Diane Alonso, MD, FACS, Program and Surgical Director for Abdominal Transplant Services at Intermountain Medical Center, talks about a new method for transplanting organs.
I am surprised at how much liver transplants have not changed in a long time.
ALONSO: That’s very true. The surgery and technical aspects of it have been very consistent for decades now. There’s been some refinements over time that some people adopt, and others don’t, but generally the basic approach is the same. So, innovation in the operative space is something that we strive for. We do things like robotics and laparoscopy. But at the end of the day, a liver transplant itself is a big open surgery where you take out an organ and put one back in and sew it in just like our generations before us did. The preservation fluid is the same for decades. That hasn’t changed at all. And the way we package and go and get the organs and bring them back, that’s all pretty much the same. It hasn’t changed dramatically.
How do you, as a surgeon, get that organ?
ALONSO: You have patients on your list, and when a donor becomes available, an offer is sent out electronically for you to evaluate. If your patient is first for that offer and you think it’s a good organ for your patient because there is some element of matching, then we would say yes, we’re going to accept that organ. At that point, they’ll set a donor and say you need to be here at “X” time. We have a procurement team that goes with us, and there may be other teams there like cardiac teams, heart teams, lung teams, that sort of thing. Together these people come together, and we coordinate and remove the organs that we are there to get for our patients. Then we pack, we preserve them, package them up, and bring them home.
And, what’s happening is the change in that? You pack it up and it’s just on ice, right?
ALONSO: Yes. It’s been flushed of all the blood, preserved with a solution to try to slow the metabolic process and metabolic death and the cellular death that will occur in an organ when it doesn’t have blood. That process is slowed enough so that we have the time to bring the organ back, put it in, and then re-establish blood flow with minimal damage or injury to the organ or enough that the organ can get beyond it with some time.
So, there’s nothing keeping that organ alive in the cooler?
ALONSO: Well, not in the cooler but in the preservative solution there are things like sugar and certain amino acids that will help retard or slow what we would call that cellular death process. It doesn’t keep it alive necessarily, but it sort of holds off that process long enough that we can re-establish it.
How is that changing now?
ALONSO: Nowadays, there’s a lot of work in the technology field. It exists in the kidney space, in the lung space, and the heart space. There are some pumps out there that keep the organ alive with blood if you will. Then there’s other ones that pump preservative solution through there and keep the blood vessels open and washing the toxins from that slow cellular degradation out of the organs. So that will minimize any kind of injury or even halt the injury. So that organ, if it is one that is more susceptible to stress, such as an older organ or a fatty organ, will not sustain that kind of injury to the degree that it might have been if it had not been put on a pump. In addition, sometimes the pump parameters, where you take data from the pump, allows you to determine if that organ is not going to work as well as you hope in that recipient. In that way, the pump can function as sort of a triaging device. It allows you to triage the organs and decide is that an organ we want to use? Or, maybe we’re not going to use that organ for this patient but can still use it for another patient who may have more physiologic reserve to be able to handle that organ. When we put the livers in, they have this period where they are a little bit dysfunctional and then they start to work as the blood flow is resumed and it sort of heals itself. During that period of healing, the physiology within the recipient can be a little rough. If a patient is very fragile and sick, they may not be able to handle that period of rockiness where someone who’s younger and robust, would be able to handle that. They get through that period of recuperation much better than the more fragile patient. The pump is helpful for that because it is a process that sort of preconditions the organ. It minimizes that injury that might normally occur in a static cold storage setting and then allows us to put these organs that we traditionally call extended criteria into someone that we can then choose from because that reperfusion period may not be so rocky. Or similarly, we can take an organ that is marginal, like an older organ or a fatty organ, and say it’s going to be on the pump. So, it’s more likely to work and more willing to accept those organs. It not only expands our recipient pool, but also expands our donor pool where these organs were ones that we would not maybe even consider in the past.
Someone said to me it’s like you’re starting at 80 miles an hour instead of zero?
ALONSO: Yes. It’s kind of already revved up and ready to go. I think that’s a great analogy because we do know that when the organs stay in the ice, sometimes the little blood vessels stay in spasm. When you re-establish blood flow, it takes a while for those blood vessels to relax and release the spasm. That period of spasticity is what leads to more cellular dysfunction in the liver. We call this an ischemia reperfusion injury sort of setting. We feel the pump is going to minimize or eliminate that. That is what makes you more willing to be able to take an organ that might be a little more marginal, or less-than-ideal, because every organ out there has a chance of possibly being used if we just figure out how we can modify it or precondition it and then pick the right recipient for it. This expands our armamentarium in transplant to maximize organ donation, which is incredibly imperative given the fact that we always have an organ shortage. We always have more patients that need organs than we have. This technology is incredibly important for us in the future to be able to move forward and continue to explore and expand our donor pool, which is highly essential.
So, traditionally, your patient would not have gotten an organ for years?
ALONSO: It’s very possible. She particularly had a disease process that disadvantages folks on the transplant list because they’re very, very sick. Their quality of life is incredibly diminished. They’re very miserable, typically very uncomfortable, itching all the time, very tired. But their liver numbers don’t get to a point that their score is high that makes them very competitive for organs. So, they usually have to be sick for many, many years before they can get to a position on the list that will afford them an organ opportunity.
And, the patient got Hep C?
ALONSO: She did. She was very open-minded in exploring all the possibilities that would allow her improved access to a transplant. Her willingness to take on a Hep C liver is what offered her an opportunity for transplant a lot earlier than she would have if she had not been open to that.
It wouldn’t even have been possible without this pump, correct?
ALONSO: We can still do a Hep C liver transplant without a pump. But we know that when we put that liver on the pump, that liver is probably going to work out of the gate a little faster and not have that rocky period. Then, their hospitalization is a little smoother, their recovery is smoother, and they get back to life a little. That’s the theory behind the pump. That’s what this study is about is demonstrating that it expands the organ pool and improves the post-transplant phase and hopefully leads to reduction in length of stay and complications after transplant.
What was the outcome of this patient?
ALONSO: She did great and she feels great. She’s totally back to life. What I loved about Laura was when she learned she was going to need a liver transplant, it was very overwhelming for her. But, despite feeling overwhelmed, she said, OK, I’m open to it. When the patient says that, it gives us so much opportunity as a surgeon to find them an organ that will work and get them off the list faster. That’s our goal is to get our patients transplanted as quickly as possible so that their chance of dying on the waitlist is substantially diminished. This study will hopefully prove that this is going to allow us to be able to get more organs for people and get them off the list.
Interview conducted by Ivanhoe Broadcast News.
END OF INTERVIEW
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