Giuliano Testa M.D.

Testa, G. and L. Johannesson (2017). “The ethical challenges of uterus transplantation.” Curr Opin Organ Transplant: 2017 Aug [Epub ahead of print].

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PURPOSE OF REVIEW: As the techniques of uterus transplantation have evolved, culminating in a birth in 2014, the ethical debate has been enriched by several considerations. Uterus transplantation raises issues because of its unique features of being temporary, nonlifesaving, experimental, and expensive, with established alternatives. RECENT FINDINGS: Uterus transplantation entails risks for the recipient related to multiple surgeries and immunosuppression, yet studies have shown that women see infertility as a distressing element in their lives, justifying the risks. The alternative of surrogacy has its own ethical issues, and adoption does not provide for genetic progeny. Although patient decisions are susceptible to inconsistent reasoning, misconception of risks or wishful thinking, a carefully drafted and clearly explained informed consent can represent a valid ethical response in balancing risks and benefits. There is no evidence of increased risks for children born from uterus transplant. For living donors, the risks of hysterectomy are known and can be explained to facilitate proper informed consent. Allocation of deceased donor organs needs to be determined, as guidelines for other organs cannot readily be applied. Cost is an issue, as the procedure is expensive and not covered by insurance. SUMMARY: In this rapidly advancing field, a strong ethical foundation is needed to guide regulations and legislation.

Draoua, M., N. Titze, A. Gupta, H. T. Fernandez, M. Ramsay, G. Saracino, G. McKenna, G. Testa, G. B. Klintmalm and P. T. W. Kim (2017). “Significance of measured intraoperative portal vein flows after thrombendvenectomy in deceased donor liver transplantations with portal vein thrombosis.” Liver Transpl 23(8): 1032-1039.

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Adequate portal vein (PV) flow in liver transplantation is essential for a good outcome, and it may be compromised in patients with portal vein thrombosis (PVT). This study evaluated the impact of intraoperatively measured PV flow after PV thrombendvenectomy on outcomes after deceased donor liver transplantation (DDLT). The study included 77 patients over a 16-year period who underwent PV thrombendvenectomy with complete flow data. Patients were classified into 2 groups: high PV flow (>1300 mL/minute; n = 55) and low PV flow (60 years (hazard ratio [HR], 3.04, 95% confidence interval [CI], 1.36-6.82; P = 0.007) and low portal flow (HR, 2.31; 95% CI, 1.15-4.65; P = 0.02) were associated with worse survival. In conclusion, PV flow <1300 mL/minute after PV thrombendvenectomy for PVT during DDLT was associated with higher rates of biliary strictures and worse graft survival. Consideration should be given to identifying reasons for low flow and performing maneuvers to increase PV flow when intraoperative PV flows are <1300 mL/minute.

Zamora-Valdes, D., P. Leal-Leyte, T. W. K. P and G. Testa (2017). “Fighting mortality in the waiting list: Liver transplantation in north america, europe, and asia.” Ann Hepatol 16(4): 480-486.

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Liver disease is a major cause of mortality worldwide. Liver transplantation (LT) is the most effective treatment for end stage liver disease. Available resources and social circumstances have led to different ways of implementing LT around the world. The experience with pediatric LT corroborates the hypothesis that a combination of surgical strategies can be beneficial. The goal of this manuscript is to describe the strategies used by LT centers in North America, Europe and Asia and how these strategies can be applied to reduce waitlist mortality and increase access to LT.

Garcia Aroz, S., I. Tzvetanov, E. A. Hetterman, H. Jeon, J. Oberholzer, G. Testa, E. John and E. Benedetti (2017). “Long-term outcomes of living-related small intestinal transplantation in children: A single-center experience.” Pediatr Transplant 21(4).

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Pediatric patients with irreversible intestinal failure present a significant challenge to meet the nutritional needs that promote growth. From 2002 to 2013, 13 living-related small intestinal transplantations were performed in 10 children, with a median age of 18 months. Grafts included isolated living-related intestinal transplantation (n=7), and living-related liver and small intestine (n=6). The immunosuppression protocol consisted of induction with thymoglobulin and maintenance therapy with tacrolimus and steroids. Seven of 10 children are currently alive with a functioning graft and good quality of life. Six of the seven children who are alive have a follow-up longer than 10 years. The average time to initiation of oral diet was 32 days (range, 13-202 days). The median day for ileostomy takedown was 77 (range, 18-224 days). Seven children are on an oral diet, and one of them is on supplements at night through a g-tube. We observed an improvement in growth during the first 3 years post-transplant and progressive weight gain throughout the first year post-transplantation. Growth catch-up and weight gain plateaued after these time periods. We concluded that living donor intestinal transplantation potentially offers a feasible, alternative strategy for long-term treatment of irreversible intestinal failure in children.

Draoua, M., N. Titze, A. Gupta, H. T. Fernandez, M. Ramsay, G. Saracino, G. McKenna, T. Giuliano, G. B. Klintmalm and P. T. W. Kim (2017). “Significance of measured intraoperative portal vein flows after thrombendvenectomy in deceased donor liver transplants with portal vein thrombosis.” Liver Transpl: Apr [Epub ahead of print].

Full text of this article.

BACKGROUND: Adequate portal vein (PV) flow in liver transplantation is essential for a good outcome, and it may be compromised in patients with portal vein thrombosis (PVT). This study evaluated the impact of intraoperatively measured PV flow after PV thrombendvenectomy on outcomes after deceased donor liver transplantation. STUDY DESIGN: The study included 77 patients over a 16-year period who underwent PV thrombendvenectomy with complete flow data. Patients were classified into two groups: high PV flow (>1300 mL/min, N = 55) and low PV flow (60 years (hazard ratio 3.04, confidence interval 1.36-6.82; P = 0.007) and low portal flow (HR 2.31 (1.15-4.65, P=0.02) were associated with worse survival. CONCLUSION: PV flow <1300 mL/min after PV thrombendvenectomy for PVT during deceased donor liver transplantation was associated with higher rates of biliary strictures and worse graft survival. Consideration should be given to identifying reasons for low flow and performing maneuvers to increase PV flow when intraoperative PV flows are <1300 mL/min.