Lung allocation score

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I'm Dr. Tom Fishbein, I'm the executive director of the MedStar Georgetown Transplant Institute. I'm a surgeon the primarily sees patients who need liver transplants or have liver or pancreas tumors and does small bowel transplants. There's an exceptional value and importance placed on how we care for patients in this hospital. The term "cura personalis" refers to caring for the whole patient and that's the motto of this hospital and that's really taken very seriously. We have developed over the last decade here into an extremely robust and multi-disciplinary program for the care of patients who come for transplants. The quality of the nursing care, the social workers, all the other different personnel in addition to the doctors and surgeons who are involved in the care of patients are all extremely high and extremely important to the way our care is delivered. Transplantation is one of the rare and unique fields in which we give something more to the person than they had when they came to you. And that's very transformative in the life of a patient who gets a transplant. People celebrate the birthday of their transplant like their birthday every year. I think our goal is similar for every patient and that is to maximize the length of their lives and the quality that they have in that life. And how we get there will be very unique and individualized for each person. The MedStar Georgetown Transplant Institute is a somewhat unique setup in which we have medical doctors and surgeons, nurse practitioners, social workers, dietitians, all working together in pediatrics and adult care in the same institute so that our global goal is all the same. We're not in different departments or different institutions being brought together to care for somebody. We live and exist together to care for patients who need transplants. I find it tremendously gratifying to be able to work with the people that I work with. Every day I come in and see different people in different job titles and types of educational backgrounds working together to take care of our patients. We have a really tremendous, committed and caring team and I think that's really what gives me pause when I come to work. Well, there are a bunch of factors that I think people should consider when they're picking a transplant program. One is the experience of the center. And so, you'd like to choose a center that has a significant amount of experience for the organ that you need. And another one is, results speak for themselves. The results of liver transplants are published on a website on the internet and are publicly available to everybody. Our results are excellent for the outcomes of liver transplants and everyone should look into those sorts of things before they decide where to go. It's also important to recognize that the outcomes of transplants are correlated with the volume of transplants that centers do. So very small centers that tend to do very small transplants don't tend to have the amount of experience and the quality of outcomes as larger centers like ours. MedStar Georgetown Transplant Institute has excellent outcomes of all its organ-specific programs. So if we're talking about liver transplants here for today, I mentioned that the volume of the transplant program tends to correlate with the outcomes and we have a large... in fact - the largest liver transplant program in the mid-Atlantic and we also thereby have the best survival rates with liver transplants in the mid-Atlantic region. That's also an important factor in determining where you go for a transplant. If you have the resources to be able to travel around to different programs and survey them, then you can compare the wait times are for transplant at a different place. And some parts of the country have much shorter waiting times than others. Generally, on the East Coast, they tend to be longer over-all than other areas of the country like the south and central United States. We at Georgetown have a shorter waiting time than any of the programs in the mid-Atlantic area. Experience is very very important in the outcome of a transplant. We know, as transplant surgeons, that we look at 3 things in the outcome of a transplant. One is the patient. When we get a patient who is referred early and has not become too debilitated by the time they get their transplant, that's a major factor in determining the outcome. A second, is the quality of the organ that they get, and so when we're fortunate to have a superb quality organ, which is what we look for for every patient, that has an impact on the outcome. And the third one is the quality of the surgery and the care around the time of the surgery. And so, the most important factor is probably that you have an uncomplicated course when you get the actual operation and are able to be discharged from the hospital soon. that's a very variable time period, depending on what type of transplant we're doing. In little babies, often we will do a live donor transplant where a parent or another member of the family will donate a portion of their liver to a little baby. And that operation is done at the same time as the operation on the baby. We overlap two operating rooms simultaneously and that tends to take the entire day. On a patient who is uncomplicated and hasn't had prior surgery and we get a whole organ for instance, it'll be a fairly straightforward procedure that might take 5-6 hours. Patients come for an evaluation for a transplant and undergo a thorough medical evaluation to assure that they're a good candidate for a transplant. That includes all of the routine health screening that you might have, including mammogram for a woman of the appropriate age, colonoscopy, and the like. We assess to make sure you don't have other underlying medical problems that have been undiscovered before you go to your transplant. Then we evaluate the status of your organ to be sure that you need the transplant. And we'll have many medical and surgical therapies that we can employ that help patients avoid the transplant. So, for instance, we see many patients with medical liver disease who come to one of our medical specialists and they can control or slow down the disease and avoid the need for transplant. Sometimes I will see patients with liver tumors who are thought to need a transplant and yet I can re-sect or remove the tumor and we can treat that and cure it without a transplant. Other patients then will be found to need the transplant as no other treatment will be as effective. In those cases, when we finish the evaluation, determine that you're a candidate for a transplant, your name gets placed on a national list with all the other patients who are waiting for a liver transplant. It's then that by the determination of how ill each individual patient is that when a liver becomes available it gets allocated to the person who's the sickest at the top of the list first and then down the list to the less sick patient. The typical waiting period would depend on how sick you are at the time that you come for your transplant evaluation. We will have patients who come with acute liver failure and they will immediately come into the hospital even into an ICU and may die within days without a transplant. Those patients will get prioritized right to the top of the list and may wait only a few days. Another patient who may be very stable, referred by their doctor early in the process, can undergo an elective evaluation get on the list, and then we decide when to activate the patient when we see that they're starting to deteriorate, so that we don't do the transplant too early, before it's helpful for them, but we don't wait till they're so sick that they're in the hospital. So there's a variation depending on when we first see you. You can, in fact it is your right protected under the federal regulations for organ allocation, that every patient can go to more than one center if they choose to for listing. The transplant itself is a large operation and all our patients will go to an ICU for the first day after the surgery. Most patients will be asleep still when they come out of the operation room and left on a breathing machine for the first day. Then they're allowed to wake up and the breathing tube is removed the first day after the transplant, and usually on the second day our patients will go to a regular floor where they will start receiving instruction about how to care for their liver, how to take the medications that they need to prevent rejection of a transplanted organ, and start to regain their strength. Most patients are eating by the 2nd or 3rd day after the transplant and generally making plans to go home by the end of about a week. There are a combination of medications used to prevent rejection of the organ which are at higher doses for the first few months after a transplant and then gently taper down so that you're at quite low doses by about three months after the transplant. Because these medications make you more susceptible to infections, you're also on a couple of antibiotics and they prevent infection during these first few months when you're at increased risk. Medications that we use to suppress the immune system and make the body accept the new organ have gotten much better over the years. We have a whole variety of different medications that we can rely on to prevent rejection, and nowadays, we generally have a patient down to one or two medications only one or two times per day by the end of the 1st year after transplant. And generally that's what one stays on for life at quite low doses. The patient is empowered to care for his organ and probably the most important thing after one gets out of the hospital, you are in charge and in control of how you do in the long run. So taking your medications, coming to your follow-up appointments, having us follow your lab results very closely in those first few months after transplant, sets the course for success in the long run. And you are the steward of you new organ. We do all the different types of transplants that are out there for liver transplant. There are about 6000-8000 people who need a liver transplant every year in the United States. That number is growing every year. The number of donors that we have has been stable, and therefore, we've had to be more and more innovative as the years have gone by, to figure new ways to get organs. The most common type of liver transplant involves the use of a whole organ from a donor who has died and his family has donated his organs. That's called a cadaveric whole organ transplant. We do many of those, in fact, probably the majority of liver transplants that we do are with whole organs. We also do different types of transplants. Sometimes a live donor will step forward and will want to donate a portion of his liver. You only have one liver, so you need to have sufficient portion of the liver that you will live off of as a donor, and then a portion that's smaller that you donate to another person and that can save his life. In fact, we do the majority of children with live donor transplants in which a mother, a father or someone else who knows the family donates a small portion of their liver. We also do split liver transplants. This is a 2 for 1 deal, where we have a whole cadaveric organ from someone who's died, and we're able to divide the liver in half and put one half perhaps into an adult and then the smaller half into a child who needs a transplant. When people are interested in donating a part of their liver, the most important function of our team is to assure the safety of the health of that donor. This is an operation that a patient undergoes for no benefit to themselves, only to help another person. So it is imperative that we have a very thorough process to assure that the donor goes through surgery, recovers fully, and goes back to his normal life. That involves a very thorough evaluation in which a patient has extensive blood-work screening and cardiac screening to make sure they don't have undiscovered medical problems that haven't come to light yet, and if a patient is found to be perfectly healthy to be a donor, then we evaluate the anatomy of his liver. If the anatomy is such that a portion can be removed and successfully used, then the rest of their liver can regenerate, and the liver is the only organ that does this, it will regenerate within 6 weeks after the surgery, then he may be accepted as a donor. We would plan the surgery very specifically at the perfect time for both the donor and the recipient to undergo surgery and then we follow that donor to assure that they have recovered completely for several years after the transplant. Interestingly, it's the insurance of the recipient of the transplant that covers the donor and his care so that there's no cost incurred by the donor himself for helping someone else. If you've undergone a liver transplant it's very important that we follow you very very closely for the first several weeks after the transplant and most people don't return to work for at least 6 weeks. If your liver function is stable and you're not having any problems with the medications after 6 weeks from the surgery, often people will return to school if they're children or to work if they're grownups, after that period of time. There will still be office visits and doctor appointments that must be made, but generally the quality of life and the style of life that people maintain after a liver transplant really returns pretty much to normal. This depends on what type of liver donor you are. For an adult to donate to a child is a relatively smaller operation. Most patients are back t work within 6 weeks after the surgery. To donate to an adult a larger portion of the liver, it may be slightly longer before someone returns to work. Most people wake up after their liver transplant and are a little groggy and tired from the anasthesia, but otherwise feel fairly normal. Once the breathing tube is taken out on the first day after transplant they can converse and communicate with the family, they can take some liquids by mouth, and generally, the 2nd day, when they get to a floor they feel pretty good, Interestingly, pain after the operation is not a major complaint and patients tend to recover fairly quickly and fairly well in those first few days. MedStar Georgetown has got a very sophisticated team that does surveillance on all of our patients after transplants. In fact, we're one of the few places that has specialized units with special nursing teams just to take special care of the patients that we perform transplants on. We have a 30-bed unit that takes care of adults after transplant with nurses, nurse practitioners, social workers, many physicians and surgeons that are on the unit all day, that look after these patients. The ability to respond immediately is essential in dealing with complications in the cases that they arise. On the children's side we have another similar unit which is only for children who need transplants and that's one of only a few in the entire Unites States that are dedicated to children with liver and bowel transplants. One of the challenges of having developed into a national and international referral center, has been that people come from far away and don't have a place to stay when they come here. As a result of that, the board of our hospital in fact dedicated resources so that people that come from far away can stay in apartments that are set up and dedicated just for patients who need transplants. So we have families that come from far away to donate an organ or because their child or loved one needs an organ transplant and they can live in the apartments in fact for several weeks or months while the transplant process is unfolding. Our pediatric unit is actually a live-in unit where a parent or caregiver can live with the child in the unit even for several months at a time around the transplant process. So while it's very disruptive to a family to have to move to another area of the country in the short run to get the care that they need, we've tried to make it easy so that people can live right alongside the hospital, receiving their care. We have a broad age range between our pediatric and adult programs. We've transplanted children as small as just the first few days of life that weigh only 4-5 Lbs, all the way up to adults who are in their late 70's. In our program we have not set a specific age limit on who can receive a liver transplant but it really is much more dependent on what the functional status of a patient who may be a candidate is. So we've done patients who have been in their late 70's but are robust and physically active and we feel can recover. It doesn't preclude us from breaking the age barrier into the 80's if we have the right patient who has the right problem. Liver tumors can be treated in a variety of different ways, depending on the type of tumor and the patient's underlying condition. As we are a transplant program, we see many patients who have cirrhosis of the liver and they then develop a cancer within that liver that has cirrhosis. Many of those patients to go onto a transplant. However, that's not the only treatment that we have available. We have a broad program of people who treat liver tumors and we have a variety of different techniques that we use. I as a liver surgeon, often will remove or re-sect a portion of the liver with the tumor in it, and if the cirrhosis is early or if a patient doesn't have cirrhosis, many people I can cure from their tumors that way. We have several other treatment options that we employ with a multi-disciplinary team, so we have oncologists, interventional radiologists, who can put little beads with radiation inside of tumors, we can do what's called an RFA, or Radio Frequency Ablation in which we burn or ablate a tumor. We can use micro-wave, we can inject alcohol into tumors sometimes, so that in addition to surgical techniques to treat liver tumors, there are a variety of other treatments and we use a weekly conference in which we evaluate each patient with each liver and each tumor independently and come up with a plan from the whole team on what's the best approach. In the mid-Atlantic area I would say MedStar Georgetown Transplant Institute by far has the greatest conglomeration of experience and physicians who treat liver diseases. This is the place in this region of the country where the majority of people come. We have the history, we have the techniques, the personnel, and this is what we're dedicated to.