the liver transplant program indonesia...
TRANSCRIPT
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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
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RSUPN Cipto Mangunkusumo
Medical Staff Building 4th floor
Medical school IMERI
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EAGLE & PROMETHEUS REGENERATION SEGMENTATION
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IMPOSSIBLE BE POSSIBLE
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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
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DONOR CLASSIFICATION
Living DONOR : Genetic related : (parents, children brother & sister cousin )
Emotional related : (spouse, adoption, relatives)
Non related
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PRINCIPAL & CONSIDERATION IS A PROGRAM NOT A PROCEDURE
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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
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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
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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.
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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
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LDLT PROCEDURE
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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
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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
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SURABAYA
Feb 2010 : Pediatric
• Siapkan Diri Jadi Liver Transplant Center
Jawa Post. 20 February 2010
Case : Atresia Bilier (Mother to Son)
No Progress reported
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THE FIRST ADULT LDLT IN INDONESIA FMUI/RSUPNCM –ZHENJIANG UNIV CHINA
JAKARTA
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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
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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
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PROGRESS IN RSCM The Frst THREE
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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
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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
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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
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0
2
4
6
8
10
12
14
16
2010 2011 2012 2013 2014 2015 2016 2017 2018
Adult
Pediatric
2019
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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
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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
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HEROS /DONOR
56 DONOR no op mortality
2 relap due bleeding and cysticys leaks,
Ssi superficial 1
BW decreasing
Good Qol
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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
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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
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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
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SEBELUM SESUDAH SEBELUM SESUDAH
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SEBELUM SESUDAH SEBELUM SESUDAH
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SEBELUM SESUDAH SEBELUM SESUDAH
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SEBELUM SESUDAH SEBELUM SESUDAH
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SEBELUM SESUDAH SEBELU
M
SESUDAH
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SEBELUM SESUDAH SEBELUM SESUDAH
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SEBELU
M
SESUDAH SEBELU
M
SESUDAH
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SEBELUM SESUDAH
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NCCHD NATIONAL CENTRE FOR
CHILD HEALTH AND
DEVELOPMENT
PROF M KASAHARA
ZHEJIANG UNIV. HANGZOU ,CHINA.
NUH. SINGAPORE PROF PRABAKARAN
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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 ……
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WE CAN DO IT WAITING FOR MORE LDLT
TEAM WORK
Multidiscipline Approach
RSCM-FKUI / AHS Universitas INDONESIA
Conclusion
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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