News - Around the world... Mumbai-Omaha-Heidelberg: Hepatobiliary surgery and Transplantation

Anna Sparaco

Arrival at midnight on the 26th February 2008 in Mumbai was the beginning of an epic hepatobiliary and transplantation adventure that would take me around the world in less than 4 months. The first leg of a three stage journey started with the International Hepatobiliary Association conference. Here the most influential people in hepatobiliary surgery and some also in transplant converged to exchange ideas and debate therapeutic strategy.

This congress lasted 5days and one of the most striking insights was seeing the passion of colleagues from developing countries, not dissimilar from our own, pursuing the outer limits of our profession and challenging the boundaries, striving to be part of the cutting edge. They are not held back by socioeconomic distress or political instability. A week later I left Mumbai to travel the wrong way around the world to arrive the previous day in Omaha, Nebraska in the United States of America at 11pm. The objective of this three month stay was to work in the Transplant Unit at the University of Nebraska. This unit is rapidly becoming the world’s leading small bowel transplantation unit having done the most small bowel transplants in 2007. They practice an open door policy and I got access to everything I needed immediately and experienced great hospitality. The unit has 4 dedicated consultants or attendings as they are called in the USA.

All four consultants are interchangeable, that is they can all do everything in the unit. So they all do liver and small bowel transplants and some hepatobiliary work. The unit practically runs its own ICU with the help of intensivists. This unit is also the home of a wonderful Intestinal Rehabilitation Program (IRP). This program was lead until recently by Dr Debora Sudan, who has subsequently left to take charge of the Transplant Unit at Dukes University. The IRP boasts excellent figures of only having to transplant about 15% of the patients referred to them for short bowel syndrome. They use various nutritional strategies and some surgical procedures like the STEP to achieve enteral independence. Short Bowel Syndrome management and small bowel

This was a photo of a poster I came across in downtown Omaha. Thought that it was particularly pertinent.	This is Jean Botha, an attending transplant surgeon at the UNMC and graduate from Wits and UCT. Here we sit with the world's biggest and tastiest margaritas. Needless to say the American way!

transplantation is not for the faint hearted. This unit has provided the template for orthotopic liver transplantation as we practice it in Johannesburg. However, I also got exposure to living related donation and sometimes the donor is not even related. There are numerous good Samaritan acts in the USA and anecdotes of individuals hearing that a friend needs a segment of liver or a kidney and they simply step up to the plate and offer themselves as donors with no financial incentive at all. Nonetheless, the art of procuring a lobe of the liver, usually the left, is very sophisticated and intricate requiring two teams working synchronously. Taking the lobe of the liver without compromising the donor is challenging. Splitting a cadaveric liver so that one liver provides part of a liver for two recipients is an attempt to expand the donor pool.We split a liver and then transplanted an adult in our centre and the remaining segment was taken to another centre to be transplanted into a child.

We also did a number of liver resections and pancreatic cases. This team generally uses total vascular exclusion for their liver resections. New technologies such as microwaving as opposed to radiofrequency ablation were being used to ablate tumours or for resecting the liver similarly to the Habib system. This unit is also looking at dealing with the small-for-size graft by creating a portocaval shunt that is meant to deflect the high pressured mesenteric flow away from a potentially small liver thereby averting the small-for-size syndrome. This is cutting edge development and should it be shown to work then could have significant implications and impact on donor pool expansion. Participation in the procuring of organs allowed me to fly around the states and be exposed although briefly to other hospitals in the country. Although the UNMC is state of the art, I realised that this was not the case all over the states.

The most impressive factor was the American work ethic. The intensity with which they work and the drive to be productive, was not even replicated in Germany. The three months passed very quickly and I was soon on my way to Heidelberg, Germany to spend two weeks in Professor Markus Buchler’s unit. He is a well known pancreatic surgeon. Yet again the work ethic was impressive. The emphasis on research was much more tangible in Germany. This unit boasts running 5 operating lists a day and on any single day there are several pancreatic cases and liver cases. I was impressed by the aggressive approach to cancer that they have and furthermore their use of intraoperative radiotherapy. This unit however is a general surgery unit and they do all types of general surgery. Interestingly enough my visit coincided with a workshop run by Professor Heald on total mesorectal excision. I was also briefly exposed to stapled technique of liver resection and participated in a split liver transplant.

I met many different doctors from all over the world. It was wonderful to spend time with likeminded people with a strong desire to learn. I have been most fortunate to have been afforded this opportunity and the exposure and inspiration has been priceless. This experience has inevitably added a new dimension to my practice and I return full of hope and optimism that in spite of some challenges, if we really wanted to we could do the same! I am immensely grateful to The Gastroenterology Foundation for the support that they gave me to undertake this journey.


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