Juggling in the OT

  • Multi-organ transplants represent a high level of interdisciplinary medical care. Even in the west, only the most mature transplant programmes do them.

A young man from rural Tamil Nadu had been suffering from progressive jaundice, bloated abdomen, fatigue and breathlessness for around eight years. He was diagnosed with a congenital developmental anomaly that prevented his heart from functioning well. This led to increased pressure on the veins connecting the heart and liver, which in turn led to liver failure. A combination of end stage heart failure and end stage liver failure ruled out treatment options. The only solution was combined transplant of the two organs.

On October 14, 2015, the young man underwent surgery—Asia’s first en-bloc combined heart and liver transplant—at Apollo Hospitals, Chennai. Single organ transplantation is being undertaken in several centres in India. Multi-organ transplants, however, represent a different level of interdisciplinary medical care. Even in the west, only the most mature transplant programmes attempt them.

Apollo Hospitals, Chennai, has over the years evolved such an interdisciplinary environment. The hospital has done the most number of combined heart and lung transplants in India. It has also done this for the second oldest man in the world to ever receive this operation successfully.

Untreated, single organ dysfunction can affect other organs, too. The heart and lung are intimately connected, physically and functionally. Therefore, failure of one will eventually lead to failure of the other. Patients with end stage heart disease can develop irreversible damage to lungs and vice versa.

In the past, nothing could be done for such patients. But, now, with the help of a variety of devices—such as ventricular assist devices which could be short term or long term or artificial lungs or combined artificial heart and lungs called extra corporeal (outside the body) life support machines (also called ECMO)—it is possible to stabilise these patients and improve their condition while they wait for a transplant.

Most multi-organ transplants are more challenging because the patients requiring the transplants tend to be sicker. The operations themselves are longer and technically more difficult. The post-operative care requires intensive, interdisciplinary teamwork. Typically, it will involve cardiologists, respiratory physicians, critical care specialists, infectious disease specialists, endocrinologists and nephrologists. It may also require liver or renal transplant surgeons and vascular surgeons. The level of expertise required at the laboratory (eg pathology, microbiology, biochemistry and the blood bank) is also very high. Critical care, theatre and rehabilitation nurses of a high standard are also required.

We see a high level of value in such operations because the technology, medical and paramedical expertise, and clinical and laboratory skills required to have a functioning multi-organ transplant programme are immense. However, in time, as the multi-organ transplant programme matures, these enhanced skill sets will percolate to other areas of health care and will enhance the level of patient care.

Dr Paul Ramesh is senior consultant cardiothoracic and transplant surgeon, Apollo Hospitals, Chennai.

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