EDITORIAL REVIEW
Sharing the gift of life Gonzalo P. Rodriguez-Laiz Recanati/Miller Transplantation Institute, Mount Sinai Medical Center, New York, New York, USA Correspondence to Gonzalo P. Rodriguez-Laiz, MD, Recanati/Miller Transplantation Institute, The Mount Sinai Hospital, 1 Gustave L. Levy Place, New York, NY 10029, USA E-mail:
[email protected] Current Opinion in Organ Transplantation 2008, 13:257–258
This issue of Current Opinion in Organ Transplantation brings us new insights into the world of intestinal replacement, when more than a century has elapsed since the first experiments performed by Alexis Carrel would begin to pave the way to a challenging therapy, that has undergone significant remodeling to become a saving procedure, as we know it today [1]. The development of intestinal transplantation has been largely due to considerable immunological and pharmacological advances, while the surgical procedure has undergone minimal modifications since its early inception [2,3]. The status of intestinal transplantation, as nicely as Dr Fryer’s depicts it in his comprehensive review, still shows room for improvement. It seems quite obvious now, and only a minority would still insist on challenging it, that the idea of isolated intestinal transplant pulls through as a better therapy, directed towards improvement of the hepatic function, preventing the deterioration of the patient, and showing an overall benefit that clearly surpasses any combined transplant procedure that includes the intestine and the liver, plus any other organ. Several reports have already shown improved hepatic function after isolated intestinal transplantation [4], and we have also seen significant biochemical and histological regression of advanced hepatic fibrosis, even in older patients, after intestinal transplant [5]. Furthermore, we can improve the benefit provided to the intestinal recipient with the sparing of an organ that can benefit a different patient in need of a liver. Thus, the whole idea of favoring isolated intestinal transplantation over combined liver–intestine transplantation, when seen from this perspective, has a benefit even for those who never thought of it as an additional stipend for sharing. And sharing is what matters, as our entire field of transplantation is founded on generosity and the so-called ‘gift
of life’. We, as physicians, merely act as intermediaries in a trade of goodwill and need, making the latter match the former. Quite interestingly, only recently I came to realize that it is only (or rather mostly) us who can hurt this fair trade; and you would think that we all share this white glove spirit. So I thought. A few weeks ago, however, I encountered a situation that made me reshape this editorial, and now I find myself in the process of rewriting it, with the aim of sharing (once again, that beautiful word) with you an experience that, to this day, I cannot fully comprehend. I shall try to summarize the event objectively: an offer was made to a very small pediatric patient in our waiting list, who is a candidate for isolated intestinal transplantation. As it is the rule in our program (it should be obvious by now), we favor single organ transplant and, when possible, with a timely referral, proper line care, optimization of the total parenteral nutrition and management of secretions, this approach can be achieved in the overwhelming majority of cases. The other side would be a rather more deteriorated candidate for combined liver–pancreas–intestine transplantation, which, at times, can be the only solution to a very late referral. We planned our long flight, therefore, and arranged transportation for our little patient, when we got a call from one of the recovering surgeons for the liver team, a few thousand miles away. The shocking news was that they would be recovering the liver en-bloc with the pancreas, and we would be ‘allowed’ to take only the superior mesenteric artery (SMA) and superior mesenteric vein caudal to the lower edge of the pancreas. Now, let us rethink this situation. No argument enabled, and no trading. Despite a seemingly understanding person at the other end of the line, who could see that a potential right branch from the SMA would be present in just one out of five donors, no concessions were made. Whatever happened to fair share? Only after a few phone calls, and some detective work, could I get the phone number of the program director, the one in charge. Yes, it is true that the liver might take priority, and preserving it as a preferential life-saving organ could be allowed, although there is not a single United Network for Organ Sharing policy that backs that ‘principle’ [6]. That principle is not even the point here. When discussing the situation with the liver program director, his ruling
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258 Small bowel transplantation
(or rather bulling) stemmed from his previous experience, claiming that many times in the past, he had seen livers ruined by intestinal transplant teams. So I wonder: what is the value of his own surgical team in the field? How little trust did he have invested in his own subordinate colleagues? How well did he train them? Unfortunately, generalization is the unfair ruler here, as we, as a program, never had a prior interaction in liver and intestine donor procurement with them. No argument, no trade, no deal. No matter how much you can argue that, in a 2-month-old baby, a right branch from the SMA would be more visible than the Empire State Building on a clear, sunny day. As I was the one flying and harvesting the intestinal graft, I even offered to give up the aortic Carrel patch of the SMA if I had the slightest doubt regarding the potential existence of that variation, which again, is present in only one-fifth of all livers. ‘No’, this approach was refined bulling, in a world of ‘colleagues’ who live and work thanks to the sharing of others: others, yes, but not us.
In a life of generosity and giving, the brothers Saints Cosmas and Damian devoted their lives to heal unselfishly the sufferings of thousands of poor peasants, in an unstoppable quest for health. Even after their death, multiple miracles were attributed to them, including the renowned transplant of a leg from a deceased (and buried) Ethiopian Muslim to replace the gangrenous limb of a Christian sacristan [8]. There, once again, is sharing at its best, in the very dawn of the history of transplantation, in a miracle that transcends faiths, an example to be followed in today’s religiously intolerant world. Maybe that is all that it takes: a miracle, the miracle of enlightening the narrower minds to look beyond themselves, to share. Sharing the gift of life. We, the ones entrusted with ‘the gifts’, must ensure that they reach their maximum benefit. Another miracle for Saint Cosmas and Saint Damian; would that not be something?
References When we look back at our history in the medical field, and the advances that have brought us the broad field of transplantation as we know it today, we can admire beautiful examples of cooperation, sharing, and unselfishness. We can see how unusual it was for a notorious pilot, who became famous after daring to cross the Atlantic in a solo flight, to share mind and effort with a French surgeon, Nobel Prize winner, one of the fathers of transplantation, to create the first reliable tissue and organ perfusion pump [7]. Now, we do not question when a kidney is pumpperfused. What was the spark that put Lindbergh and Carrel in such an uncommon quest? Perhaps it was the need for an answer to a medical condition that was afflicting a relative of the pilot. Nevertheless, the bottom line is that they unified efforts, and shared knowledge and expertise. Sharing, is it not all about sharing?
1
Grant D, Abu-Elmagd K, Reyes J, et al. 2003 Report of the intestine transplant registry: A new era has dawned. Ann Surg 2005; 241:607–613.
2
Starzl TE. The puzzle people: memoirs of a transplant surgeon. Pittsburgh: University of Pittsburgh Press; 1992.
3
Reyes J, Mazariegos GV, Bond GM, et al. Pediatric intestinal transplantation: historical notes, principles and controversies. Pediatr Transplant 2002; 6:193–207.
4
Sudan DL, Kaufman SS, Shaw BW Jr, et al. Isolated intestinal transplantation for intestinal failure. Am J Gastroenterol 2000; 95:1506–1515.
5
Fiel MI, Sauter B, Wu HS, Rodriguez-Laiz GP, et al. Regression of hepatic fibrosis after intestinal transplantation in total parenteral nutrition liver disease. Clin Gastroenterol Hepatol 2008; (in press).
6
United Network for Organ Sharing. Resources: policies. UNOS; 2008. http:// www.unos.org/policiesandbylaws/policies.asp?resources=true. [Accessed 2 April 2008].
7
Men in black. TIME. June 13, 1938. http://www.time.com/time/magazine/ article/0,9171,849014-1,00.html. [Accessed 2 April 2008].
8
Rutkow IM. Surgery: an illustrated history. St. Louis: Mosby-Year Book Inc./ Norman Pub; 1993.
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