the liver transplant program indonesia...

LIVER TRANSPLANT PROGRAM AND

PROGRESS IN INDONESIA

Toar JM Lalisang MD. PhD

Surgeon Consultant in Digestive surgery

Department of surgery

Cipto Mangunkusumo Hospital Jakarta

Medical Faculty Universitas Indonesia

RSUPN Cipto Mangunkusumo

Medical Staff Building 4th floor

Medical school IMERI

EAGLE & PROMETHEUS REGENERATION SEGMENTATION

IMPOSSIBLE BE POSSIBLE

LIVER TRANSPLANT

Has revolutionized the care of patients with end-stage liver disease (ESLD)

It is now the standard treatment for acute and chronic liver failure

Primary Liver Ca

CCR n NET Met

LDLT choice in ASIA / Indonesia

DONOR CLASSIFICATION

Living DONOR : Genetic related : (parents, children brother & sister cousin )

Emotional related : (spouse, adoption, relatives)

Non related

PRINCIPAL & CONSIDERATION IS A PROGRAM NOT A PROCEDURE

ETHICAL CONSIDERATION “primum non nocere “ OR “first do no harm”

A doctor should approach a healthy individual with Extreme Caution

A positive outcome for a recipient can never justify harm to a live donor that both recipient and donor have done well.

Donor should be monitored as long as he/she live

THE DONOR ORGAN SHORTAGE

USA in 2000

17000 patients on WL

§ Only 4579 cadaveric transplants done and

§ 371 living related transplants.

§ 1347 deaths on the waiting

INDONESIA

Adult Recipient : 50

Donor : 20

Pediatric Recipient : 95

Donor : 82

2018 data

All LDLT

ATTENTION IN LDLT

Death of a Healthy Donor is a Disaster

For the Family, Surgical, Medical and Nursing Staff.

The, INSTITUTION LDLT PROGRAM BE POSTPONED AND REEVALUATED.

GRAFT SIZE

Remnant liver donors left more than 31% TLV

Normal liver 2-3 % TBW

GRWR PEDIATRIC 2-4% TBW

GRWR ADULT 0.8-1%

Surg Clin N Am 2006; 86:107-17

LDLT PROCEDURE

1. 11 Jan 2006 – Suherdjoko, The Jakarta Post, Semarang Indonesia's liver transplant team, comprising doctors of the Semarang's Kariadi Hospital Case : Atresia Bilier(Mom to Son)

2. Surabaya Siapkan Diri Jadi Liver Transplant Center Jawa Post. 20 February 2010

3. December 2010 at RSCM, Jakarta (Adult & Ped. LDLT)

4. September 2015 Adam Malik Hospital, Medan (Ped. LDLT)

5. November 2015 Sardjito Hospital, Jogjakarta (2 Ped. LDLT)

5

65

Indonesia:

Semarang Jan 11, 2006 : Pediatric liver Transplant

11 Jan 2006 – Suherdjoko, The Jakarta Post, Semarang Indonesia's liver transplant team, comprising doctors of the Semarang's Kariadi Hospital Case : Atresia Bilier (Mother to Son)

No progress reported

SURABAYA

Feb 2010 : Pediatric

• Siapkan Diri Jadi Liver Transplant Center

Jawa Post. 20 February 2010

Case : Atresia Bilier (Mother to Son)

No Progress reported

THE FIRST ADULT LDLT IN INDONESIA FMUI/RSUPNCM –ZHENJIANG UNIV CHINA

JAKARTA

Total Hepatectomy (R)

Graft Hepatectomy (D)

Bench /Back Table

Replantation

V to Caval V,

V Portal

Hepatic Artery

Bile anastomosis.

• Team Donor: Dig. Surgeon

• Ped . Recipient: Ped. Surgeon

• Adult recipient: Dig. Surgeon

• Bench /back table Dig. Surgeon

• Vascular vein & portal Ped.Surgeon

• Artery microsurgery: Vas S & Ped.S

DONOR

GRAFT HEPATECTOMY CONVETIONAL APPROACH

AVERAGE OPERATION 5-7 HOUR

BLEEDING AVERAGE 300 CC

CHOLAGIOGAFIE INTRA OP MINIMAL 3 X

BACK TABLE

AVERAGE TIME 45-60

UKT SOLUTION

MEASUREMENT

COOLING

RECIPIENT

TOTAL HEPATECTOMY 2-4 HOURS

BLEDDING 100– 11000.

INPLANTASI

HEPATIC V TO CAVA

POTRA TO R/L PORTA

ARTERI HEPATICA COM TO R/L HEPATIC A

BILE ANASTOMOSIS DTO D/ E T D

VASCULAR PATENCY ASSESSMENT BY US

RANGE OP TIME 10- 18 H

PROGRESS IN RSCM The Frst THREE

Name Age sex

Bw (Kg)

H (cm)

Diagnosis Segment Graft

Masalah Asal Related

Tanggal Operasi

LOS Mortalitas Penyebab Kematian

1 AM 44 th L 59 164 HBV /CH Right lob(5,6,7,8)

Doughter 13/12/10 43 AWD

2 FM 47 th L 69 173 HBV Sirosis Hepatis Child C

Right lobe (5,6,7,8)

Unrelated 31/07/11 30 Afetr 1,5 y rejection.

3 TZ 18 th L 55 178 Bilier CH post Kasai

Right lobe (5,6,7,8)

Bile Leakage Brother 03/03/15 42 Op Mortal trombo emboli paru

4 RS 37 th L 54.8 165 HBV Sirosis Hepatis

Left (1,2,3,4)

small for size syndrome

wife 19/09/15 49 AWD

5 EL 51 th P 70 159 HCV CH Left (2,3,4) Delirium ec tacro intoksikasi

Nece 28/11/15 68 i AWD

6 Grd 21 L 62 165 HBV CH Left lobe 1,2,3,4

PRES mother 050518 35 Die after 6 mo

Infection

7. Sy 46 L 93 175 HCC/HBV right lobe CMV wife 011218 21 die after 6 mo MOF

TOTAL PATIENTS 7

Chronic Hepatitis B 4

Chronic Hepatitis C 1

Biliary atresia

Post Kasai Procedure 1

HCC/HEB 1

Chronic Hepatitis BChronic Hepatitis CBiliary Atresia post Kasai

PRIMARY DIAGNOSIS 49 PED LDLT Biliary atresia 39

Alagille syndrome 3

Neonatal hepatitis 2

Budd chiari syndrome 1

Caroli disease 1

Autoimmune hepatitis 1

Choledochal cyst 2

Biliary Atresia

Alagille Syndrome

Neonatal Hepatitis

Budd-Chiari Syndrome

Caroli Disease

Autoimmune Hepatitis

choledochal cyst

0

2

4

6

8

10

12

14

16

2010 2011 2012 2013 2014 2015 2016 2017 2018

Adult

Pediatric

2019

Donor ( n= 55)

Age (y) 31

Sex 27Male

28 Female

Weight (kg) 59

IMT 22.79

Relation related

Hepatectomy procedure 3 right lobe hepatectomy

3 left lobe segmentectomy

47 left lateral segmentectomy

Fatty liver 8 (mild fatty liver)

LOS (days) 7-8

Demographic data of Donors

Pediatric ADULT TOTAL

PATIENTS 49 7 56

AGE

Range 0.5 – 4.8 y.o 18 – 51 y.o 0.5 – 51 y.o

GENDER

Female 21 1 12

Male 28 7 34

SURVIVAL 33 (67.3%) 4 (66.6%) 29 (85.3%)

Op Mortal 3 1 5

HEROS /DONOR

56 DONOR no op mortality

2 relap due bleeding and cysticys leaks,

Ssi superficial 1

BW decreasing

Good Qol

Bleeding 400 cc

Duration ( mean /minuts) 755 minutes

LOS/day 7-8 days ( 8-22)

Days in ICU 2 days

Morbidity SSI :1, pleural effusion : 1, bile

leakage : 3, difficulties in drain

removal : 1, anxiety post op : 1,

burn wound 1.

Operative Mortality ZERO

Parameter Value

Bleeding 234 cc

Duration 293 minutes

LOS 9 days

Days in ICU 1 day

Morbidity SSI :1, pleural effusion : 1, bile

leakage : 1, difficulties in drain

removal : 1, anxiety post op : 1

Mortality 0

DONOR SPECIAL ISSUES

Pool of donors : potential number of donor for LDLT is small

most chronic diseases occur at a younger/productive age due contact infection

Donation program not well informed

Obesity : prevalence of obesity is increasing

Hepatic steatosis

“Financial”

Recipient Special Issue

Infection

Maintain Immunosuppressant

SEBELUM SESUDAH SEBELUM SESUDAH

SEBELUM SESUDAH SEBELUM SESUDAH

SEBELUM SESUDAH SEBELUM SESUDAH

SEBELUM SESUDAH SEBELUM SESUDAH

SEBELUM SESUDAH SEBELU

M

SESUDAH

SEBELUM SESUDAH SEBELUM SESUDAH

SEBELU

M

SESUDAH SEBELU

M

SESUDAH

SEBELUM SESUDAH

NCCHD NATIONAL CENTRE FOR

CHILD HEALTH AND

DEVELOPMENT

PROF M KASAHARA

ZHEJIANG UNIV. HANGZOU ,CHINA.

NUH. SINGAPORE PROF PRABAKARAN

Don’t send your organ to heaven because we need it for organ Transplant

Modern technology are safe, Modern and smart surgeon made the patients save for that technology.

Introduction to public society

Clinical Pathways Guideline an Indonesia needed

PHYSICIANs AND SURGEONs DON’T SENT THE PATIENTS ABOARD ……

WE CAN DO IT WAITING FOR MORE LDLT

TEAM WORK

Multidiscipline Approach

RSCM-FKUI / AHS Universitas INDONESIA

Conclusion

THANK YOU

A l l t h e R S C M L D L T t e a m

A L L p a t i e n t s

A l l D O N O R