Monday, November 30, 2015

Transplantation 2

Transplantation of human cells, tissues and organs

Transplantation of human cells, tissues or organs saves many
lives and restores essential functions where no alternatives
of comparable effectiveness exist

In 50 years, transplantation has become a successful worldwide practice. However, there are large differences between countries in access to suitable transplantation and in the level of safety, quality, efficacy of donation and transplantation of human cells, tissues and organs. The ethical aspects of transplantation are at the forefront. In particular, the unmet patients’ needs and the shortage of transplants lead to the temptation of trafficking in human body components for transplantation.

WHO Guiding Principles on Human Cell, Tissue and Organ Transplantation

In 1987 the fortieth World Health Assembly, concerned at the trade for profit in human organs, initiated the preparation of the first WHO Guiding Principles on Transplantation, endorsed by the Assembly in 1991 in resolution WHA44.25. These Guiding Principles have greatly influenced professional codes and practices as well as legislation around the world during almost two decades. After a consultation process that took several years, the Sixty-third World Health Assembly adopted resolution WHA63.22 on 21 May 2010, endorsing the updated WHO Guiding Principles and identifying areas of progress to optimize donation and transplantation practices.

WHA63.22 - Human organ and tissue transplantation

WHO Guiding Principles

The Declaration of Istanbul

Professionals of donation and transplantation from all regions, through many of their organizations and institutions, are endorsing the Declaration of Istanbul on organ trafficking and transplant tourism developed under the leadership of the Transplantation Society and the International Society of Nephrology in May 2008.

Transplantation

Donation and transplantation

Donations from deceased persons should be developed to their maximum therapeutic potential avoiding, whenever possible, the inherent risks to live donors, as stated in WHO Guiding Principle 3. There is a recognized need for communities, and health professionals, to become better educated about donation and transplantation and that is the key to the success of deceased donation programmes.

However, despite the frequent use of materials donated from deceased donors, the donations from living donors are necessary for some types of transplants or to compensate for the limited supply of material available from deceased donors in order to meet patient needs. Living donation is thus practised despite the fact that it involves risks for the donor that may not be negligible.

As the procurement of human material for transplantation from deceased or living donors and the subsequent allogeneic transplantation may entail ethical and safety risks for both the recipient and the donor, strict controls and effective oversight should be carried out by the health authorities to protect them. The Guiding Principles mandate optimal care for donors and recipients.

The transparent oversight of the health authorities over donation and transplantation activities is also essential to increase the trust of the public in the system. In addition, the decision to be a donor is often based on the understanding that a contribution to the availability of transplant resources may someday benefit the health needs of the donor’s family.

If we are prepared to receive a transplant should we need one, then we should be ready to give

Tuesday, November 24, 2015

Laparoscopy and endometriosis

A laparoscopy (keyhole surgery) can be used in the diagnosis or treatment of a number of conditions of the abdomen and pelvic area. The advantage of laparoscopy is that only a small cut (incision) is required.

The added advantage of laparoscopy in endometriosis is that your diagnosis can be confirmed and treatment can be carried out at the same time. It can also be used to find out where the endometriosis is and how much of it there is, as well as making sure there is no other medical problem that is causing your symptoms.

If endometriosis can be seen during the laparoscopy, a sample will usually be taken for biopsy. This will confirm the diagnosis.

Your treatment will depend on where the endometriosis is found and how much is found.

Spots of endometriosis throughout the pelvis can be removed surgically or by burning (using diathermy or laser). Endometriosis in the ovaries will usually have formed a cyst called an endometriotic cyst (endometrioma). This will need to be removed.

Studies have shown that five years after surgery, up to 70 per cent of women will have no evidence of endometriosis returning.

Not all endometriosis can be treated with laparoscopy, however. Sometimes endometriosis affects other organs such as the bowel or ureter (the tube from the kidney to the bladder). If this is the case, you may require further surgery at a later date. Further surgery is likely to involve other specialist surgeons.

Laser or diathermy?

Laser and diathermy are tools the doctor can use to heat tissue. Both can be used for either burning the endometriosis (ablation) or cutting it out. Both methods have advantages and disadvantages. A gynaecologist will use the method they are most experienced and comfortable with.

Burning or cutting

The Royal Women's Hospital is researching both to find out which is the most effective treatment for endometriosis. In some areas though, cutting it out does seem to be better.

Risks

There are risks with all surgery. With laparoscopy, problems are rare but can be severe. They include:

infection in the bladder, uterus or cuts on the abdomen
organ damage or bleeding – (one in five hundred)
death – (one in twenty thousand).

The specific risks of treating endometriosis with laparoscopy include:

damage to bowel (one in three thousand).
damage to the bladder or ureter.

These complications may require immediate treatment. They can be serious and may require more extensive surgery at a later time.

Other risks include:

the possibility of the symptoms not improving,
scar (adhesion) formation.

In some cases it may not be possible to remove all endometriosis or the endometriosis may come back at a later time.

Before surgery your doctor must discuss the risks with you so when you provide consent for the operation you understand what the risks are. Don't be afraid to ask questions.

Treating endometriosis

Endometriosis can be treated medically (with drugs or medicine) or with surgery. Sometimes both medicine and surgery are used. Some women also benefit from alternative therapies.

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Medications range from pain relief drugs (such as paracetamol and non-steroidal anti-inflammatories) to hormonal treatments that suppress ovulation and menstruation).

Surgery can be used to remove or burn the endometrioses. The most common surgery used is laparoscopy (key-hole surgery).

If the ovaries contain cysts of endometriosis these are best treated surgically as they are unlikely to disappear on their own and they can't be treated with medicine.

Treatment to improve fertility

Surgery has been shown to improve fertility for women with mild endometriosis. Treating more severe endometriosis with surgery, especially if there are cysts in the ovaries, also appears to improve fertility, although this hasn't been fully proven. Medication for endometriois has not been shown to improve fertility.

Other causes of infertility should be looked for and treated.

Treatment for pain

When pain is the main problem, the treatment aims to relieve symptoms and lessen the pain.

Simple pain relievers (paracetamol, etc)
Many women will experience some relief of symptoms with over-the-counter drugs such as paracetamol (Panadol) and non-steroidal anti-inflammatories (Ponstan, Nurofen, Naprogesic, etc).
Hormonal treatments (the Pill, etc)
Hormone treatments are used to suppress the normal menstrual cycle, which in turn stops or slows endometriosis growth. The simplest way to achieve this is with the Pill. Other hormonal therapies that have been shown to be effective in reducing endometriosis-related pain, are also available. Some women will experience side effects with hormonal treatments.
Keyhole surgery or laparoscopy
May be offered initially to help make the diagnosis. Some women are offered surgery because they don't want to take medicine or because medicines haven't worked. Surgery for endometriosis includes laparoscopy (key-hole surgery), which may be used to make the diagnosis and treat all visible endometriosis. This is done with laser or diathermy, which destroys the endometriosis by burning it. Alternatively the deposits of endometriosis can be cut away.
Hysterectomy
In a small group of women who have severe symptoms that are not relieved by medical or other surgical treatment, more extensive surgery such as hysterectomy and removal of the ovaries may be considered.
Bowel surgery
Sometimes the endometriosis affects the wall of the bowel. When this is causing significant symptoms it may be suggested that the affected piece of bowel is removed. This would require bowel surgery and is uncommon.

Alternative and complementary therapies

There are various treatments available that can either complement your medical treatment or are an alternative to medical treatment. The most popular is traditional Chinese medicine and herbal preparations. Some women experience improvement of their symptoms with these but there is no scientific evidence to support the effectiveness of Chinese medicines in reducing symptoms or improving fertility.

If you use complementary treatments it is wise to discuss their use with your doctor as they may interfere with other prescribed medications. The Pharmaceutical Benefits Scheme (PBS) does not cover the costs of alternative or complementary therapies.

Choosing not to treat endometriosis

Mild endometriosis doesn't always need treatment. You are usually offered treatment to help relieve the symptoms rather that to cure the disease itself.

If left untreated, some endometriosis will improve, but most will stay the same. Some will become more severe without treatment.

For most women with endometriosis, the symptoms will settle once they go through the menopause. Deciding whether or not to treat endometriosis is often a matter of balancing the risks of the treatment against the effect the endometriosis is having on your life.

Benefits and disadvantages of different treatments

	Benefits	Disadvantages
Doing nothing – no treatment	No side effects of drugs No risks of surgery	Most symptoms continue Some symptoms may get worse
Simple pain relief (paracetamol, ibuprofen)	Easy to get Side effects uncommon	Often not effective Ibuprofen use has some health risks
Progesterone-like medications	Reduced pain Irregular or no periods Stops endometriosis growth in most cases Some are contraceptive	Side effects possible – weight gain, moodiness, acne, increased hair, cramps, breast tenderness Symptoms may recur when treatment is stopped May not fix pain Doesn't improve fertility Shouldn't get pregnant while on drug Not all contraceptive
Menopause-causing medications	No periods Reduced pain Stops endometriosis growth in most cases	Side effects – hot flushes, sweats Bone thinning if used for more than six months Symptoms may recur when treatment is stopped Shouldn't get pregnant while on drug Not a contraceptive May not fix pain
The combined contraceptive pill	Contraceptive Reduced pain Can be taken to reduce or stop periods	Side effects – nausea, weight gain Shouldn't get pregnant while on it Small risk of clots in legs or lungs
Laparoscopy	A definite diagnosis A long-term cure in up to 70 percent of women No need to use medications long-term	Not all endometriosis can be treated this way There are risks assoicated with surgery May not cure the pain Recurrent endometriosis in 30 percent of women
Hysterectomy and removal of endometriosis	Achieve long-term cure in over 90 percent of women No need to use medications No more periods	Risks of surgery greater than laparoscopy Removes fertility Some women grieve for uterus loss May need HRT if ovaries removed May not cure pain

About endometriosis

The exact cause of endometriosis is still unknown. The most popular theory is that during menstruation, the menstrual tissue passes backwards through the fallopian tubes and into the pelvis where it attaches and grows.

Endometriosis does seem to run in families, so you will be more likely to have it if your mother or another woman in your family has had it.

What are the symptoms?

Many women have endometriosis with no symptoms or problems but this is not always the case.

Common symptoms of endometriosis include:

period pain
pain with sex
pelvic pain at other times of the menstrual cycle
back pain
low energy
pain passing a bowel motion.

All of these symptoms have other possible causes.

Some women who have difficulty becoming pregnant are found to have endometriosis, even when they don't have other symptoms.

How is endometriosis diagnosed?

A discussion about your symptoms and a physical examination should provide your doctor with enough information to determine if you might have endometriosis.

If your doctor thinks you may have endometriosis they will most likely recommend you have an ultrasound. This will usually be able to show if you have lumps (nodules) of suspected endometrium growing near or into your bowel and bladder. A definitive diagnosis can only be made if you have a laparoscopy (keyhole surgery). A tiny incision is made in your abdomen and a small sample of tissue taken. Tests done on the tissue will confirm if it is endometrium or not. Based on the severity of your symptoms, your doctor will plan the best treatment for you.

There are currently no non-invasive tests for endometriosis available in Australia.

Endometriosis and fertility

There are many reasons why a couple may be infertile. Endometriosis is sometimes found in women who are having trouble getting pregnant. In a minority of these women, scar tissue caused by the endometriosis will have caused a blockage of the fallopian tubes.

However, in most women it is not clear why the endometriosis affects their fertility. Theories include that the endometriosis:

results in eggs that are less likely to fertilise
produces natural toxins to sperm.

Treating with MRI

Uterine fibroids are one of the causes for heavy periods. An MRI scanner is used to heat and shrink the fibroids and thus treat your heavy menstrual bleeding.

This is a relatively new treatment for uterine fibroids. It is also referred to as MRgFUS and uses an MRI scanner to deliver a focussed, high-intensity ultrasound beam to heat the fibroid and shrink it. It is only suitable for some women and while it is non-invasive it can be hard for some patients to remain still for the whole procedure.

Risks and benefits

Benefits	Disadvantages
Fast recovery time, women are able to go home the same day Less complications than with surgery	Not suitable for fibroids larger than 10cm or too close to surrounding tissue Not suitable for women who are unwell and require immediate treatment as complete effect of MRgFUS will take twelve months. Long-term effectiveness and safety is not yet known. Not readily available at most hospitals

Treating with surgery

If you have tried medication treatments for your heavy periods with no improvement, surgery may be your next option.

You may consider surgery if you:

tried medication but it didn’t help
could not try medication because of other health issues
have fibroids
have other conditions which cause bleeding and pain (e.g. endometriosis).

Surgery aims to stop bleeding and pain completely by removing or reducing the cause (fibroids, polyps or the lining of the uterus) or by removing the uterus completely.

There are three main operations used to treat heavy menstrual bleeding.

Endometrial ablation removes or destroys the lining of your uterus using heat or microwaves. A long, narrow instrument called a hysteroscope is put inside your uterus (through your vagina) to allow the doctor to see and to perform the ablation. This can be done under local or general anaesthetic.

Myomectomy removes fibroids from your uterus. Sometimes this involves one long cut across your belly (abdominal myomectomy) or several small cuts across your belly (laparoscopic or ‘keyhole’ myomectomy). Sometimes it is done using a hysteroscope and so there are no cuts at all (hysteroscopic myomectomy). This is done under general anaesthetic

Hysterectomy removes your entire uterus and sometimes your cervix, ovaries and fallopian tubes. This can be done with one cut (abdominal hysterectomy), several small cuts (laparoscopic or‘keyhole’ hysterectomy) or without any cuts (vaginal hysterectomy).

You and your doctor or surgeon will discuss the best course of action for you. Write down any questions or concerns about your possible treatment and discuss them and your options with your doctor.

Treatment options

	Benefits	Disadvantages
Endometrial ablation	Safest surgical treatment Usually only in hospital for one day Significantly reduces heavy bleeding (around 85 percent of women have improvement and around 35 percent have no further bleeding) Can also be used to remove some fibroids and polyps	For some women heavy bleeding returns May not reduce period pain There are major complications in about 1 in 1000 procedures. These can include infection, damage to the bowel or a hole in the uterus It may be difficult to investigate any future problems in the uterus
Myomectomy	Reduces heavy bleeding The best surgical option for women who want to be able to have (more) children May improve other symptoms caused by fibroids such as feelings of pressure	There is a small risk that an emergency hysterectomy will be need to be done There is also a risk of excessive bleeding requiring a blood transfusion Fibroids can regrow
Hysterectomy	The only guaranteed way to stop menstrual bleeding completely May reduce period pain Most women are very satisfied with it Reduces the risk of uterine and ovarian cancer (even when your ovaries are not removed)	Is a major surgical procedure with potential complications Recovery takes 2-6 weeks depending on the type of hysterectomy You will no longer be able to have children May lead to early menopause (even if your ovaries are not removed) May increase the risk that your bladder or bowel move down into your vagina

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