Slashdot Mirror
Six Months Old, Eight New Organs
AEton writes "According to the BBC, Dr. Andreas Tzakis has just successfully replaced six-month-old Alessia Di Matteo's liver, stomach, pancreas, small and large intestine, spleen, left kidney, and right kidney in a record-setting operation. The child is so far doing fine with a one-year-old baby's organs. Tzakis is no stranger to multiple-organ transplants; in 1997 he set the previous record of seven organs by replacing seven of a two-and-a-half-year-old's organs. It must be a little odd to know that a growing plurality of your tissue used to be someone else's."
Do kids who get transplants this young need to be on anti rejection drugs for the rest of their lives? I know they're exceptional at healing & recovering from major surgery at extreme young ages, but don't know if there's an extra ability to 'adapt' to foreign tissue.
I'm a med student working on the multi-organ transplant service in Toronto. I wonder what the real goal of these kinds of commmando surgeries are. The more organs transplanted, the greater are the hemodynamic derangements, the more compensation that has to be made for natural fluid balances and what not. The more organs, the more likely it is for her immune system to react and reject the foreign organs. I wonder what their plan is for the child's immune system. A 6 month old immune system is fairly weak, and in a normal infant it would gradually develop and become capable of defending the infant from your regular run of the mill pathogens. I'm not sure what would happen in this case; Alessia will certainly need lifelong suppression of her immune system with drugs like Tacrolimus (or steroids for bouts of acute rejection) which have their own side effects. The flip side is that a weak immune system predisposes you to develop systemic infections, sepsis and other nasty things. I know that in infants with HIV and other immunocompromising illnesses, they still get most of their vaccinations (except the live vaccines), so she may still be protected against those. It comes down to a dilemma not unknown to those who work in Neonatal Intensive Care Units. How far should we go to save these unfortunate children? I've seen in my time the so-called "Sick Kids Specials", children at our Hospital for Sick Children who were born incredibly premature (24 weeks versus 36-40 weeks for normal gestation) and sustained in increasingly advancing NICU's. These children rarely turn out normal, and in some cases, have up to 12 different major medical problems (kidney failure, cerebral palsy) etc. etc. What kind of future is in store for Alessia? I don't think a particularly long one; she will most certainly require re-transplantation of many of her organs (things like kidneys can last 10 years or so, small bowel transplants are so rare that I don't think there's that many studies of them). When you consider the cost, the mental anguish to both parents and to this increasingly developing child, and the cost to the public health system, I wonder if the right decision was made.
1. The number of organs transplanted is NOT an indication of the pre-op condition/prognosis of the baby or an indicator of post-op "quality of life".
Her disorder is a single disease process that happens to affect most of her vital organs. All other things being equal, a baby born with several disorders, requiring fewer organs transplanted (even as little as 1 or 2), actually could be considered "sicker", have a much lesser chance of survival and be a greater "burden on society".
2. Of the eight organs transplanted, some might not have actually been "diseased" (more on this later).
3. The greater the number of organs transplanted is not proportional to the surgical difficulty.
Not to take away from Dr. Tzakis' great achievement, but technically the surgery might have been easier than transplanting a few non-contiguous organs. Here is why:
If you ask any transplant surgeon, the most difficult aspect of the surgery is doing the anastamoses (or "rejoinings"). Essentially taking the entire foregut and midgut en bloc significantly decreases the number of "rejoinings" one has to perform.
Tzakis likely only had to join this single unit of organs (the liver+stomach+pancreas+spleen+small bowel+large bowel) at two points (those being #1 the original esophagus-to-new stomach and #2 the new large bowel-to-original rectum) for complete continuity of the gastrointestinal tract and then probably about another 4 anastamoses for blood supply.
The entire blood supply for all the aforementioned organs (minus the kidneys) originate from only 2-3 arteries arising from the aorta. To leave the original pancreas and spleen (which are not significantly affected by her disorder) would have been several times more difficult than taking the "whole package" because the vascular supply for each organ would have to be dissected and reanastomed individually. This is more difficult because it's more vessels to join and the vessels are smaller i.e. more difficult to work with.
Transplanting even only 3 of these organs in non-continuity would have required 1-2 GI tract and 2+ vascular anastamoses for EACH organ. If you do the math you can quickly realize why it was probably easier to take all the organs, even if some were not diseased.
4. Transplanting both kidneys is NOT the transplant surgery standard of care. The baby would have done fine with one kidney and there has yet to be any studies proving that transplanting two kidneys vs. one improves a patient's post-op outcome. But if Tzakis did not take both kidneys he would be stuck at 7 and we wouldn't be talking about this whole topic right now (take it however you want).
So to make a long story short:
1. The baby was not as sick or doomed as one might think.
2. It's a great accomplishment but it wasn't "pushing the envelope".
3. The ethical issues raised are no different than those for any other medical procedure or treatment: should society help the inherently weak at the expense of the strong or should we fall into the Darwinian model of society were it's survival of the fittest? Or is there a middle-ground as to how much help we give the weak and who/what determines how much and what is too much help to give?
I used to think the same way too... 'till we ran to this case while doing rounds during my edical ethics class: A teenage girl was dying from heart failure (we were not told what this was caused by, since the this was an undergraduate ethics class) and required a heart transplant. Her cardiologist requested one from UNOS (United Network for Organ Sharing), and got one. The operation went reasonably well, but as I understand it, multiple clots eventually developed in her bloodstream post-surgery. Some lodged in her brain, causing multiple strokes of varying severity, rendering her comatose. Others lodged in varying organs, including her newly transplanted heart, causing it to slowly fail. Since her cardiologist was an attending physician at a large medical school, he had quite a lot of connections. He pulled some strings, and got the girl back on the heart transplant list. Second heart was found and flown in. (Second verse, same as the first, a little bit louder, a little bit worse...) After a few days... turns out it's incompatable. The girl starts rejecting the second heart, and it slowly begins to fail. Dr. Promenent Attending Physician with Connections pulls more strings (he's got a lot invested in this girl), and she's back up on the heart transplant list. Our professor, who was the pediatric neurologist called, assessed that the girl had no significant chance of recovering due to multiple strokes. And yet there she was, high up on the transplant list for her third heart! Morals of the story: 1) connections matter; if you're gonna get a transplant, go to a major teaching facility and get the attending physician to do it. 2) resource allocation of something as precious as a heart isn't as cut and dry as, say, deciding who gets a scholarship to college. You give away multiple grants to somebody, and everybody else who applied will scrape by and find another way to fund their education; you give away multiple organs to one person, and there's a good chance that many, many people will die waiting. Your argument presents a false dichotomy of either save the kid, or don't save the kid. (Who in their right minds would, without any other piece of information, say "don't save the kid"?) In reality, the case is this: Save the kid, or save a kid who needs a stomach, a kid who needs a liver, two kids who need kidneys, etc... Until the day that we are able to grow organs, scarcity will be an issue. And regardless of how "feel good" it is to perform heroic measures to save somebody, it is ethically remiss to give multiple transplants to the same person, whether it be in the form of three consecutive hearts, or a half dozen organs. Chosing one organ recipient over another because of their health, importance to society, etc., is an ethical gray area. But how anybody can claim that it's better to save a kid by giving her multiple organs, over saving eight separate kids each of whom needs one organ transplant, is beyond me.