Chat transcript: Amadeo Marcos on living donor liver transplants
August 9, 1999
Web posted at: 12:44 p.m. EDT (1644 GMT)
(CNN) -- Dr. Amadeo Marcos, with the Medical College of Virginia,
did the first unrelated living-donor liver transplant a year ago and has done 27 since then. Most have been between husbands and wives. The following is an edited transcript of a chat with Marcos that took place Friday, August 6, 1999.
Chat Moderator: Welcome, Dr. Amadeo Marcos!
Chat Moderator: Dr. Marcos, you have now done 35 living donor transplants. How dangerous are they for the donor?
Dr. Amadeo Marcos: Yes, that is correct. We have performed 35 adult-to-adult living donor liver transplants in a year and a half. The surgery for the donor is of high risk due to the liver itself and the surgery of the liver.
Chat Moderator: Since it isn't necessary to be related to the person in need, how do you find your donors?
Dr. Amadeo Marcos: No, it is not necessary to be related to the recipient. When we say "related," it means "blood-related." A friend, spouse or relative can be a donor for a liver patient. In the Medical College of Virginia, 40 percent of our donors are non-related to the recipient.
paul: Greetings, Doc! You saved my buddy Bruce's life with this procedure. He looks great. She looks great! THANK YOU!
Dr. Amadeo Marcos: Yes, thank you, Paul, for your comment. The result speaks for itself. They look wonderful, and they are waiting for a baby next month.
plucker: What is the percentage of non-related liver transplant recipients who are still doing well after approximately five years?
Dr. Amadeo Marcos: The fact that they are related or non-related does not seen to affect the survival or status of the recipient. With this new procedure of living donors between adults, we still do not have enough cases and enough follow-up to be able to answer the second part of the question. Most of the serious like ours are one and a half to 2 years old.
Chat Moderator: Can you explain how this procedure works?
Dr. Amadeo Marcos: The donor operation, when doing transplants between adults, consists in the removal of the right lobe of the liver. For this to happen, the vessels that go into the right lobe and vessels that come off the right lobe have to be isolated and reserved. The bile ducts that go into the right lobe also have to be isolated. Then transection (cutting) of the liver is then performed while tying out all the little vessels as you go through the liver. The operation has to ensure that the left lobe that is left in the donor has adequate inflow and outflow and no damage to its own bile ducts. The recipient operation is a standard orthotopic liver transplant that accommodates for the now-different size in vessels. The bile ducts are then performed rerouting the small bowel to accommodate them.
JoeCNN: Those vessels that come off the right lobe in the donor, and the bile ducts going to the right lobe -- are they ever "opened up" again? Does that "regenerated lobe" ever function again?
Dr. Amadeo Marcos: The liver that is left in the donor (left lobe) will regenerate almost to full size within 14 days after surgery. Nevertheless, the liver will not grow the vessels or bile ducts that were removed with surgery, and those vessels therefore will not reopen again.
Sunny1: Can this procedure be done with other organs, or just the liver?
Dr. Amadeo Marcos: Living donors have been used for kidney transplants for quite a long time now, though the liver is unique in its ability to regenerate. Therefore, with a donor in a kidney transplant, the same phenomenon will not occur.
paul: There is much debate in D.C. about organ allocation. HHS (Department of Health and Human Services) is trying to change things. Not getting too much into the thorny details of the national/regional proposals, is your split liver procedure mentioned, affected or impacted by the proposed regulations?
Dr. Amadeo Marcos: Today we are talking about living donor transplants, which is a graft (organ) that comes from a living donor. Splitting of organs is related to cadaveric organs. Therefore, splitting is influenced by new regulation or change in policy. One advantage of the living donor transplant is that even though patients are listed, following United Network for Organ Sharing (UNOS) criteria, still they do not depend on any policy of organ allocation.
JoeCNN: I think that's sort of significant, because the press has been reporting "The liver grows back in a week!" And that implies "everything is normal." But the "drainage" blood vessels don't grow back, and you are left with half the bile duct.
Dr. Amadeo Marcos: Joe, what I said about vessels and bile ducts, about not growing again, I was referring to main vessels and main bile ducts. Your question was more directed to the small vessels and small bile ducts, and those will grow with the liver that is left behind, and this is what explains how the liver can grow back to full size within 14 days.
Dave1: Are living donors favored over cadaver organ donors?
Dr. Amadeo Marcos: Living donors will never take the place of cadaveric donors. If we were confronted with the situation in which we had at the same time a living donor and a cadaveric donor for the same patient, we will do the cadaveric donor that ensures a working organ without any risk to the donor. The two procedures, which are the donor operation and the recipient operation, overlap in a way that we try to take the organ out from the donor and put it into the recipient without having it sit on ice for more than an hour. Both surgeries together last around 13 to 14 hours, with the donor operation lasting about seven to eight hours and the recipient operation lasting six to seven hours. For this to happen, two teams of surgeons have to be working simultaneously on both the donor and recipient. And that says that this procedure can only be done by centers that have a roundup group of surgeons that can operate at the same time.
Chat Moderator: What is required in order to qualify to be a donor?
Dr. Amadeo Marcos: In order to be a donor, the only motive should be the altruistic desire of helping someone else's life. After this, the donor and the recipient have to be of compatible blood groups, and the donor has to undergo a series of evaluations. That ensures that they have no medical disease that would put them at risk during surgery, that they have no infectious diseases that could be passed on to the recipient, and of course that they have no problems related to the liver function. They also have to undergo a series of tests designed to study the anatomy of the liver in order to plan the surgery.
Lady: What are some of the risks associated with being a donor?
Dr. Amadeo Marcos: The risks related to being a donor start with the preoperative evaluation. All the invasive tests performed have some risks, even though minimal. Surgery itself is a high-risk procedure because of the nature of the liver. We still do not have the experience to be able to quote accurate statistics as to the real risks involved with this technique. At the Medical College of Virginia, we quote our patients with the statistics that come from performing the same procedure for other indications (cancer, trauma, etc.), and these statistics show a 30 percent morbidity and a 5 percent mortality risk. We have seen that the complications related to the donors so far have been insignificant, but it is still too early to determine what is the real risk involved in this surgery. And therefore we consider it safe to quote to the potential donors those statistics that come through many years of surgical experience.
JoeCNN: Morbidity being some illness or degraded health, and mortality being death?
Dr. Amadeo Marcos: Morbidity means complications (any complications) related to the procedure itself. Mortality means death. We do not have enough numbers so far; there have only been 65 procedures done so far.
Dave1: Does the recipient need to take cyclosporin the rest of his life?
Dr. Amadeo Marcos: Dave, the recipient of a living donor transplant will take immunosuppression drugs for the rest of his life, including cyclosporin, like any other transplant patient in the world would. The donor does not have to take any medicines after the normal postoperative. They usually leave the hospital after surgery within five days, some in three days, and they are able to return to their usual activities within a month after surgery.
Lady: Are animal organs still being considered as experimental surgery?
Dr. Amadeo Marcos: Yes, transplants using animal organs (xenotransplantation) have not been performed in humans in a consistent basis and therefore are experimental.
paul: What are the biggest challenges facing this surgery in the future? Education? Costs? Drugs? Institutional resistance? Government regulations?
Dr. Amadeo Marcos: Our biggest obstacle nowadays is that insurance companies will accept this procedure as standard for patient care. The results so far have indicated that it is comparable to cadaveric liver transplant with the advantage that it can be performed when a donor is available and not when the patient is so sick and waiting for a long time on a list.
Chat Moderator: What are the possible complications in an adult-to-adult live-donor liver transplant vs. the possible complications in an adult-to-child live-donor transplant?
Dr. Amadeo Marcos: The complications in adult-to-adult are foreseen to be higher than those from adult to child or pediatric recipient, and this is a consequence of having to remove a much more significant amount of liver to perform the operation. This increases the chances of complications in the donor. At our center, we still have not seen significant complications in donors, but the risk is always there. For the recipient of either adult-to-adult or adult-to-pediatric, the risks involved are the same as any cadaveric liver transplant recipient.
worldtraveler63: What is the estimated number of lives this new transplantation may save on a yearly basis?
Dr. Amadeo Marcos: At the Medical College of Virginia, almost 50 percent of the patients that undergo liver transplant are through a living donor. This can potentially cover 30 to 40 percent of all patients on a waiting list in a center that has the capabilities to offer this procedure. Considering that 12 to 15 percent of the patients on the nation's waiting list will die because they cannot get a transplant, this technique therefore can meet the demand and significantly decrease mortality on the waiting list.
Dave1: What's the latest on liver cell implantation?
Dr. Amadeo Marcos: Liver cell implantation or transplantation has mainly been used as a bridge for patients that are waiting for organs while the organ becomes available. In this context, cell transplantation plays a role in delivering patient care when dealing with fulminating liver patients.
Chat Moderator: How many places across the country are doing this?
Dr. Amadeo Marcos: Live donor adult-to-pediatric transplants are performed in many centers in America. Adult-to-adult living-donor transplants are performed in a handful of centers consistently at the present time.
Dave1: Do you collaborate with other centers outside your region and pool knowledge and experiences, or are you competitive with each other?
Dr. Amadeo Marcos: The transplant community is totally unified when it comes to breakthrough techniques that can end up saving lives. At the end of the month (August 25, 1999) in Pittsburgh, the first U.S. living donor symposium will be held, in which different centers from America and the world will share their experiences with this breakthrough procedure.
Evangeline: Can you address this hypothetical? A female PBC (primary biliary cirrhosis) patient, age 45, having had the disease since at least 1986 but only being definitely diagnosed in 1996, is doing extremely well on ursodiol and colchicine. What is the likelihood of transplant; would this type be a possibility; and could an adult nephew be a possible donor?
Dr. Amadeo Marcos: In order to qualify for a living donor in a liver transplant, you have to qualify for a cadaveric transplant. One must meet listing criteria. This is the way we set this procedure so far. Yes, the nephew can be considered to be a living donor provided he is at least 21 years old and he undergoes the whole donor evaluation.
Chat Moderator: How has the increase in hepatitis C affected the need for liver transplants?
Dr. Amadeo Marcos: Hepatitis C is the single most frequent indication for transplantation in America. Since we don't have today any effective therapy against the virus, I can foresee more and more patients in need for liver transplants in the future.
beuller: Is it true that you have called past recipients and sung "Happy Birthday" to them on their transplant anniversary?
Dr. Amadeo Marcos: LOL beuller, yes, I have, but I have to admit that I'm a very lousy singer.
Chat Moderator: What do you see as the future of live-donor liver transplants? Will we see this kind of surgery on an increasing basis?
Dr. Amadeo Marcos: Living donor transplants will play a major role in transplantation in the next century. In the last five years we have seen almost the same amount of cadaveric donors available in our nation,
whereas we have in the same time seen an increase in patients joining the transplant list. The living donor program is a way to meet this demand. And as this method is performed in more qualified centers, at the end, less patients will die while waiting for donors. Up to date, there is no other significant solution to the organ shortage.
veronica: Where did you go to medical school?
Dr. Amadeo Marcos: I attended the Universidad Central Venezuela.
Chat Moderator: Doctor, do you have any final comments?
Dr. Amadeo Marcos: Transplant decisions would not have considered a living donor if there were organs available or conventional cadaveric transplantation could have met the significant increase in demand. The disadvantage of this procedure (living donor) will always be ethical issues, subjecting a healthy person to a high-risk surgery. The donor and the recipient and their families want to have control in the otherwise desperate situation which, if a patient joins a list for transplantation and does not have an organ available, will die of liver failure. Transplant decisions can then provide this technology to bring the donor and recipient together in the main goal, saving lives. Again the risks are immense, but it is all done with the intent to save lives.
paul: Got to go. God bless you, Dr. Marcos. Keep up the great work, and give Bruce a hard time for me!
Dr. Amadeo Marcos: OK, paul :)
Chat Moderator: Thank you, Dr. Amadeo Marcos, for joining us to discuss living liver transplant donors.
Dr. Amadeo Marcos: Thank you. The media play a significant role in making this known. And that itself helps the fight for this organ shortage. Thank you all!
Sharing your liver with a stranger
July 21, 1999
Medical College of Virginia
United Network for Organ Sharing
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