Liver transplantis a challenging surgery which requires skilled multidisciplinary team-Dr. Khalid Sharif


 Organ Transplant in Children

Liver transplantis a challenging surgery
which requires skilled multidisciplinary
team - Dr. Khalid Sharif

Five year survival after liver transplant is 84% and it is growing

LAHORE: Dr. Khalid Sharif a noted Hepato Biliary Surgeon from Birmingham UK was one of the key note speakers at the Plenary Session during the recently concluded  11th Annual Symposium  of Children’s Hospital and Institute of Child Health Lahore.  He spoke on organ transplants in children. In his presentation he discussed at length the history, indications and contra indications for liver transplant. Thomas Starz, he said, first attempted liver transplant in1963 but the patient died on the table and the liver could not be taken out. The aim of liver transplant, Dr. Khalid Sharif opined should be that the patient returns to high quality of life, has normal growth and development, can become productive member of the society and have normal life expectancy.

Primary indications for liver transplant Dr. Khalid Sharif said include metabolic diseases, cirrhosis and cancers etc. The number of contra indications has now reduced significantly. Systematic sepsis, life threatening hepatic disease and malignancy are now considered as contra indications for liver transplantation. Continuing Dr. Khalid Sharif said that liver transplantation was a multidisciplinary team work in which each member has an important role to play.The team consists of surgeon, nurses, doctors, intensive care staff, social workers, and teachers. Therapists and physiotherapists are all very important.

Main sources of liver are cadaver, living donor transplantation but Xeno transplants may be possible in the days to come. There is no ready made solution for all the problems. For children, a portion of liver is taken out from the donors. There is a need to establish a cadaver programme to ensure regular supply of organs for transplantation. Liver transplant requires skilled multidisciplinary team and it is a challenging surgery.Post-transplant management was extremely important. Availability of organ has to be ensured and the staff working in this programme cannot expect any holiday as they might get a donor any time and they will be required to undertake the procedure. When the organ becomes available the transpolar team is supposed to do the procedure then and there. He also referred to life saving medications required for these patients and likely complications. He then talked about pre-transplant programme, screening of the patient and the donors which is again extremely important. Change of life style of the patient after BMT are important and they have to stop smoking if they are smokers. It is not a cure and it has its own mortality, he remarked. 

Speaking about the complications Dr. Khalid Sharif mentioned rejection, infection and delayed closure of abdomen.  Sepsis accounts for about 10-30%, acute rejection 10-20% and chronic rejection 5%.  Now there is increasing survival after liver transplantation but the problem is lifelongmedications and how the patients are going to adhere to it. The patient suffer from chronic life time illness. Adolescents can be non-compliant, patients will have to carry stoma withthemand they need to be mentally prepared for this. Five years liver transplant survival is about 84% and it is growing.

Talking about the future Dr. Khalid Sharif mentioned cell therapy, stem cell, Gene therapy. Organogenesis is going to happen but it will have challenges. It is extremely important that we keep in mind the basic principles of medical ethics i.e.  Autonomy, Beneficence, Non-maleficence and Justice.  Post-operative services need to be standardized, he concluded.

During the discussion one of the participants asked do we really need transplant programme while a vast majority of our patients were dying due to preventablediseases? We have poor EPI coverage, hence we do not need to give too much importance to organ transplantation. Prof. Sajid Maqbool who was chairing the session along with other eminent guests opined that we must use technology for the patient’s benefit. It was also emphasized that we need to know how to build multidisciplinary teams in India and Pakistan. How to involve and respect other healthcare professionals in the team like nurses. The importance of collaboration between India, Pakistan and UK was also highlighted while starting a collaboration programme between India and Pakistan was also proposed.

Dr. Staish Rao spoke on “Difficult asthma-is it asthma or not”. He discussed a number of cases of poorly controlled asthma and also depicted a number of X-Ray films. One of the patient was suffering frombronchogenic cyst but it was treated as asthma. In such patients symptoms will not go away, the patients do not respond to steroids. We usually tend to ignore cough. Asthma patients must be wheezing and those children who fail to thrive do not have asthma, he remarked. Patients are prescribed metered dose inhalers but many of the patients do not know how to use it or do not use it properly. Compliance is yet another problem. Patients need to be educated on the use of bronchodilators, inhaled steroids. Since the doctors are too busy and do not have time, one should train the nurses to educate the patients.

 He also referred to severe asthma treatment protocol and opined that one should reduce the dose of steroids after careful patient selection. At our center, almost 90% of patients respond to steroids, he added. We cannot predict responders. Clinical monitoring is important and one must ensure that ithas minimum impact on lung function. We usually stop treatment after two years. They are free of disease and remain so for many years. The important point to remember was that if there is no wheeze, it is not asthma.  It is extremely important that we must get our basics right, rule out other alternate diagnosis and other diseases, he added.

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