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Bambha K, Biggins SW, Hughes C, Humar A, Ganesh S, Sturdevant M. Future of U.S. living donor liver transplant: Donor and recipient criteria, transplant indications, transplant oncology, liver paired exchange, and non-directed donor graft allocation. Liver Transpl 2025; 31:92-104. [PMID: 39172018 DOI: 10.1097/lvt.0000000000000462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 07/24/2024] [Indexed: 08/23/2024]
Abstract
In the United States, living donor liver transplant (LDLT), from both directed and nondirected living donors, has expanded over the past several years. LDLT is viewed as an important opportunity to expand the overall donor pool for liver transplantation (LT), shorten waiting times for a life-prolonging LT surgery, and reduce LT waitlist mortality. The LT community's focus on LDLT expansion in the United States is fostering discussions around future opportunities, which include the safe expansion of donor and recipient candidate eligibility criteria, broadening indications for LDLT including applications in transplant oncology, developing national initiatives around liver paired exchange, and maintaining vigilance to living donor and recipient candidate risk/benefit equipoise. Potential opportunities for expanding living liver donor and recipient candidate criteria include using donors with more than minimal hepatic steatosis, evaluating older donors, performing LDLT in older recipients to facilitate timely transplantation, and providing candidates who would benefit from an LT, but may otherwise have limited access (ie, lower MELD scores), an avenue to receive a life-prolonging organ. Expansion opportunities for LDLT are particularly robust in the transplant oncology realm, including leveraging LDLT for patients with advanced HCC beyond Milan, intrahepatic cholangiocarcinoma, and nonresectable colorectal cancer liver metastases. With ongoing investment in the deliberate growth of LDLT surgical expertise, experience, and technical advances in the United States, the LT community's future vision to increase transplant access to more patients with end-stage liver disease and selected oncology patients may be successfully realized.
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Affiliation(s)
- Kiran Bambha
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Scott W Biggins
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Christopher Hughes
- Division of Transplantation, Department of Surgery, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Abhi Humar
- Division of Transplantation, Department of Surgery, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Swaytha Ganesh
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Mark Sturdevant
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, Washington, USA
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2
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Kakembo N, Loy JI, Fitzgerald TN, Antiel RM. Biliary atresia in Uganda: Current ethical challenges and advancement of public policy. World J Surg 2024; 48:2317-2321. [PMID: 38557980 DOI: 10.1002/wjs.12166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 03/17/2024] [Indexed: 04/04/2024]
Abstract
Biliary atresia is a progressive cholangiopathy in neonates, which often results in liver failure. In high-income countries, initial treatment requires prompt diagnosis followed by Kasai portoenterostomy. For those with a late diagnosis, or those in whom Kasai portoenterostomy fails, liver transplantation is the only lifesaving treatment. Unfortunately, in low- and middle-income countries, timely diagnosis is a challenge and liver transplantation is rarely accessible. Here, we discuss the ethical dilemmas surrounding treatment of babies with biliary atresia in Uganda. Issues that require careful consideration include: risk of catastrophic health expenditure to families, ethical dilemmas of transplant tourism, medical risks of maintaining the transplant in a low-resourced health system, and difficult decisions encountered by the surgeon caring for these patients. Four distinct models of the patient-physician relationship are applied to biliary atresia in Uganda. These models describe differences in patient and physician roles, and patient values and autonomy. Solid organ transplantation is a rapidly evolving segment of healthcare in Uganda and ongoing policy advancements may shift ethical considerations in the future.
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Affiliation(s)
- Nasser Kakembo
- Department of Surgery, Makerere University, Kampala, Uganda
| | - J Isaac Loy
- Initiative for Science & Society, Duke University, Durham, North Carolina, USA
- College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Tamara N Fitzgerald
- Department of Surgery, Duke University, Durham, North Carolina, USA
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
| | - Ryan M Antiel
- Department of Surgery, Duke University, Durham, North Carolina, USA
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3
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Emond JC, Di Sandro S, Pomfret EA. American perspectives for LDLT in 2024. Updates Surg 2024:10.1007/s13304-024-01994-1. [PMID: 39302556 DOI: 10.1007/s13304-024-01994-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2024] [Accepted: 09/05/2024] [Indexed: 09/22/2024]
Abstract
Living donor liver transplantation (LDLT) was first performed in the US in 1989, primarily benefiting pediatric patients. Its adoption for adults faced setbacks after a donor death in 2001, causing widespread risk aversion. Despite ethical justification and demonstrated safety, LDLT remains underutilized, with fewer than 10% of liver transplants being LDLT. Recent trends indicate improved access to deceased donor liver transplantation (DDLT) due to increased organ donation and technological advances like Normothermic Regional Perfusion (NRP). However, LDLT remains critical, especially for pediatric patients and specific adult populations who benefit significantly from it. Barriers to LDLT include public and clinician apprehensions about donor risks, despite studies showing low-complication rates. Non-directed donations and broader social media engagement have increased donor pools, though the volume of LDLT in the US remains lower than in Asia due to limited training and experience. The A2ALL consortium has been pivotal in studying LDLT safety and outcomes. Currently, around 40 US centers perform LDLT, with high-volume centers leading by example. Training paradigms for LDLT are evolving, with initiatives like the ASTS LDLT master class aiming to enhance surgical expertise. While LDLT is embedded in US liver-transplant practices, its expansion is hampered by risk aversion and the availability of DDLT. Nonetheless, LDLT is essential for addressing the supply-demand mismatch in liver transplantation.
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Affiliation(s)
- Jean C Emond
- Division of Transplantation, Department of Surgery, Columbia University Medical Center, New York Presbyterian Hospital, New York, NY, USA.
| | - Stefano Di Sandro
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, HPB Surgery and Liver Transplant Unit, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, MO, Italy.
| | - Elizabeth A Pomfret
- Transplant Surgery, Department of Surgery, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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4
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Ethical Issues Concerning Organ Donation. Camb Q Healthc Ethics 2022; 31:344-347. [PMID: 35899543 DOI: 10.1017/s0963180121001031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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5
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Cotter TG, Minhem M, Wang J, Peeraphatdit T, Ayoub F, Pillai A, Hernandez-Alejandro R, di Sabato D, Charlton M. Living Donor Liver Transplantation in the United States: Evolution of Frequency, Outcomes, Center Volumes, and Factors Associated With Outcomes. Liver Transpl 2021; 27:1019-1031. [PMID: 33619854 PMCID: PMC9257956 DOI: 10.1002/lt.26029] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 01/31/2021] [Accepted: 02/17/2021] [Indexed: 12/13/2022]
Abstract
Recent modifications in organ allocation policies and increases in chronic liver diseases may have resulted in important changes in living donor liver transplantation (LDLT) in the United States. We examined the trends, outcomes, and factors associated with outcomes in adult LDLT. United Network for Organ Sharing data on 2566 adult LDLT recipients who received transplants from January 1, 2010, through December 31, 2019, were analyzed. LDLT graft and patient survival rates were compared with propensity score-matched deceased donor liver transplantation recipients by the Kaplan-Meier curve estimator. The association between preceding LDLT frequency and subsequent outcomes were assessed by Cox proportional hazards mixed effects modeling. After a stable annual frequency of LDLTs from 2010 to 2014 (~200 per year), the number of LDLTs doubled to 440 in 2019. The 1-year and 5-year graft survival rates for LDLT recipients were 88.4% and 78.1%, respectively, compared with 92.5% and 80.7% in the propensity score-matched donation after brain death recipients (P = 0.005), respectively. Older donor age and recipient diabetes mellitus and life support requirement were significantly associated with graft failure among LDLT recipients (P values <0.05). Average preceding LDLT frequencies of <3 per year, 3 to 20 per year, and >20 per year resulted in 1-year graft survival rates of 82%, 88% to 89%, and 93%, respectively (P values <0.05). There were 3 living donor deaths (0.12%). The frequency of LDLTs has doubled during the past decade, with good outcomes and acceptable donor safety profiles. However, there appear to be varying threshold transplant frequencies (volume/unit time) associated with acceptable (88%-89%) and aspirational (93%) 1-year graft survival rates. These data should be reassuring and encourage LDLT practice as efforts continue to expand the donor pool.
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Affiliation(s)
- Thomas G. Cotter
- Center for Liver Diseases, The University of Chicago Medicine, Chicago, IL, USA
| | - Mohamad Minhem
- Department of Medicine, Loyola University Medical Center at Trinity Mercy Chicago, Chicago, IL, USA
| | - Jennifer Wang
- Center for Liver Diseases, The University of Chicago Medicine, Chicago, IL, USA
| | | | - Fares Ayoub
- Center for Liver Diseases, The University of Chicago Medicine, Chicago, IL, USA
| | - Anjana Pillai
- Center for Liver Diseases, The University of Chicago Medicine, Chicago, IL, USA
| | | | - Diego di Sabato
- Department of Surgery, The University of Chicago Medicine, Chicago, IL, USA
| | - Michael Charlton
- Center for Liver Diseases, The University of Chicago Medicine, Chicago, IL, USA
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6
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Patel MS, Mohamed Z, Ghanekar A, Sapisochin G, McGilvray I, Sayed BA, Reichman T, Selzner M, Gross JA, Galvin Z, Bhat M, Lilly L, Cattral M, Selzner N. Living donor liver paired exchange: A North American first. Am J Transplant 2021; 21:400-404. [PMID: 32524750 DOI: 10.1111/ajt.16137] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 05/12/2020] [Accepted: 06/01/2020] [Indexed: 02/06/2023]
Abstract
Paired organ exchange can be used to circumvent living donor-recipient ABO incompatibilities. Herein, we present the first case of successful liver paired exchange in North America. This 2-way swap required 4 simultaneous operations: 2 living donor hepatectomies and 2 living donor liver transplants. A nondirected anonymous living donor gift initiated this domino exchange, alleviating an ABO incompatibility in the other donor-recipient pair. With careful attention to ethical and logistical issues, paired liver exchange is a feasible option to expand the donor pool for incompatible living liver donor-recipient pairs.
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Affiliation(s)
- Madhukar S Patel
- Multi Organ Transplant Program, University Health Network, University of Toronto, Toronto, Canada
| | - Zubaida Mohamed
- Multi Organ Transplant Program, University Health Network, University of Toronto, Toronto, Canada
| | - Anand Ghanekar
- Multi Organ Transplant Program, University Health Network, University of Toronto, Toronto, Canada
| | - Gonzalo Sapisochin
- Multi Organ Transplant Program, University Health Network, University of Toronto, Toronto, Canada
| | - Ian McGilvray
- Multi Organ Transplant Program, University Health Network, University of Toronto, Toronto, Canada
| | - Blayne A Sayed
- Multi Organ Transplant Program, University Health Network, University of Toronto, Toronto, Canada
| | - Trevor Reichman
- Multi Organ Transplant Program, University Health Network, University of Toronto, Toronto, Canada
| | - Markus Selzner
- Multi Organ Transplant Program, University Health Network, University of Toronto, Toronto, Canada
| | - Jed A Gross
- Multi Organ Transplant Program, University Health Network, University of Toronto, Toronto, Canada
| | - Zita Galvin
- Multi Organ Transplant Program, University Health Network, University of Toronto, Toronto, Canada
| | - Mamatha Bhat
- Multi Organ Transplant Program, University Health Network, University of Toronto, Toronto, Canada
| | - Les Lilly
- Multi Organ Transplant Program, University Health Network, University of Toronto, Toronto, Canada
| | - Mark Cattral
- Multi Organ Transplant Program, University Health Network, University of Toronto, Toronto, Canada
| | - Nazia Selzner
- Multi Organ Transplant Program, University Health Network, University of Toronto, Toronto, Canada
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Reding R, Chardot C, Paul K, Veyckemans F, Obbergh LV, Clety SCD, Detaille T, Clapuyt P, Saint-Martin C, Janssen M, Lerut J, Sokal E, Otte JB. Living-Related Liver Transplantation in Children at Saint-Luc University Clinics : A Seven Year Experience in 77 Recipients. Acta Chir Belg 2020. [DOI: 10.1080/00015458.2001.12098576] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- R. Reding
- Pediatric Liver Transplant Program. Departments of Surgery, Saint-Luc University Clinics, Universite catholique de Louvain, Brussels, Belgium
| | - Chr. Chardot
- Pediatric Liver Transplant Program. Departments of Surgery, Saint-Luc University Clinics, Universite catholique de Louvain, Brussels, Belgium
| | - K. Paul
- Pediatric Liver Transplant Program. Departments of Surgery, Saint-Luc University Clinics, Universite catholique de Louvain, Brussels, Belgium
| | - F. Veyckemans
- Pediatric Liver Transplant Program. Departments of Anaesthesiology, Saint-Luc University Clinics, Universite catholique de Louvain, Brussels, Belgium
| | - L. Van Obbergh
- Pediatric Liver Transplant Program. Departments of Anaesthesiology, Saint-Luc University Clinics, Universite catholique de Louvain, Brussels, Belgium
| | - S. Clement De Clety
- Pediatric Liver Transplant Program. Departments of Intensive Care, Saint-Luc University Clinics, Universite catholique de Louvain, Brussels, Belgium
| | - Th. Detaille
- Pediatric Liver Transplant Program. Departments of Intensive Care, Saint-Luc University Clinics, Universite catholique de Louvain, Brussels, Belgium
| | - Ph. Clapuyt
- Pediatric Liver Transplant Program. Departments of Radiology, Saint-Luc University Clinics, Universite catholique de Louvain, Brussels, Belgium
| | - Chr. Saint-Martin
- Pediatric Liver Transplant Program. Departments of Radiology, Saint-Luc University Clinics, Universite catholique de Louvain, Brussels, Belgium
| | - M. Janssen
- Pediatric Liver Transplant Program. Departments of Surgery, Saint-Luc University Clinics, Universite catholique de Louvain, Brussels, Belgium
| | - J. Lerut
- Pediatric Liver Transplant Program. Departments of Surgery, Saint-Luc University Clinics, Universite catholique de Louvain, Brussels, Belgium
| | - E. Sokal
- Pediatric Liver Transplant Program. Departments of Pediatrics, Saint-Luc University Clinics, Universite catholique de Louvain, Brussels, Belgium
| | - J.-B. Otte
- Pediatric Liver Transplant Program. Departments of Surgery, Saint-Luc University Clinics, Universite catholique de Louvain, Brussels, Belgium
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8
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Carpenter D, Chaudhry S, Samstein B. The Current State of Minimally Invasive Living Donor Hepatectomy. CURRENT TRANSPLANTATION REPORTS 2020. [DOI: 10.1007/s40472-020-00287-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
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9
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Frader JE, Bosk CL. Plus ça change: Renée Fox and the Sociology of Organ Replacement Therapy. Hastings Cent Rep 2020; 50:6-7. [PMID: 32311124 DOI: 10.1002/hast.1095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Rereading Renée C. Fox's "A Sociological Perspective on Organ Transplantation and Hemodialysis," published in 1970, one is likely to be struck more by continuity than by change. The most pressing of the social, policy, and ethical concerns that Fox raised remain problematic fifty years later. We still struggle with scientific and clinical uncertainty, with the boundary between experimentation and therapy, and with the cost of organ replacement therapies and disparities in how they are allocated. We still have an imperfect understanding of transplant immune responses. We still debate when a potential donor "actually" dies, and we still seem to think better empirical criteria could harmonize the diverse religious, cultural, and socioeconomic values of patients, providers, third-party payers, and policy-makers. Organ transplantation was for Fox both a particular case unfolding in time and an entryway for discussing the difficult moral questions presented by many new medical technologies in a context of high demand and limited resources.
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Risk of biliary tract disease in living liver donors: A population-based cohort study. PLoS One 2020; 15:e0230840. [PMID: 32226025 PMCID: PMC7105125 DOI: 10.1371/journal.pone.0230840] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 02/25/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND & AIMS Whether living liver donors have a higher risk of biliary tract disease compared with non-donors remains unknown. METHODS Data were collected from the Taiwan Longitudinal Health Insurance Database for the 2003-2011 period. The study cohort comprised 1,446 patients aged ≥ 18 years who had served as living liver donors. The primary outcome was the incidence of biliary tract disease. Cox proportional hazards modeling was used to determine the hazard ratios. RESULTS The incidence density rate of biliary tract disease was 13.9-fold higher in the liver donor (LD) cohort than in the non-LD cohort (10.2 vs. 0.71 per 1,000 person-years), with an adjusted hazard ratio (HR) of 14.2 (95% confidence interval [CI] = 7.73-26.1). Stratified by comorbidity, the relative risk of biliary tract disease was higher in the LD cohort than in the non-LD cohort for both patients with or without comorbidity. The incidence density rate of biliary tract disease was significantly higher in the first 3 years (13.5 per 1,000 person-years in the LD cohort). The highest adjusted HR of biliary tract disease for LD patients compared with the non-LD cohort was 22.4 (95% CI = 10.8-46.1) in the follow-up ≤ 3 years. CONCLUSION Living liver donors had a higher risk of biliary tract disease compared with non-donors.
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11
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Siegler M. Clinical Medical Ethics: Its History and Contributions to American Medicine. THE JOURNAL OF CLINICAL ETHICS 2019. [DOI: 10.1086/jce2019301017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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12
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Abstract
Living donation has become a medically and ethically accepted practice in solid organ transplantation. Published proceedings from the international kidney transplant community and from the Ethics Committee of The Transplantation Society articulated the general principles and specific recommendations for living donation, which remain the backbone of Centers for Medicare and Medicaid Services and Organ Procurement and Transplantation Network requirements and policies. Meanwhile, there have been major advancements in another revolutionary field of transplant medicine: vascularized composite allotransplantation. Recent interventions have demonstrated potential for superior functional and aesthetic outcomes in a single operation when compared to staged conventional reconstructions. In view of these successes, the indications for vascularized composite allotransplantation are expected to broaden to include less extensive types of transplants, which would introduce the possibility of using living vascularized composite allotransplantation donors. In this article, the authors discuss the feasibility and ethics associated with living donation of vascularized composite allografts. The authors explore the current guidelines and policies set by the Organ Procurement and Transplantation Network regarding living organ donation. In addition, the authors provide several clinical scenarios in which living donation of vascularized composite allotransplantation could be used to augment the reconstructive ladder currently used by reconstructive surgeons to guide their reconstructive strategies.
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13
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Mishra A, Lo A, Lee GS, Samstein B, Yoo PS, Levine MH, Goldberg DS, Shaked A, Olthoff KM, Abt PL. Liver paired exchange: Can the liver emulate the kidney? Liver Transpl 2018; 24:677-686. [PMID: 29427562 DOI: 10.1002/lt.25030] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 01/14/2018] [Accepted: 02/05/2018] [Indexed: 02/07/2023]
Abstract
Kidney paired exchange (KPE) constitutes 12% of all living donor kidney transplantations (LDKTs) in the United States. The success of KPE programs has prompted many in the liver transplant community to consider the possibility of liver paired exchange (LPE). Though the idea seems promising, the application has been limited to a handful of centers in Asia. In this article, we consider the indications, logistical issues, and ethics for establishing a LPE program in the United States with reference to the principles and advances developed from experience with KPE. Liver Transplantation 24 677-686 2018 AASLD.
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Affiliation(s)
- Ashish Mishra
- Division of Transplant, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Alexis Lo
- Temple University School of Medicine, Philadelphia, PA
| | - Grace S Lee
- Division of Transplant, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA.,Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA
| | - Benjamin Samstein
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Weill Cornell Medical College, New York, NY
| | - Peter S Yoo
- Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Matthew H Levine
- Division of Transplant, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - David S Goldberg
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia, PA.,Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Abraham Shaked
- Division of Transplant, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Kim M Olthoff
- Division of Transplant, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Peter L Abt
- Division of Transplant, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
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Samstein B, de Melo-Martin I, Kapur S, Ratner L, Emond J. A liver for a kidney: Ethics of trans-organ paired exchange. Am J Transplant 2018; 18:1077-1082. [PMID: 29442420 DOI: 10.1111/ajt.14690] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 02/01/2018] [Accepted: 02/04/2018] [Indexed: 01/25/2023]
Abstract
Living donation provides important access to organ transplantation, which is the optimal therapy for patients with end-stage liver or kidney failure. Paired exchanges have facilitated thousands of kidney transplants and enable transplantation when the donor and recipient are incompatible. However, frequently willing and otherwise healthy donors have contraindications to the donation of the organ that their recipient needs. Trans-organ paired exchanges would enable a donor associated with a kidney recipient to donate a lobe of liver and a donor associated with a liver recipient to donate a kidney. This article explores some of the ethical concerns that trans-organ exchange might encounter including unbalanced donor risks, the validity of informed consent, and effects on deceased organ donation.
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Affiliation(s)
| | | | - Sandip Kapur
- Department of Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Lloyd Ratner
- Department of Surgery, Columbia University Medical Center, New York, NY, USA
| | - Jean Emond
- Department of Surgery, Columbia University Medical Center, New York, NY, USA
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15
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16
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Paquette ET, Ross L. The Challenges of Incorporating Research Ethics Consultation Into Institutional Human Subjects Protections Programs. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2018; 18:49-51. [PMID: 29313769 PMCID: PMC6214683 DOI: 10.1080/15265161.2017.1401179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
| | - Lainie Ross
- b University of Chicago and MacLean Center for Clinical Medical Ethics
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17
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Baker TB, Zimmerman MA, Goodrich NP, Samstein B, Pomfret EA, Pomposelli JJ, Gillespie BW, Berg CL, Emond JC, Merion RM. Biliary reconstructive techniques and associated anatomic variants in adult living donor liver transplantations: The adult-to-adult living donor liver transplantation cohort study experience. Liver Transpl 2017; 23:1519-1530. [PMID: 28926171 PMCID: PMC5818204 DOI: 10.1002/lt.24872] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 08/11/2017] [Accepted: 09/12/2017] [Indexed: 12/27/2022]
Abstract
Living donor liver transplantation (LDLT) is a technically demanding endeavor, requiring command of the complex anatomy of partial liver grafts. We examined the influence of anatomic variation and reconstruction techniques on surgical outcomes and graft survival in the 9-center Adult-to-Adult Living Donor Liver Transplantation Cohort Study (A2ALL). Data from 272 adult LDLT recipients (2011-2015) included details on anatomic characteristics and types of intraoperative biliary reconstruction. Associations were tested between reconstruction technique and complications, which included first biliary complication (BC; leak, stricture, or biloma) and first vascular complication (VC; hepatic artery thrombosis [HAT] or portal vein thrombosis [PVT]). Time to patient death, graft failure, and complications were estimated using Kaplan-Meier curves and tested with log-rank tests. Median posttransplant follow-up was 1.2 years. Associations were found between the type of biliary reconstruction and the incidence of VC (P = 0.03) and BC (P = 0.05). Recipients with Roux-en-Y hepaticojejunostomy had the highest probability of VC. Recipients with biliary reconstruction involving the use of high biliary radicals on the recipient duct had the highest likelihood of developing BC (56% by 1 year) compared with duct-to-duct (42% by 1 year). In conclusion, the varied surgical approaches in the A2ALL centers offer a novel opportunity to compare disparate LDLT approaches. The choice to use higher biliary radicals on the recipient duct for reconstruction was associated with more BC, possibly secondary to devascularization and ischemia. The use of Roux-en-Y biliary reconstruction was associated with VCs (HAT and PVT). These results can be used to guide biliary reconstruction decisions in the setting of anatomic variants and inform further improvements in LDLT reconstructions. Ultimately, this information may contribute to a lower incidence of technical complications after LDLT. Liver Transplantation 23 1519-1530 2017 AASLD.
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Affiliation(s)
- Talia B. Baker
- Department of Surgery, University of Chicago Medicine, Chicago IL
| | | | | | - Benjamin Samstein
- Department of Surgery, Columbia University College of Physicians and Surgeons, New York, New York
| | - Elizabeth A. Pomfret
- Division of Transplant Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - James J. Pomposelli
- Division of Transplant Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | | | - Carl L. Berg
- Division of Gastroenterology, Department of Medicine, Duke University Medical Center, Durham, NC
| | - Jean C. Emond
- Department of Surgery, Columbia University College of Physicians and Surgeons, New York, New York
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18
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Feng S. Living donor liver transplantation in high Model for End-Stage Liver Disease score patients. Liver Transpl 2017; 23:S9-S21. [PMID: 28719072 DOI: 10.1002/lt.24819] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 06/28/2017] [Indexed: 01/02/2023]
Affiliation(s)
- Sandy Feng
- Department of Surgery, Division of Transplant Surgery, University of California, San Francisco, San Francisco, CA
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Live Donors of the Initial Observational Study of Uterus Transplantation—Psychological and Medical Follow-Up Until 1 Year After Surgery in the 9 Cases. Transplantation 2017; 101:664-670. [DOI: 10.1097/tp.0000000000001567] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Lavoué V, Vigneau C, Duros S, Boudjema K, Levêque J, Piver P, Aubard Y, Gauthier T. Which Donor for Uterus Transplants. Transplantation 2017; 101:267-273. [DOI: 10.1097/tp.0000000000001481] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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21
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Baker TB. Living liver donation, donor safety, and social media: Preparing for a new frontier. Liver Transpl 2017; 23:131-132. [PMID: 28006869 DOI: 10.1002/lt.24698] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 11/29/2016] [Indexed: 01/13/2023]
Affiliation(s)
- Talia B Baker
- Liver Transplant Institute, University of Chicago Medicine, Chicago, IL
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22
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Cronin DC, Cronin TM. Twenty years of Milan criteria and live-donor liver transplantation in the US: a contrast in transparency, regulation, and expectation. Hepatobiliary Surg Nutr 2016; 5:495-497. [PMID: 28124006 PMCID: PMC5218913 DOI: 10.21037/hbsn.2016.12.07] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 11/11/2016] [Indexed: 11/06/2022]
Affiliation(s)
- David C. Cronin
- Transplantation Surgery, Porter Adventist Hospital, Denver, CO, USA
| | - Timothy M. Cronin
- Department of Chemistry, University of Chicago, Chicago, Illinois, USA
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Olbrisch ME, Benedict SM, Haller DL, Levenson JL. Psychosocial Assessment of Living Organ Donors: Clinical and Ethical Considerations. Prog Transplant 2016; 11:40-9. [PMID: 11357556 DOI: 10.1177/152692480101100107] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
This article outlines psychosocial and ethical issues to be considered when evaluating potential living organ donors. Six types of living donors are described: genetically related, emotionally related, “Good Samaritan” (both directed and nondirected), vendors, and organ exchangers. The primary domains to be assessed in the psychosocial evaluation are informed consent, motivation for donating and the decision-making process, adequacy of support (financial and social), behavioral and psychological health, and the donor-recipient relationship. Obstacles to the evaluation process include impression management, overt deception, minimization of behavioral risk factors, and cultural and language differences between the donor and the evaluator. Ethical concerns, such as the right to donate, donor autonomy, freedom from coercion, nonmaleficence and beneficence in donor selection, conflicts of interest, “reasonable” risks to donors, and recipient decision making are also explored. To fully evaluate living organ donation, studying psychosocial as well as medical outcomes is crucial.
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Affiliation(s)
- M E Olbrisch
- Medical College of Virginia of Virginia Commonwealth University, Richmond, Va., USA
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24
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Otte JB. Pediatric liver transplantation: Personal perspectives on historical achievements and future challenges. Liver Transpl 2016; 22:1284-94. [PMID: 27096329 DOI: 10.1002/lt.24470] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 04/13/2016] [Indexed: 02/06/2023]
Abstract
This review presents the author's personal perspective and contributions to the first steps, the development, the current status, and the remaining issues of pediatric liver transplantation (LT). Innumerable children around the world who have undergone LT have reached adulthood. The techniques have reached maturity. As shown by my own group's experience, grafts donated by living donors might provide the best short-term and longterm results. Debate persists about the optimal immunosuppression (IS), although the place of tacrolimus remains unchallenged. Tolerance induction protocols aiming to induce microchimerism have been tried in clinical transplantation without convincing results. Withdrawal of maintenance IS is possible in some children who underwent liver transplantation who have excellent clinical status and normal liver function tests but is not without risk of rejection and subsequent worsening of histology. The current trend favored by the Brussels' group is to minimize IS as soon after transplant as possible, aiming to obtain a state of "prope" or "almost" tolerance. Liver grafts are threatened in the long term by increasing hepatitis-related fibrosis, resulting most likely from immunological assault. Nowadays, the focus is on the longterm survival, quality of life (growth, academic performance, employment, self-fulfillment, fertility, raising a family, etc.), induction of tolerance, prevention of risks bound to decades of IS (nephrotoxicity and neurotoxicity, cardiovascular risk, de novo malignancies, etc.), and prevention of graft fibrosis. All these issues are fertile fields for younger scientists. Liver Transplantation 22 1284-1294 2016 AASLD.
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Affiliation(s)
- Jean-Bernard Otte
- Department of Pediatric Surgery and Liver Transplantation, Cliniques Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
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25
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Live Donor Liver Transplantation: An International Perspective. Transplantation 2016; 100:1182-3. [PMID: 27203591 DOI: 10.1097/tp.0000000000001220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Innovation is responsible for most advances in the field of surgery. Innovative approaches to solving clinical problems have significantly decreased morbidity and mortality for many surgical procedures, and have led to improved patient outcomes. While innovation is motivated by the surgeon's expectation that the new approach will be beneficial to patients, not all innovations are successful or result in improved patient care. The ethical dilemma of surgical innovation lies in the uncertainty of whether a particular innovation will prove to be a "good thing." This uncertainty creates challenges for surgeons, patients, and the healthcare system. By its very nature, innovation introduces a potential risk to patient safety, a risk that may not be fully known, and it simultaneously fosters an optimism bias. These factors increase the complexity of informed consent and shared decision making for the surgeon and the patient. Innovative procedures and their associated technology raise issues of cost and resource distribution in the contemporary, financially conscious, healthcare environment. Surgeons and institutions must identify and address conflicts of interest created by the development and application of an innovation, always preserving the best interest of the patient above the academic or financial rewards of success. Potential strategies to address the challenges inherent in surgical innovation include collecting and reporting objective outcomes data, enhancing the informed consent process, and adhering to the principles of disclosure and professionalism. As surgeons, we must encourage creativity and innovation while maintaining our ethical awareness and responsibility to patients.
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Affiliation(s)
- Megan E Miller
- Department of Surgery, The University of Chicago Medicine, 5841 S. Maryland Avenue, MC6040, Chicago, IL, 60637, USA,
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29
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"Current state and prospects in managing liver transplanted children". Clin Res Hepatol Gastroenterol 2015; 39:292-5. [PMID: 25241997 DOI: 10.1016/j.clinre.2014.08.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2014] [Revised: 08/27/2014] [Accepted: 08/27/2014] [Indexed: 02/04/2023]
Abstract
Pediatric liver transplantation (LTx) has revolutionized life chances and perspectives of children with liver disease. Following rapid establishment of the therapeutic concept in the early years of pediatric transplant medicine, more aspects beyond plain survival become increasingly important. In addition to improving the short to medium-term survival rates, researchers are focusing on themes such as rehabilitation, adherence and quality of life, long-term graft fibrosis and dysfunction, as well as the consequences of long-term immunosuppression. Also, more protocol biopsy data are available to evaluate increasing graft fibrosis. To manage their conditions, patients will need access to highly experienced pediatric liver transplant centers where clinical research will examine modulators of renal disease, endocrine and cardiovascular comorbidity and the development of graft fibrosis and malignancies. Assessment and evaluation of health-related quality of life and factors which influence clinical tolerance, adherence and transition from child to adult care will also be investigated. The analysis of multi-national registry data and more than 40years of experience with large patient cohorts will provide important clues to treatment and will thus get increasing attention. In the future, longitudinal assessment of the outcome for pediatric LTx patients should include more functional aspects than plain survival rates or laboratory parameters.
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Yang B, Zan RY, Wang SY, Li XL, Wei ML, Guo WH, You X, Li J, Liao ZY. Radiofrequency ablation versus percutaneous ethanol injection for hepatocellular carcinoma: a meta-analysis of randomized controlled trials. World J Surg Oncol 2015; 13:96. [PMID: 25889181 PMCID: PMC4355988 DOI: 10.1186/s12957-015-0516-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 02/14/2015] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Radiofrequency ablation (RFA) and percutaneous ethanol injection (PEI) are treatment methods for patients with early-stage hepatocellular carcinoma (HCC) who are not suitable for surgery. Although some reports indicate that RFA is better than PEI, results from previous reviews and analyses are inconsistent. Therefore, this meta-analysis was performed to more thoroughly evaluate the effects of these treatments in patients with HCC. METHODS A literature search was conducted using the Excerpta Medica dataBASE, PubMed, the Cochrane Library, the American Society of Clinical Oncology database, the China National Knowledge Infrastructure database, the Wanfang database, the Chinese Biomedical Literature Database, and the Chongqing VIP database without language limitations. The primary outcome evaluated was overall survival, and secondary outcomes included complete response and local recurrence. Comparisons were made between Asian and European studies. RESULTS Total pooled and subgroup analyses of Asian studies that included selection biases revealed that RFA is superior to PEI with respect to overall survival (hazard ratio (HR), 0.54; 95% confidence interval (CI), 0.37 to 0.80; P < 0.01) and complete response (relative risk (RR), 1.10; 95% CI 1.03 to 1.18; P < 0.01). However, no significant difference was observed between RFA and PEI in the European studies. In Asian studies, RFA was associated with a lower local recurrence rate than PEI at 1 year (RR, 0.44; 95% CI 0.20 to 0.95; P < 0.05) and 3 years (RR, 0.35; 95% CI 0.22 to 0.55; P < 0.01). However, local recurrence was significantly lower after only 3 years in European studies (RR, 0.50; 95% CI 0.32 to 0.78; P < 0.05). CONCLUSIONS RFA was only superior to PEI in Asian studies that included selection bias. Thus, there is insufficient evidence to support the idea that RFA is superior to PEI for patients with cirrhotic HCC. Additional large-scale, multicenter, randomized controlled trials that control for selection bias are needed to fully elucidate the optimal treatment method for HCC.
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Affiliation(s)
- Biao Yang
- Department of Abdominal Oncology, West China Hospital, West China Medical School, Sichuan University, No. 17 Renming Road, Chengdu, 610000, People's Republic of China.
| | - Rui-yu Zan
- Department of Abdominal Oncology, West China Hospital, West China Medical School, Sichuan University, No. 17 Renming Road, Chengdu, 610000, People's Republic of China.
| | - Shi-yu Wang
- Department of Radiology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
| | - Xiang-lian Li
- Chinese Evidence-Based Medicine Centre, West China Hospital, West China Medical School, Sichuan University, No. 17 Renming Road, Chengdu, 610000, China.
| | - Mao-ling Wei
- Chinese Evidence-Based Medicine Centre, West China Hospital, West China Medical School, Sichuan University, No. 17 Renming Road, Chengdu, 610000, China.
| | - Wen-hao Guo
- Department of Abdominal Oncology, West China Hospital, West China Medical School, Sichuan University, No. 17 Renming Road, Chengdu, 610000, People's Republic of China.
| | - Xin You
- Department of Abdominal Oncology, West China Hospital, West China Medical School, Sichuan University, No. 17 Renming Road, Chengdu, 610000, People's Republic of China.
| | - Jing Li
- Chinese Evidence-Based Medicine Centre, West China Hospital, West China Medical School, Sichuan University, No. 17 Renming Road, Chengdu, 610000, China.
| | - Zheng-yin Liao
- Department of Abdominal Oncology, West China Hospital, West China Medical School, Sichuan University, No. 17 Renming Road, Chengdu, 610000, People's Republic of China.
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31
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Currie A, Brigic A, Blencowe NS, Potter S, Faiz OD, Kennedy RH, Blazeby JM. Systematic review of surgical innovation reporting in laparoendoscopic colonic polyp resection. Br J Surg 2015; 102:e108-16. [DOI: 10.1002/bjs.9675] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 09/18/2014] [Accepted: 09/19/2014] [Indexed: 11/09/2022]
Abstract
Abstract
Background
The IDEAL framework (Idea, Development, Exploration, Assessment, Long-term study) proposes a staged assessment of surgical innovation, but whether it can be used in practice is uncertain. This study aimed to review the reporting of a surgical innovation according to the IDEAL framework.
Methods
Systematic literature searches identified articles reporting laparoendoscopic excision for benign colonic polyps. Using the IDEAL stage recommendations, data were collected on: patient selection, surgeon and unit expertise, description of the intervention and modifications, outcome reporting, and research governance. Studies were categorized by IDEAL stages: 0/1, simple technical preclinical/clinical reports; 2a, technique modifications with rationale and safety data; 2b, expanded patient selection and reporting of both innovation and standard care outcomes; 3, formal randomized controlled trials; and 4, long-term audit and registry studies. Each stage has specific requirements for reporting of surgeon expertise, governance details and outcome reporting.
Results
Of 615 abstracts screened, 16 papers reporting outcomes of 550 patients were included. Only two studies could be put into IDEAL categories. One animal study was classified as stage 0 and one clinical study as stage 2a through prospective ethical approval, protocol registration and data collection. Studies could not be classified according to IDEAL for insufficient reporting details of patient selection, relevant surgeon expertise, and how and why the technique was modified or adapted.
Conclusion
The reporting of innovation in the context of laparoendoscopic colonic polyp excision would benefit from standardized methods.
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Affiliation(s)
- A Currie
- Department of Surgery, St Mark's Hospital, Harrow
| | - A Brigic
- Department of Surgery, St Mark's Hospital, Harrow
| | - N S Blencowe
- Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Bristol
| | - S Potter
- Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Bristol
| | - O D Faiz
- Department of Surgery, St Mark's Hospital, Harrow
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - R H Kennedy
- Department of Surgery, St Mark's Hospital, Harrow
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - J M Blazeby
- Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Bristol
- Division of Surgery, Head and Neck, University Hospitals Bristol NHS Foundation Trust, Bristol
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Olausson M, Johannesson L, Brattgård D, Diaz-Garcia C, Lundmark C, Groth K, Marcickiewizc J, Enskog A, Akouri R, Tzakis A, Rogiers X, Janson PO, Brännström M. Ethics of uterus transplantation with live donors. Fertil Steril 2014; 102:40-3. [DOI: 10.1016/j.fertnstert.2014.03.048] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 03/26/2014] [Accepted: 03/26/2014] [Indexed: 11/29/2022]
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Namm JP, Siegler M, Brander C, Kim TY, Lowe C, Angelos P. History and Evolution of Surgical Ethics: John Gregory to the Twenty-first Century. World J Surg 2014; 38:1568-73. [DOI: 10.1007/s00268-014-2584-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Abstract
The ethics of the clinical practice of transplanting human organs for end-stage organ disease is a fascinating topic. Who is the "owner" of the transplantable organs of a deceased, brain-dead patient? Who should have a right to receive these organs? Who set the boundaries between a living donor's autonomy and a "paternalistic" doctor? What constitutes a proper consent? These questions are only some of the ethical issues that have been discussed in the last 60 years. All of these ethical issues are intensified by the fact that supply of human organs does not match demand, and that, as a consequence, living-donor organ transplantation is widely utilized. The aim of this article is not to be exhaustive but to present the general ethical principles of beneficence, nonmaleficence, and justice as applied to organ transplantation. Moreover, the topic of reimbursement for organ donation is also discussed.
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Affiliation(s)
- Giuliano Testa
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center at Dallas, 3410 Worth Street, Suite 950, Dallas, TX, 75246, USA,
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35
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Nasr AS, Rehm RS. Parental Live Liver Donation: A Transformational Experience. Prog Transplant 2014; 24:69-75. [DOI: 10.7182/pit2014286] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background Parental live liver donation is an attractive alternative to deceased donation for pediatric patients with end-stage liver disease (ESLD), yet very little has been published about the long-term emotional consequences of live liver donations on donors and their families. Objectives To better understand the impact that a parental live liver donation has on the everyday life of the donor. Method Thirteen living parental donors from 2 West Coast transplant centers participated. Data included semistructured interviews, observations, and field notes about the donors and their physical, emotional, and familial lives since their donation. The perceived impact of donation on parental donors and their intrafamilial relationships are reviewed and the social and emotional context of parental liver donation, including impacts on the predonation decisions and life after donation are analyzed. Results Thematic analysis was used to analyze this set of interviews, and after open coding, 3 major categories emerged: a self-awareness process, a clarification of familial relationships, and a change in perspectives on community. The overarching theme that was constructed from the interviews suggested that the impact the donation had on the donors' lives was one of transformation.
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Affiliation(s)
- Annette Sue Nasr
- Lucile Packard Children's Hospital at Stanford, Palo Alto, California (ASN), University of California, San Francisco (RSR)
| | - Roberta S. Rehm
- Lucile Packard Children's Hospital at Stanford, Palo Alto, California (ASN), University of California, San Francisco (RSR)
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Szijártó A, Fujimoto Y, Izumi K, Shinji U. [Specific considerations in living-donor liver transplantation]. Orv Hetil 2013; 154:1417-25. [PMID: 23996923 DOI: 10.1556/oh.2013.29698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Due to the limited number of cadaver donors, adult living liver donor transplantation became an alternative for liver transplantation. During living liver donor transplantation, the safety and uncomplicated recovery of the donor are as important as the appropriate volume and weight of the donated graft. The middle hepatic vein causes a significant dilemma, due to the special anatomical position. The reconstruction of the middle hepatic vein branches supplying S5, S8 is suggested when the anatomically right liver lobe is transplanted. AIM The aim of the present study was to investigate the requirements of the reconstruction of middle hepatic vein and to give an accurate description about the discrepancy between the portal vein in- and outflow. METHOD The authors analyzed the liver anatomic characteristics of 130 donors undergoing living liver donor transplantation with the use of MeVis software. The so-called porto-hepatic disparity index (shift) was introduced. RESULTS The right hepatic vein was dominant in 64.6% of all cases, while the left hepatic vein was never observed to be dominant. The territories of V5 and V8 were responsible for the 33.2±8.9% of the right hepatic lobe area. The correlation between portal venous territory and vein dominancy were as follows: R2 = 0.7811 in the left liver lobe; R² = 0.5463 in the area of middle hepatic vein and R² = 0.5843 in the case of the right hepatic vein. The average value of the shift was 28.2%. CONCLUSIONS The differences among the pattern of portal in- and hepatic outflow is an important issue that should be taken into consideration when deciding the necessity for reconstruction of the middle hepatic vein.
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Affiliation(s)
- Attila Szijártó
- Semmelweis Egyetem, Általános Orvostudományi Kar I. Sebészeti Klinika Budapest Üllői út 78. 1082
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The Concept of Self and Emotional Involvement in Living Kidney Donation: A Psychometric Investigation. Transplant Proc 2013; 45:2604-6. [DOI: 10.1016/j.transproceed.2013.08.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Lavery JV, Green SK, Bandewar SVS, Bhan A, Daar A, Emerson CI, Masum H, Randazzo FM, Singh JA, Upshur REG, Singer PA. Addressing ethical, social, and cultural issues in global health research. PLoS Negl Trop Dis 2013; 7:e2227. [PMID: 23951371 PMCID: PMC3738463 DOI: 10.1371/journal.pntd.0002227] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- James V Lavery
- Centre for Research on Inner City Health and Centre for Global Health Research, Keenan Research Centre in the Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada.
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Transplantation: Partial liver grafts are safe for young children. Nat Rev Gastroenterol Hepatol 2013; 10:450-1. [PMID: 23835490 DOI: 10.1038/nrgastro.2013.124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
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40
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Kisu I, Mihara M, Banno K, Umene K, Araki J, Hara H, Suganuma N, Aoki D. Risks for donors in uterus transplantation. Reprod Sci 2013; 20:1406-15. [PMID: 23793471 DOI: 10.1177/1933719113493517] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Uterus transplantation (UTx) is an alternative to gestational surrogacy and adoption for patients with absolute uterine infertility. Studies have been conducted in animals, and UTx is now within the reach of clinical application in humans. Procedures in humans have been published, but many medical, ethical, and social problems and risks of UTx require discussion prior to widespread clinical application, from the perspectives of donors, recipients, families, and newborns. In this article, we summarize the burdens and risks of UTx, with a focus on donors who provide the uterus.
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Affiliation(s)
- Iori Kisu
- 1Department of Obstetrics and Gynecology, School of Medicine, Keio University, Tokyo, Japan
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41
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Shen A, Zhang H, Tang C, Chen Y, Wang Y, Zhang C, Wu Z. Systematic review of radiofrequency ablation versus percutaneous ethanol injection for small hepatocellular carcinoma up to 3 cm. J Gastroenterol Hepatol 2013; 28:793-800. [PMID: 23432154 DOI: 10.1111/jgh.12162] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIM Radiofrequency ablation (RFA) and percutaneous ethanol injection (PEI) have been used for patients with hepatocellular carcinomas (HCCs) < 3 cm, but there is controversy which of the two methods is superior. Therefore, we aimed to conduct a systematic review to assess survival, complete tumor necrosis, recurrence and metastasis, major complications, costs, hospital stays, and posttreatment survival quality of RFA versus PEI for treating small HCCs < 3 cm. METHODS We conducted a search for published articles in PubMed, Embase, and the Cochrane Library until March 2012. Only randomized controlled trials (RCTs) and quasi-randomized clinical trials were included. RESULTS Four RCTs with 766 patients were included in this review. We found that RFA is significantly better than PEI with respect to a 3-year overall survival for small HCCs (RFA vs PEI, hazard ratios [HR] = 0.66, 95% confidence interval [CI]: 0.48-0.90, P = 0.009), especially for HCCs > 2 cm (HR = 0.56, 95% CI: 0.31-0.99, P = 0.045). RFA had a lower risk of local recurrence (HR = 0.38, 95% CI: 0.15-0.96, P = 0.040), but no difference is seen for distant intrahepatic recurrence. RFA had higher rates of complete tumor necrosis, but RFA also caused more major complications and was more costly than PEI. Begg's and Egger's tests detected no significant publication bias among the four RCTs. CONCLUSIONS RFA appears superior to PEI with respect to local tumor control and 3-year survival for small HCCs < 3 cm. RFA was more feasible in patients with HCCs > 2 cm or Child-Pugh A liver function.
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Affiliation(s)
- Ai Shen
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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42
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Testa G, Carlisle E, Simmerling M, Angelos P. Living Donation and Cosmetic Surgery: A Double Standard in Medical Ethics? THE JOURNAL OF CLINICAL ETHICS 2012. [DOI: 10.1086/jce201223202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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44
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Yang HR, Jeng LB, Li PC, Lee CC, Poon KS, Chen TH, Yeh CC, Lai HC, Su WP, Peng C, Chen YF, Ho YJ. Living Donor Right Hepatectomy With Inclusion of the Middle Hepatic Vein: Outcome in 200 Donors. Transplant Proc 2012; 44:460-2. [DOI: 10.1016/j.transproceed.2012.01.060] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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45
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Wakata Y, Nakashima N, Taketomi A, Shirabe K, Maehara Y, Hagihara A. Factors associated with the postoperative status of donor patients for living donor liver transplantation. Liver Transpl 2011; 17:1412-9. [PMID: 21898769 DOI: 10.1002/lt.22427] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Deceased donor liver transplantation has been an established surgical procedure since the 1960s. More recently, the technique of living donor liver transplantation (LDLT) was introduced, and it is being performed with increasing frequency. However, there is a paucity of information on the clinical outcomes of donor patients. In this study, which was conducted at a single university hospital, the relationship between potentially relevant factors (eg, patient characteristics, preoperative status, and operation characteristics) and postoperative developments in donor patients was examined. We used electronic critical pathways, which are charts of medical process that include favorable states (defined as outcomes) to be achieved during the hospital stay of a patient; predefined outcomes that are not achieved are recorded as variances. With the electronic critical pathway system, objective data about the conditions of patients and relevant clinical processes could be collected readily. Using data from the electronic critical pathways for LDLT donor patients and applying multiple logistic regression analysis, we examined factors that were related to the variance of each outcome measure for postoperative developments. Among the various donor characteristics, the duration of the operation was related to variance in 5 types of health outcomes, age and blood loss volume were related to variance in 2 types of health outcomes, and other characteristics (ie, sex, body surface area, operation urgency, and volume ratio of the remnant liver) were related to variance in 1 type of health outcome. In conclusion, the findings in this study may facilitate improvements in the postoperative status of LDLT donor patients. Further studies that incorporate analogous data from other medical facilities are necessary to verify these findings.
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Affiliation(s)
- Yoshufumi Wakata
- Department of Health Services Management and Policy, Graduate School of Medical Science, Kyushu University, Fukuoka City, Japan
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Kapoor A, Bhatia V, Jain S, Sharma D, Jerath N, Wadhawan M, Gupta S, Sibal A. Pediatric Liver Transplantation. APOLLO MEDICINE 2010. [DOI: 10.1016/s0976-0016(12)60019-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Elective Surgical Patients as Living Organ Donors: A Clinical and Ethical Innovation. Am J Transplant 2010. [DOI: 10.1111/j.1600-6143.2010.03099.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Gruttadauria S, Francesco FD, Pagano D, Petri SL, Cintorino D, Spada M, Gridelli B. Liver resections for liver transplantations. World J Gastrointest Surg 2010; 2:51-6. [PMID: 21160850 PMCID: PMC2999215 DOI: 10.4240/wjgs.v2.i3.51] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2009] [Revised: 02/22/2010] [Accepted: 03/01/2009] [Indexed: 02/06/2023] Open
Abstract
Split-Liver and living-related donor liver transplantation are the newest and both technically and ethically most challenging developments in liver transplantation and have contributed to a reduction in donor shortage. We report the technical aspects of surgical procedures performed to achieve a partial graft from a cadaveric and a live donor.
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Affiliation(s)
- Salvatore Gruttadauria
- Salvatore Gruttadauria, Fabrizio di Francesco, Duilio Pagano, Sergio Li Petri, Davide Cintorino, Marco Spada, Bruno Gridelli, Mediterranean Institute for Transplantation and High Specialization Therapies, University of Pittsburgh Medical Center in Italy, Palermo 90127, Italy
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Letter to the Editor in Response to: Gordon et al., Elective Surgical Patients as Living Organ Donors: A Clinical and Ethical Innovation by Testa et al. Am J Transplant 2010. [DOI: 10.1111/j.1600-6143.2009.02989.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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