Some patients are ‘dying while waiting’ as Korea’s liver transplant system falls into crisis

The operating rooms are still there. So are the patients. But in hospitals across Korea, the teams that once “led the world” in liver surgery are disappearing -- burned out, overworked, and increasingly absent from the country’s operating tables.

Many have walked out since February 2024 when thousands of trainee doctors resigned in protest of the government’s plan to increase medical school admissions by 2,000 seats. More than a year later, the absence is being felt across the system.

In the words of Professor Kim Jong-man of the Division of Transplant Surgery at Samsung Medical Center, “we may not even have enough surgeons to perform basic liver operations in 10 years.”

Liver transplant surgeries have fallen by 16.8 percent nationwide between February and July 2024, while liver cancer procedures dropped by over 13 percent, according to new figures presented Monday ahead of The Liver Week 2025, a multidisciplinary international conference organized by liver-related societies in Korea.

Speaking at a press briefing in Seoul, Kim called it “one of the steepest drops across cancer types” and a clear sign that the surgical system is starting to fracture. Postoperative complication rates, once in the single digits, have nearly doubled. Emergency transplants are halting. Staffing rosters are thinning to single digits. And the next generation of specialists? It’s barely arriving at all.

“There are only 12 first-year HPB fellows nationwide this year,” Kim said, referring to the field of liver, bile duct, and pancreatic surgery. “Very few will go on to complete full training across liver, biliary, and pancreatic surgery.”

At a conference preview co-hosted by four medical societies -- including the Korean Association for the Study of the Liver and the Korean Liver Transplantation Society -- speakers described a system buckling under a “quadruple crisis”: collapsing surgical teams, worsening patient outcomes, disappearing trainees, and declining research output.

Surgeries that once demanded full teams are now performed by solo surgeons, often assisted only by physician assistants. Complication rates have surged across the board -- from 3.8 to 6.9 percent for all liver surgeries, and from 2.8 to 4.8 percent for severe cases. Among older or high-risk patients, including those undergoing open or pancreatic procedures, complication rates now reach as high as 27 percent.

Kim said the shift to single-surgeon models is having a direct impact on outcomes. “Some patients are dying while waiting. Others miss their surgical window and get worse before we can even get to them. This isn’t a theoretical concern. It’s already happening.”

And the pipeline is disintegrating. After peaking at 77 fellows in 2018, the number dropped to 39 in 2024, with only 12 new first-year HPB fellows entering training this year. Many hospitals have none. “At this rate,” Kim said, “we may not even have enough surgeons to perform basic gallbladder operations, let alone liver resections.”

The situation is especially dire in regional centers, where anesthesiologists and specialists have quit or relocated, and many transplant units now operate with just two to four staff surgeons. “Outside Seoul, things are really falling apart,” said Professor Jung Dong-hwan of the Department of Liver Transplantation and Hepatobiliary Surgery at Asan Medical Center. “Some hospitals have seen their annual transplant numbers cut by more than half.”

In 2023, Korea performed 1,497 liver transplants. By 2024, that number had dropped to 1,256. “Not a single hospital reported an increase in transplant volume,” Jung said. “In the worst-hit centers, procedures fell from 11 to 4. Others dropped from 20 to 13.”

Jung warned that regional programs have been scaled down so severely that some can no longer perform emergency transplants. “Without immediate, coordinated action across specialties, patients with liver failure -- especially from alcohol-related disease -- will be left behind.”

Burnout is at the heart of the crisis. Surgeon fatigue has surged since the 2024 standoff between doctors and the government over medical school expansion. A recent survey showed that 70.5 percent of surgeons now report burnout -- up from just over 30 percent in 2019.

The legal environment isn’t helping. Kim said HPB surgeons face some of the country’s highest malpractice risks, yet receive "very little protection," pointing out that Korea’s prosecution rate is 14.7 times higher than Japan’s and 580 times higher than the U.K.’s. 

He called the liability system “one of the biggest deterrents” for new doctors. “Just look at what happened after the Ewha Womans University Mokdong Hospital case,” he said, referring to the 2017 incident in which four premature infants died within 90 minutes in a Seoul neonatal ICU, triggering a high-profile investigation and criminal charges against doctors. Pediatric residency applications collapsed afterward, falling from more than 113 percent to just 16 percent. “We’re watching the same thing happen now to surgical specialties.”

The research ecosystem is also showing signs of strain. Surgical publications dropped 12 percent last year, far outpacing the 4 percent decline in hepatology overall. “That tells you how deeply clinical fatigue has infiltrated our academic system,” Kim said.

And as transplant numbers fall, ethical questions are rising. Surgeons flagged concerns about the growing number of liver transplants performed for alcohol-related cirrhosis. In the U.S., candidates are typically required to abstain from drinking for at least six months. But in Korea, Jung said, “many resume drinking soon after surgery,” adding that relapse rates can reach 49 percent. “That raises the question of whether it’s ethical to offer a second transplant.”

Underlying it all is a fear that Korea’s transplant reputation is slipping away. “This is no longer just about workforce burnout,” Kim said. “It’s about whether we can even sustain the minimum level of surgical care for liver disease in this country.”