The new horizon of liver transplants? Organ regeneration and artificial intelligence. But also pharmacological molecules immunosoppressive innovative, laparoscopic and robotic surgery, new ways of preserving the organ through cold and hot perfusion machinesThe future of transplants in writing in our ability to invest today. We will have a future if we are capable of allocate resources to health and transplantation, warns the professor Paolo De Simone, director of the Operative Unit of Hepatic Surgery and Liver Transplantation, Pisa University Hospital. The first transplant performed in Pisa dates back to 1996: what has changed since then? Transplant number one was performed on January 3, 1996. The report of the historic night deposited in the memory of Professor Giandomenico Biancofiore, current director of the Anesthesia and Transplant Operative Unit. Of the team that performed the first intervention, Professor Franco Filipponi retired from 30 June 2018 and Professor Franco Mosca left us at the end of May last year. The patient was a 56-year-old woman who received a liver taken in Florence from a 47-year-old donor, says De Simone. Transplant number 2,500 was performed on February 25, 2021 in a 66-year-old patient while the liver was from an 81-year-old donor. The data already tells us what has changed. Recipients and donors are older than they were 25 years ago. Today we treat older patients and transplant older livers: we have been able to successfully transplant organs over ninety, reaching up to 97 years. The donor from 1996 was a patient victim of road trauma, the current one an elderly individual hospitalized for cerebrovascular disease. These are, in short, the most important epidemiological changes.
What are the main peculiarities of the intervention?
It is about one of the most complex surgeries in modern medicine. Liver replacement requires technical skills in general, hepatic and vascular surgery; knowledge of the functioning of the liver and its diseases; identification of the most appropriate therapies and management of any complications for the entire life span of the transplant patient. In particular, the transplant consists of three stages: the removal of the diseased organ; l’implantation of the new organ with the connection of its vascular and biliary structures, and the final stage of control of sources of bleeding. The procedure can make use of particular technical tools, such as the extracorporeal circulation or be associated with other surgical procedures in very special cases. I would like to point out that the liver transplant rit requires considerable anesthetic and intensive care in the pre, intra and post-operative period. The anesthetic team is as important as the surgical team for the success of the transplant. Indeed, the growing care complexity of the transplant patient population pays off the role of the anesthetist is increasingly important transplantation and its integration with surgeons, hepatologists, nurses and technicians.
What about the most frequent surgical and medical complications?
Contrary to what one might commonly imagine, organ rejection is not the most frequent or most fearful complication. Its incidence is about 3-4 percent in the first year after transplant and in most cases the rejection is treatable with drug treatments. The most frequent complications the biliary ones remain and these may interest a About 20 percent of transplant patients. These are complications related to the decrease in oxygen supply to the liver and biliary tract during the procedure of collection in the donor and implantation in the recipient. These complications are followed by i vascular problems arterial or venous, affecting about 5 percent of transplant patients. Then the complications related to immunosuppressive drugs, which must be taken after the transplant for life and which may in the long run impair kidney function, lead to diabetes or hypertension. Today, however, we have learned how to make better use of these drugs and take early action to mitigate their side effects.
How does a transplant patient live today?
The quality of life satisfactory in most cases e excellent in some. It is the patients themselves who tell us this with scientific studies and daily reports. At the international level, theaverage survival rates of 88 percent one year after transplantation and about 70 percent after five years. In Italy, even higher. However, there are still categories of patients who they cannot fully return to a normal life, particularly the elderly or those with complications and those requiring later hospitalizations after transplantation. It is necessary to consider that for them transplantation represents the only possibility of life in the face of very serious terminal illnesses.
What awaits us in the coming years?
Here in Pisa we have worked and are working in numerous sectors: we have tested new immunosuppressive pharmacological molecules and we are currently conducting some experiments to find less toxic drugs for our patients and that they can improve their daily life. We are working on new ways of preserving the liver using cold and hot perfusion machines and experimenting with the implantation of drugs in the liver to improve quality and improve results after transplantation. We carry out a national study of donors with cardiac criteria. We are developing artificial intelligence systems to “read” the data stored in many years of activity and to be able to develop predictive systems that allow to predict the outcome and risks of the transplant. We have also developed laparoscopic and robotic liver surgery techniques to be used before transplantation for patients with liver tumors. We are working on new oncological indications in transplantation in collaboration with national centers and, finally, the possibility of suspending immunosuppressive therapies in some transplant patients.
Transplant Oncology: what is it all about?
The most important evolution-revolution of liver transplantation is its expansion in the treatment of cancer patients: the so-called “Transplant Oncology” of primary and metastatic liver tumors. The decline in virus-induced cirrhosis (especially for anti-hepatitis C drugs) and the emergence of regenerative medicine help to save more and more organs allowing their use for the many patients with cancer. Italian research stands out for the use of increasingly precise criteria able to identify tumors in which transplantation can be a real tool for healing or improving the quality and quantity of life, explains the Professor Vincenzo Mazzaferro, University of Milan, National Cancer Institute Irccs Milan, among the world experts in the sector.
How did the transplant system work in the pandemic?
Nationally, the transplant network essentially withstood the impact, although donations and transplants have been affected. The suffering of the system as a whole has heavily affected: the donation processes were conducted in critical organizational conditions. It should be considered that specialist services, laboratories, diagnostic procedures are usually activated which, in the course of a pandemic, tend to a scarcely modifiable decline in efficiency. Even if, for example, regions such as Tuscany have approved provisions to “protect” the system, he observes Adriano Peris, director of Ott (Tuscan Transplant Organization).
April 9, 2021 (change April 9, 2021 | 18:40)
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