat poison and developed acute liver failure. She was on the verge of death. We listed her for a priority transplant, she underwent a successful liver transplant, and she made a complete recovery. Seeing her recover was incredibly heartening. It reinforced my passion for transplantation and showed me the true value of this therapy in transforming a person's life. It is a field that demands technical expertise as well as the ability to make difficult and decisive choices.
However, not every decision has had a successful outcome. We have also learnt difficult lessons from managing very complicated, late-stage illnesses. Even when the decisions we made were the most appropriate at the time, the outcomes were not always favourable.
One case that I often think about involved a college student who had developed hepatotoxicity after inhaling toluene because of an addiction. We listed her for a liver transplant, and a family member donated half of their liver. She initially showed signs of recovery, but the hepatic artery became blocked, requiring an urgent re-transplant. Another family member came forward as a donor, and we performed a second transplant within fifteen days. The greatest challenge in a re-transplant is the arterial and bile duct anastomoses because the tissues have already been operated on once. Unfortunately, she later developed arterial thrombosis and died of sepsis.
We've all seen television shows where things suddenly take an unexpected turn in the operating theatre during surgery. Has there been a moment like that in your experience when you were under pressure and had to make a difficult decision?
Here at PSG, we treated a patient with liver trauma who had a cirrhotic liver and a history of Grade 4 liver trauma a year earlier. When a suitable donor organ became available, we scheduled him for a liver transplant. While removing the diseased liver, he developed uncontrollable haemorrhage because of open sinusoids resulting from the previous liver injury. This led to an air embolism, and unfortunately, he did not survive.
On a more positive note, we treated a young police constable with a wife and children who had advanced liver failure. He was severely emaciated, had massive ascites, and had been turned away by several hospitals because of the complexity of his condition. Many surgeons felt that transplantation was not possible because of portal vein thrombosis. When he came to us, the family had very little hope. We managed him medically while placing him on the transplant waiting list. Once a donor liver became available in Salem, I personally travelled to procure the organ, and we successfully performed the transplant. He has since made a complete recovery and continues to visit us for regular follow-up.
On a more recent note, as our hospital prepares to perform intestinal transplants, how do they differ from other organ transplants?
Intestinal transplantation requires the anastomosis of two major blood vessels—the incoming arterial supply and the outgoing venous drainage—followed by joining the intestine. Technically, the procedure is relatively simpler than liver transplantation. However, the post-operative period is far more challenging because the intestine contains a large amount of lymphoid tissue. As a result, immune management and immunosuppression are much more complex. Patients are at a higher risk of infection, rejection, and graft-versus-host disease. Although newer immunosuppressive drugs have improved outcomes, post-operative immunosuppression protocols for intestinal transplantation are still evolving. Compared with liver and kidney transplantation, intestinal transplantation continues to present greater post-operative challenges.
If you could leave students with one message, both as future doctors and as individuals, what would it be?
Be truly passionate about the field you choose. Transplantation is a specialty that brings together surgery, medicine, immunology, infectious diseases, and oncology. You need to be knowledgeable, sincere, hardworking, and resilient. Maintaining a work-life balance can be difficult in the early years, but with time, both you and your family will learn to adapt.
It is a long journey, and there will be times when you feel like giving up. However, once you become a transplant surgeon, the sense of fulfilment is immense. Even after completing your training, you will face challenges such as building a patient base and establishing a transplant programme. Once your unit is well established, everything begins to run smoothly but reaching that stage requires perseverance and hard work.
I often say that a surgeon's career truly begins at the age of 50 because experience and maturity are invaluable in this profession. As long as you remain committed to your goals, it is an incredibly rewarding journey.
Dr Biku Joseph John was interviewed by-
