Transplantation of the Liver
http://www.100md.com
《新英格兰医药杂志》
Nearly a decade ago, when I reviewed the first edition of this book, I was impressed with the high quality of the individual chapters and the fact that, despite the length of the book, there was very little repetition. The second edition is even more comprehensive than the first because of the many recent advances in liver transplantation.
Nearly 1500 pages of text cover virtually every aspect of liver transplantation, including speculations on xenografting and interesting sections on ethics. Since the publication of the first edition, the most important advances have been in the management of immunosuppression, particularly the recent tendency to use minimal immunosuppression consistent with good graft function. In the case of the liver (as compared with other organs), true tolerance has been reported with use of a variety of protocols, sometimes as demonstrated by patients' noncompliance with treatment without the knowledge of their physicians. Apart from the immunologic difficulties in xenografting of the liver, the metabolic differences between species are very important. As Thomas Starzl and colleagues write in the first chapter, such interspecies variations "could make pig-to-human liver xenotransplantation tantamount to endowment of an inborn error (or errors) of metabolism."
A notable development in the field has been the enthusiasm for transplantation of portions of the liver from living donors, which initially involved the donation of grafts by parents to children. Recently, with the increasing shortage of donors and problems with graft mismatches, adult-to-adult transplantation with living donors has been used, which has required new technical modifications to help to ensure the donor's safety and a satisfactory specimen for the recipient.
Transplantation pioneer Francis Moore asked years ago, "Is it morally right and ethically acceptable to injure one person to help another?" The book appropriately points out that no documentation of the outcomes of living donors has been required. Anecdotal assessments of the rate of death among such donors have varied from below 1 percent to around 2 percent, and morbidity among donors has been reported as frequent, with serious complications occurring in up to 40 percent. With transplantations being performed in many countries, sometimes by itinerant surgeons visiting units that have little or no experience with liver transplantation, it is not surprising that there have been rumors of a number of unreported donor deaths.
The whole question of the ethics of living donation is fully discussed in this book, where it is pointed out that in kidney transplantation the risk to the donor is small, and the justification for the procedure is widely accepted by the medical profession and the public. However, in liver transplantation, for which accurate data are not available on morbidity and mortality, it is impossible to provide a potential donor with the statistics necessary for fully informed consent. This has led to an unresolved ethical dilemma. The improved overall result of liver transplantation and its transformation from a dangerous experimental venture into a routine procedure with an expectation of good results have increased the pressure on our profession to perform more transplantation procedures, but the availability of donors has not increased appropriately.
The authors are to be congratulated on providing such full coverage of the field, extending from detailed descriptions of the natural history of the diseases that may lead to indications for liver transplantation to the techniques of the various procedures and post-transplantation assessment — not only of rejection, but also of infections, histologic findings, and the well-being of patients. At the end of many chapters are boxes with the heading "Pearls and Pitfalls," which are very useful summaries of the important points made in the relevant chapters.
My only criticism of this book is that there are no color illustrations, and the black-and-white photographs of operative procedures are poor and should have been replaced with diagrams. Overall, the book should be an essential requirement in all liver transplantation units and be readily available to physicians and surgeons involved in liver transplantation at all stages in their training.
Roy Calne, M.D.
University of Cambridge
Cambridge CB2 2AH, United Kingdom(Second edition. Edited by)
Nearly 1500 pages of text cover virtually every aspect of liver transplantation, including speculations on xenografting and interesting sections on ethics. Since the publication of the first edition, the most important advances have been in the management of immunosuppression, particularly the recent tendency to use minimal immunosuppression consistent with good graft function. In the case of the liver (as compared with other organs), true tolerance has been reported with use of a variety of protocols, sometimes as demonstrated by patients' noncompliance with treatment without the knowledge of their physicians. Apart from the immunologic difficulties in xenografting of the liver, the metabolic differences between species are very important. As Thomas Starzl and colleagues write in the first chapter, such interspecies variations "could make pig-to-human liver xenotransplantation tantamount to endowment of an inborn error (or errors) of metabolism."
A notable development in the field has been the enthusiasm for transplantation of portions of the liver from living donors, which initially involved the donation of grafts by parents to children. Recently, with the increasing shortage of donors and problems with graft mismatches, adult-to-adult transplantation with living donors has been used, which has required new technical modifications to help to ensure the donor's safety and a satisfactory specimen for the recipient.
Transplantation pioneer Francis Moore asked years ago, "Is it morally right and ethically acceptable to injure one person to help another?" The book appropriately points out that no documentation of the outcomes of living donors has been required. Anecdotal assessments of the rate of death among such donors have varied from below 1 percent to around 2 percent, and morbidity among donors has been reported as frequent, with serious complications occurring in up to 40 percent. With transplantations being performed in many countries, sometimes by itinerant surgeons visiting units that have little or no experience with liver transplantation, it is not surprising that there have been rumors of a number of unreported donor deaths.
The whole question of the ethics of living donation is fully discussed in this book, where it is pointed out that in kidney transplantation the risk to the donor is small, and the justification for the procedure is widely accepted by the medical profession and the public. However, in liver transplantation, for which accurate data are not available on morbidity and mortality, it is impossible to provide a potential donor with the statistics necessary for fully informed consent. This has led to an unresolved ethical dilemma. The improved overall result of liver transplantation and its transformation from a dangerous experimental venture into a routine procedure with an expectation of good results have increased the pressure on our profession to perform more transplantation procedures, but the availability of donors has not increased appropriately.
The authors are to be congratulated on providing such full coverage of the field, extending from detailed descriptions of the natural history of the diseases that may lead to indications for liver transplantation to the techniques of the various procedures and post-transplantation assessment — not only of rejection, but also of infections, histologic findings, and the well-being of patients. At the end of many chapters are boxes with the heading "Pearls and Pitfalls," which are very useful summaries of the important points made in the relevant chapters.
My only criticism of this book is that there are no color illustrations, and the black-and-white photographs of operative procedures are poor and should have been replaced with diagrams. Overall, the book should be an essential requirement in all liver transplantation units and be readily available to physicians and surgeons involved in liver transplantation at all stages in their training.
Roy Calne, M.D.
University of Cambridge
Cambridge CB2 2AH, United Kingdom(Second edition. Edited by)