Gastric Reflux Surgery Helps Lung Transplant Patients

Gastric Reflux Surgery Helps Lung Transplant Patients

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If you are a lung transplant patient there are good chances you may eventually need an anti-reflux surgery. The name of that surgery is Nissen Fundoplication. For some lung transplant recipients this could be a

Lifesaving surgery in the long run because the purpose of it is to save the lung function. The University Of Pittsburgh School Of Medicine reports that out of 43 of their patients who have undergone this anti-reflux surgery, nearly all of them improved their lung function. Not only this surgery helps post-lung transplant but can also benefit patients waiting for a new organ.

Incidence

According to Blair Jobe, M.D., professor of surgery, Department of Cardiothoracic Surgery, Pitt School of Medicine, many end-stage lung disease patients, especially cystic fibrosis and pulmonary fibrosis patients, have what they call gastro-esophageal reflux disease (GERD). Almost half of those patients do not experience any typical heartburn symptom but still, the gastric juice coming up the esophagus and going in the lungs is damaging. It has also been recognized as causing acute lung rejection and ultimately leading to chronic rejection. Chronic rejection, medically known as Bronchiolitis Obliterans, is when the lung function slowly goes down with little chance for recovery. Patients can live many years once a diagnosis of chronic rejection has been established but with a lower quality of life. Gastric reflux is a medical problem that really needs to be addressed seriously by transplant pulmonologists.

No Heartburn? How is Gastric Reflux Diagnosed then?

Usually what happens is a patient will have an unexplained drop in lung function. A bronchoscopy will be done to rule any acute rejection, infection or narrowing of the airway. Narrowing of the airway is called bronchial stenosis. Once all of that is negative, gastric reflux is highly suspected and a 24 hours Ph probe study is ordered. This test consists of a small probe inserted into the nose going to the stomach. It stays there for 24 hours and it is attached to a small reader that the patient carries in a bag. To be noted that it is an outpatient testing and patients do go home with the probe.

Once the 24 hours has passed, a physician will interpret the data. The probe actually records the number of reflux episodes and monitors the Ph (acidity). It also records some pressure in the stomach. Sometimes you can have patients with 60 plus episodes of reflux non-acidic which means they can’t feel it since it won’t burn. With or without burning sensation, if there are many reflux episodes, the patient is referred to a general surgeon for a Nissen Fundoplication.


What Is a Fundoplication?

It is usually done laparoscopically, which means by using a small camera through small holes in the skin. The surgeon will wrap the gastric fundus (top part of the stomach) around the esophagus in order to reinforce the esophageal sphincter. The goal is to prevent the gastric content from going up and preserves the lungs for lung transplant patients. The surgery is done under anesthesia by a general surgeon and requires 4-5 days in the hospital for recovery. The main complication reported is a problem of bloating. It may be hard for patients to belch after that surgery so gas may accumulate in the stomach. After 10 years, 90% of the patients are symptoms free though.

 I can say, with my own personal experience without any scientific evidence, that lung transplants patients that had that surgery done were doing better after with improved lung function. The challenge sometimes is to explain the patients why they need the surgery when they are symptoms free.

Organ Transplantation Breakthrough: How About Uterine Transplant?

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Within the last several years we have seen major breakthrough in organ transplantation: multi-organ transplant, hair transplant, bone marrow transplant and even face and hand transplant.  Now a British surgeon wants to be the first in the world to successfully perform a uterine transplant from a mother to her daughter, the Telegraph reports. I said to successfully perform because it has been tried only once on a human before and it was in 2000 in Saudi Arabia. The uterus had to be removed 4 months later due to complications with blood supply.


What is Mayer Rokitansky Kuster Hauser Syndrome?

In this case it involves a British mother

of 53 years old and her 25 years old daughter. The daughter was born with a rare condition called Mayer Rokitansky Kuster Hauser syndrome. This genetic mishap has an occurrence in every 4,000 to 5,000 births, obviously in girls only.  In short it is the absence or malformation of a uterus. The subject will have normal ovaries and normal breast development but won’t be able to conceive children.

High-Risk Surgery

If everything goes according to the plan, the surgery is scheduled to take place next spring in Sweden. Dr Mats Brannstrom, who is leading the medical team, said a womb transplant remained one of the most complex operations known to medical science. The uterus has a very complex blood supply system and it is a procedure with a very high risk of hemorrhage. If the surgery is successful, which would be a first in the world, she could conceive by using her own eggs fertilized with her boyfriend’s sperm and then implanted in the transplanted uterus.

Pregnancy and Immunosuppressant Therapy

The major problem I see with that is the need of immunosuppressant drugs to avoid rejection with a pregnancy. They don’t mention anything in the article regarding the risk of a pregnancy after organ transplant. Obviously this would be a high-risk pregnancy and be the nightmare of most transplant physicians. If you were in the same situation, would you do the same thing?

 

You May Also Like: Should the US Government Reforms its Laws to Allow More Kidney Transplants?


Source: World’s first womb transplant planned

Tax Credit for Organ Donation

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The state of Pennsylvania voted a law for tax credit for employers who allow workers become organ donor. This is very interesting that states are getting involved at that level to promote organ donation. The only problem is only 3 companies used the credit last year. Not sure if it is by ignoranceor there was just very few living donor. Let’s hope it is well publicized and more people will enjoy that benefits.


Source: http://www.therepublic.com/view/story/d03630a60df24455a097ad0dc947fdb9/PA-XGR–Legislative-Highlights/

Euthanasia and Organ Transplants

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This is a very touchy subject here in America. It seems that nobody wants to address the issue. The physicians are still hesitant to consult palliative care. It could be because it represents failure of modern medicine for some. Privately, a lot of people are in favor of euthanasia, or assisted suicide, for chronically ill people. How often have you heard, If one day I am in this or that condition please pull the plug. In some countries, especially in Europe, euthanasia is legal, not without creating controversy thought. One specific country has found a way to make it more compassionate. In Belgium where euthanasia is legal, they use organs from the chronically ill that are deemed good quality for transplantation. Of course, they don’t do that with cancer patients. In a span of three years, from January 2007 to December 2009 they were able to recover 4 lungs suitable for lung transplant according to Dirk van Raemdonck and colleagues. During that span they also recovered kidneys and livers who were good enough for organ transplants.

How does it work?

Obviously, everything happens in a control environment and it works the same way as donation after cardiac death. The patient wishing for euthanasia, who has a non-malignant disorder, is given the drugs by a physician.  Once the heart stops beating, the patient is pronounced on cardiopulmonary criteria by three independent physicians. Then the patient is brought to the OR where they start the surgery to recover the organs.

Even if euthanasia would become legal here in this country, I don’t expect many potential organ donor since those patients, for the most part, have been sick for years and their organs may not be good. But, it is something to keep in mind for the future and will certainly require a comprehensive ethical debate. Not sure we are ready for that here.

Source: Transplantation of lungs: recovered from donors after euthanasia

Is it Time for Kidney Donation with Compensation?

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Some transplantation leaders in the US are starting to push for a compensation system to increase the number of kidney living donation. This is a very ethical debate where both sides of the argument have good points. With a waiting list approaching 90,000 patients hoping to receive a kidney transplant some argue that it is time to implement a compensation system to increase the number of living donation.


For the past 10 years the number of persons waiting for a kidney transplant almost doubled and the actual number of transplantation remained about the same. It has for consequence to dramatically increase the wait time for kidney transplant. Some regions of the US have wait time closing in on 10 years for kidney transplant. Living kidney donation is already legal but is on a voluntary basis and federal laws prohibit any kind of compensation. With treatment of dialysis running in the $70,000 per year per patient some claim money will be saved by transplanting patient faster with the help of a compensation system. Opponents to this system are afraid that people would become kidney donor with the intention of making a quick buck and not thinking about the risks and benefits of the operation.  It also could be an easy way out of debt for some but with unknown long term consequences on finances. Experts against the compensation system also see that as an opportunity for rich to exploit poor and potentially making the system unfair where wealthy patient would bypass patients with less means. In response to this argument the pro-compensation people say that compensation should not be under the form of money but more like free education or other perks like that.

I expect this debate to pick up steam within the next few months as more people are dying everyday while waiting but it will take years before something changes. There are too many variables and questions that need to be answered. What would be the legal age to receive compensation for an organ? Who pays for the compensation? The recipient? The government? The Transplant Center itself? Who will cover the cost of complications for the kidney donors? What should be the total compensation package in $$?  Should it be money or other form? Should deceased donor family be also compensated? Would it open the door to a black market for organs in the US? There are countless of questions that need to be addressed and answered in order to have a fair compensation system in this country. I think it could be possible to have a compensation system fair and equitable as long as the right people are including in the debate. But, it is going to be a long debate and until then the waiting list will keep growing.

 


Kidney Transplant and Pain Medicine

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An interesting study came out at the American Transplant Congress conference held last month in Philadelphia, Pa. Patients who were chronic opioid (pain medicine) user had a lower graft survival and higher mortality rate after kidney transplant. The study was performed at the University of Michigan with the 1064 patients who received kidney transplant between 2004 and 2008. Of that number, about 10% self-reported as being chronic opioid user (COU) before transplant. Pretransplant chronic opioid use is associated with worse patient survival at 1, 3, and 5 years claims Dr Barrentes who is a clinical transplant fellow at Michigan.  The study was done at their own hospital with their own patients and they reported more graft failure and more death with patients who had a history of pain medicine abuse before transplant. The most used pain medicines were hydrocodone, propoxyphene, oxycodone and tramadol.

At 3 and 5 years after transplant, the death rate chronic opioid user was about twice as much as the one from the non-chronic opioid user. Respectively it was 18% vs 7.5% at 3 years and 21% vs 12% at 5 years. This is a pretty significant difference. The study did not identify the reasons behind the increase number in deaths but was pointing at the fact that patients with chronic pain may have morbidities like diabetes or any vascular conditions causing pain that affects graft and patient survival. Dr Barrentes was suggesting that a better screening could be done before transplant in order to be able to provide more support from social workers or psychologists after the kidney transplant.

The system could be the one to blame for these patients addicted to pain medicines.  Sometimes it is just easier for a physician to sign the prescription for narcotics than trying to understand why a patient is hurting.  This will not change overnight thought.

Source: http://www.medscape.com/viewarticle/744117

 

Kidney Transplant Following Other Organ Transplant: What do Statistics Say?

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With the advance of medicine and better understanding of everything related to transplantation, more patients live longer than ever after transplantation these days. Drugs are better, patient management is more efficient and over the years more and more people have received an organ transplant. The main problem with patients living longer is they may eventually need a kidney transplant. Their native kidneys have been relentlessly exposed to drugs that are hard on them. The transplant drugs, especially prograf and cyclosporine are nephrotoxics and can cause chronic kidney disease in the long run.

For some post transplant patients, a kidney transplant is the only alternative to dialysis.  Some may ask themselves if it is worth it and if their prognosis will be good.  There are some data available but they are kind of limited because the overall number of kidney transplant after any other transplant is not that elevated. Here is what I found as far as number of transplant on a yearly basis from 1998 to 2007.  These include living and deceased donors with an average of 16,000 kidney transplants every year:

  • Every year about 10-12% of all kidney transplants are performed on patients that have already received an organ transplant in the past including kidney which represent about 1800 surgeries
  • About 2-3% from the above percentage have previously received non-kidney transplant and that means around 350 patients a year.

Those 350 patients include all previous heart, liver, lung, pancreas, intestine transplants who end up having a kidney transplant on a yearly basis. This is a very small pool of transplant recipients to have accurate statistics on. The good is that the survival rate one year after kidney transplant is pretty similar to the first timer. The survival rate is at about 95-96%. Of course there are plenty of variables like age, diagnosis, race, type of kidney (living or deceased donor).

We only see a small dip in the graft (organ) survival and it is only about the graft like it says. What that means is the new kidney may have failed or stopped working after transplant but it does not say if patient is alive or dead. That is most likely due to rejection. When an organ like a kidney fails, more than likely the patient is still alive. A heart, lung or liver that fails is a lot worst because those organs are a lot more important than a kidney and a kidney can be replaced by dialysis. There is no temporary replacement for the other organs. It is retransplant or death unfortunately.So let’s come back to graft survival for kidney transplant. The graft survival is about 2-3 percent lower when the kidney transplant follows any other organ transplant no matter how many years later. We are talking about 94% instead of 96% after one year, so this is a very small difference.

Based on those statistics kidney transplant seems to be a good alternative after any other organ transplant. The challenge is to find a donor since the average wait time is 2-4 years. This is a long time on dialysis! That does not include the 3-4 months the evaluation period takes. The alternative is to have a family member or friend willing to be a Someone can live with one kidney without any problem.

 

source:www.srtr.org

Lung Transplant and Bronchoscopy: How to Diagnose a Rejection

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What is a Bronchoscopy?

Patients that have received a lung transplant know too well what a bronchoscopy is.  For the ones on the waiting list who never had one; don’t worry you will get to know.  A bronchoscopy is usually done by a pulmonologist (lung doctor) and consist a small camera at the end of a long probe narrow enough to fit through the airway.  It can be inserted through the nose or mouth and also through the breathing tube is the patient is still on the breathing machine (ventilator). That camera is inserted all the way down in both lungs while the patient lightly sedated.  The patient usually receives what some hospitals called conscious sedation.  That basically means that you are awake enough to breath and gag but sleepy enough to think what’s happening is only a bad dream.


Indications after Lung Transplant

Diagnostic

There are mainly 2 reasons doctors will do bronchoscopies after lung transplant.  The first reason is for diagnostic purposes where the physician may or may not suspect something wrong but needs to find out. A bronchoscopy is done at scheduled intervals after the transplant to see if the body is rejecting the new lungs.A rejection is a sign that the body is not accepting the organ and is trying to get rid of it just like it was a bacteria. It needs immediate medical treatment once diagnosed. Biopsies will be taken from several different locations in the lungs to look for possible rejection. A biopsy consists of removing a tiny bit of lung tissue and to send it to the lab under the microscope. Usually the doctor will repeat that 6 to 8 times at each bronchoscopy depending on how the patient tolerate it and how much it bleeds. It takes about 24 hours to know if the lung biopsy showed a rejection or not.

Another diagnostic reason to do a bronch is when a patient shows some signs of lung infection and a culture needs to be performed.  By performing a culture, the pulmonologist will be able to identify the bug (bacteria, virus or fungi) that has invaded the new lung and treat it accordingly. Unfortunately, a lot of lung transplant patients are infected with “superbugs” that require powerful antibiotics because they have adapted and become resistant to the weaker ones like Cipro or Levaquin.

Therapeutic

The other purpose of a bronchoscopy has therapeutic intentions. Inother words it means to treat a condition found in the lungs where the patient is experiencing lung transplant complications.  The main ones that we see are accumulation of thick mucus that will sometimes occlude part of the lung.  The doctor will use the scope and go in and wash it out real good.  The real term used for the occlusion is a mucus plug.  Usually a patient feels 100% better once that issue is fixed.

A more rare complication after lung transplant is called bronchial stenosis.  Stenosis means narrowing.  So bronchial stenosis means that the bronchus has become narrow and it is more difficult for the air to go through.  That usually happens at the site where the surgeon hooked up together the new lung with the patients™ own bronchus.  The scar tissue that forms makes the air passage more narrow.  That condition is diagnosed during a bronchoscopy and can be treated by 2 ways that are pretty similar to what a cardiologist will do to clear blockages in a heart.  The first step is to use a balloon that is inflated at the narrow spot with the goal to open it up.  If it opens up and stays like that, it is good.  If it closes back up, then a stent may be deployed to keep it open.  Just like in your heart. The difference is it happens in the lung, not in the bloodstream.

These were the main reasons bronchoscopies are done on lung transplant patients.  The number one thing that is always suspected early on after transplant regardless if the patient has any symptoms is rejection.  This is why bronchoscopies are performed so routinely, to catch them early.


A Kid Sells his Kidney for an iPad

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A 17 years old teenager in the province of Anhui which is located in the Eastern part of China sold one of his kidney for 20,000 yuan (around $3,000 USD). The teenager did that after he saw an ad so he could buy himself some Apple products (iPhone or iPad and a laptop). When his mom found out about it she was really upset, rightfully so. To make matter worst, after filing a complaint to the police, the hospital where the surgery took place denies that it ever happened… Most likely the hospital records have either been destroyed or kept in a secure location.


Organ trafficking has been made illegal in China about 4 years ago especially to avoid that kind of situation. Obviously it did not prevent it in happening. Legally in China people can volunteer to donate a kidney just like in the US with living donor programs. The shortage is so severe that it did not stop some Chinese to run a black market of organ transplant. We can all be glad that our laws are severe in the US and we don’t have that kind of operation because you and I know a lot of kids would bite the bait.

Source: http://www.abc.net.au/correspondents/content/2011/s3235618.htm

Top 10 Mistakes Patients Make After Organ Transplant (part 2)

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Yesterday, I posted the first 5 main mistakes transplant patients make. Today I will present the remaining 5 mistakes that we observe and could shorten your survival post-transplant.

6. Not exercising.

Every single patients (actually this is good for everybody, including me!) should enrolled in a structured program of physical conditioning, providing that their physician has cleared them to do so. A structured environment is much better since you will have someone pushing in your back to have you take the extra step and to show up… Self-exercising is OK for a minority of people because most of us lack motivation and would quit after 1 week.

7. Lacking knowledge about your medication

How often have I heard the doctor asking a patient the reason why he is taking something and the patient replies: I don’t know, a doctor told me to Better informed patients make healthier patients. Cmon guys, there is no excuse today to be uninformed with all the information we can find on Internet. At least know the purpose of each meds you are taking.

8. Eating wrong diet

It is OK to eat some fast food once in a while if you really like it but I would suggest that you cook your own food at home along with some raw vegetables.  Of course, the vegetables need to be washed real good.  It will help with your weight management along with your blood sugar.  As transplant patients, you are taking so many medications that you don’t need to eat all that processed food along with their chemicals. Check with your dietitian at your transplant hospital about tips and ideas.

9. Returning to bad habits

Before transplant, while being evaluated, most patients swear they will be taking care of themselves much better. Unfortunately, once they start feeling great after the surgery, some of them go back to their old habits that led them to require a transplant (obviously it is not all patients who need transplant that fall into that category, some have acquired diseases or were born with it). What I mean is by example: a long time smoker now needing a lung transplant, a fast food eater ending up needing a heart transplant because of too many heart attacks or a high salt intake person who ends up with severe hypertension which cause kidney failure requiring transplant.  Believe it or not, some patients restart smoking after lung transplant!  A new organ does not treat the causes in most cases, it just relieves symptoms. You have received a new chance in life, it is your turn to take care of it.

10. Be positive!

This is the correct attitude towards the success of your transplantation. If you feel you have some depression please check with your hospital to see if they offer a support group. Some patients feel some guilt regarding being alive while their donor is dead. It is important to also take care of the mind.