Liver Transplantation with Dr. Blaž Trotovšek, Visiting Lecturer at the Faculty of Medicine
At the Faculty of Medicine of the University of Montenegro, a lecture on liver transplantation was held today by prof. Dr. Blaž Trotovšek, professor at the Faculty of Medicine in Ljubljana, head of the Liver Transplantation Department of the University Medical Center Ljubljana and head of the National Body for Organ Procurement in Slovenia.
His lecture, for which he was presented with a certificate by the dean of the Faculty of Medicine, prof. Dr. Miodrag Radunović, it was an occasion to talk with him about difficult and demanding surgical intervention, the success of the donation program in Slovenia, the risk and life of the patient after surgery, and the transfer of knowledge to new generations.
The lecture was preceded by a meeting of the administration of the Faculty of Medicine with Professor Trotovšek, where the modalities of further cooperation were agreed upon. Professor Trotovšek opened up the possibility of an associates stay for further education at the Department of HBP Surgery and Liver Transplantation of the University Medical Center Ljubljana.
UMNE: Today, liver transplantation is a rare operation that is not performed in all countries. When it comes to the Western Balkans, where is it dominant in practice? Also, what is the success rate of the operation?
TROTOVŠEK, PhD: Transplantation in regular clinical practice in the Western Balkans is present in Slovenia and Croatia, while in Serbia and Bosnia it is performed more sporadically. Why this is so, the answer should be sought primarily in the quality and organization of donor programs that are successful in both mentioned countries. Croatia has about 30 donors after brain death per million inhabitants, and Slovenia about 20 per million per year. It is also very important that both countries have been members of the Eurotransplant area for more than 20 years. It is the basis for carrying out any transplantation program, including the liver. As for success, one-year survival today is around 80-90%, and five-year survival, which again depends on the indication for transplantation, today is 70-85%, and even more in individual centers. In Slovenia, one-year survival after transplantation is better than in the Eurotransplant area, to which we belong (84% versus 82%), and the five-year survival rate is the same (76% versus 71%).
UMNE: In what cases is liver transplantation resorted to, and what are indications for liver transplantation? TROTOVŠEK, PhD: Today, transplantation is a method of treating both acute liver failure for various reasons and chronic organ dysfunction, which is most often, in our region, a consequence of cirrhosis of various origins. The epidemiology of the causes that lead to chronic liver failure is very different in relation to the geographical area. Alcoholism, hepatitis B and C virus infections are probably the most common causes of liver damage. Metabolic syndrome and obesity are expected to take precedence in the coming decades. New drugs for the treatment of hepatitis B and C viruses will significantly reduce the frequency of this indication in developed countries. Autoimmune diseases of the liver and biliary tract and metabolic liver diseases are important indications for transplantation. There are also numerous other indications for transplantation, such as trauma and some other diseases, which are not so common. Lets not forget about some malignant liver diseases, in which transplantation is the method of choice in certain situations, because it treats the underlying disease - cirrhosis on the one hand, and the tumor itself on the other. Such are examples of patients with liver cell carcinoma (HCC), who can have a five-year survival rate of more than 70%, when certain selection criteria are followed. This area, which today we call transplant oncology, will be increasingly important in the future. Liver cell carcinoma, epithelioid hemangioendothelioma and unresectable metastases of neuroendocrine tumors of the digestive tract as indications for liver transplantation in certain conditions will probably be joined by metastases of colorectal cancer, perihilar cholangiocarcinoma, and perhaps others. UMNE: Liver transplantation involves the joint work of a multidisciplinary team. Who does it all and is it difficult to have the same team of experts together all the time?
TROTOVŠEK, PhD: Liver transplantation is a complex treatment in which multidisciplinary work is present from the beginning. It starts already when the indication is decided and the patients preparation for treatment begins. Hepatologist, gastroenterologist, surgeon, anesthesiologist, intensivists collaborate in this work, and other professions are involved as needed and in accordance with the protocol of preparing the patient for the procedure. The scope of research on the patients suitability for transplantation is large and requires the opinion of cardiologists, neurologists, nephrologists, infectious disease specialists, psychiatrists, dentists, social workers and others, in order to establish what benefits and risks transplantation will bring to the patient.
UMNE: One of the biggest problems of organ transplantation is finding a suitable donor. What is Slovenias experience in this field?
TROTOVŠEK, PhD: As I have already said, an essential part of any transplant program is an effective donor program. The bigger the better. The procedure must be agreed and standardized. It is run separately from the transplant program, and intensive cooperation and communication are necessary. The integration of the program into international organizations, such as Eurotransplant, enables small countries such as Slovenia, and I believe in the future, Montenegro, to find donors for patients with acute liver failure, for whom transplantation is the only possibility to save life. And a sufficient number of domestic donors enables the development of a national transplant program, where the goal should be 15-25 transplants per million inhabitants. Cooperation in Eurotransplant helped Slovenia to fulfill all these requirements. In the last ten years, Slovenia sends surplus organs to the Eurotransplant area, an average of about 10 livers per year.
UMNE: How possible is the patients return to normal functioning after liver surgery? What has the experience shown so far?
TROTOVŠEK, PhD: After transplantation or after surgery on the liver, patients return to normal life. Let me explain with an example. The 45-year-old mother of two children has primary biliary cirrhosis, she is constantly tired, itchy skin is constantly present and she is depressed. She goes to work for a couple of days, and then she is on sick leave for a month because she is so tired. They grant her a disability pension and she begins to think about a liver transplant due to her poor quality of life. After the transplant, she recovers quickly, there are no complications and difficulties that destroyed her and her familys life. Her biggest problem is that she cant work because she has already been retired. Yes, post-transplant patients can play professional football, stand on the Olympic podium in skiing, work and live like normal people. Of course, the stories are different, and we as a society and individuals are obliged to welcome these people back into our midst.
UMNE: You have cooperation with the Medical Faculty of UMNE. How important is training and transfer of knowledge? We assume that, with the development of medicine, they are constantly upgraded.
TROTOVŠEK, PhD: Education in medicine is a specific topic, which is difficult to compare with any other education. The important difference is in the material we work on, which is people. Education in surgery, which is actually the most aggressive activity allowed by law in peacetime, is especially complicated. The result of a surgical procedure can be a dead patient, and I am not aware of any other activity in peace where this would be allowed. From there comes this great responsibility that we as teachers have first of all with our patients, and also with our students. The relationship between teacher and student that is so beautifully written in our Hippocratic Oath should be constantly in our thoughts. This would lead to even better cooperation, with respect for differences and even special qualities of individuals, of which there are many in our region. Transferring knowledge is the duty of us teachers, and continuous improvement is the duty of our students and us, because the function of teacher and student in medicine is not permanent. Often, even the so-called teacher can learn a lot from the students. This interaction should be in the function of better treatment of patients, that is, how to treat more patients better.
UMNE: Thank you for the conversation.