April 15, 2021

In the bowels of a transplant | Society

In the bowels of a transplant | Society



An intermittent beep Mark the tempo in the operating room. There is no music or talk. Only one sharp pipbreak the silence. Like a metronome, the vital signs monitor maintains order: if the beep does not change, everything is fine. It's 9.30. On the stretcher, a woman already submitted to the lethargy of anesthesia. Around him, a dozen toilets move in an orderly chaos, each his own. The operation has already begun. In the medical jargon is called nephrectomy. On the street, remove a kidney. She is the donor. Your son, the receiver.

"I have no doubt that it will go well. We are that pedantic, "jokes Antonio Alcaraz (Granada, 1960), head of Urology at the Hospital Clínic in Barcelona and surgeon in charge of the operation. But it is not conceit. It is experience. The Clínic is the leader in Spain in kidney transplants from a living donor (in 2018, he made 40 of the total 293) and Alcaraz is the surgeon with the most interventions: 1,400 as the first surgeon and another 400 in the surgical team.

In the operating room, Dr. Lluís Peri advances. The patient, lying on her side, has made three small incisions in her side to insert the arms of the laparoscopy that, directed from outside, work inside like the hands of the surgeon. Since 2002, the hospital it does the extraction with this less invasive technique to reduce risks of infection. "Surgeons do not like blood," laughs Alcaraz. With an electric scissor, which cuts and cauterizes at the same time, Peri makes his way to the kidney.

Alcaraz's operating theater is not like the one in the movies. There is no music or personal disputes. Nor professional fights. "The operating room is not a democracy. You do what the surgeon in charge says," ditch. However, there is also room for relaxation and talk: "Viva España", hesitates Alcaraz. "Visca Catalunya", responds Peri sarcastically. In complex situations, however, the environment becomes rigid, the team is silent and holds the breath. "The surgeon has to have the heart of a lion, the eyes of an eagle and the hands of a woman. You have to have mental strength, be skillful and that your brain knows how to control nerves, "explains the boss.

The numbers that move the system

Spain, world leader. The rate of donors in 2018 was 48 people per million inhabitants, according to the National Organization of Transplants (ONT). He has held the lead for the past 27 years, only two years after the ONT was founded.

Almost three transplants per donorIn 2018 there were 2,241 donations with which 5,316 organ transplants were performed, also a record.

Centers that do transplants. Of the almost 800 hospitals in Spain, a total of 185 are authorized to manage a donation. And 44 to perform transplants.

The kidney, the most transplanted organSince 1989, 72,166 kidney implants, 27,382 liver implants and 8,534 cardiac implants have been performed.

The waiting list is reduced. In 2018, 4,804 people waited for a transplant, 88 children.

In a calm mood, Alcaraz transfers that calm to the operating room. Take the joysticks laparoscopic (two arms are the tweezers and scissors and a third, a camera that reproduces the image in three dimensions on the monitors), puts on the 3D glasses and, begins to move through the cavity: "Look at the aorta". A thick tube with a gelatinous appearance appears on the screen. The doctor separates the renal vessels and the ureter to gain visibility. "This is more like what you see in books," he jokes.

It has to contain the breath: you have to cut the vessels that connect the kidney to the bloodstream. Alcaraz cuts the renal vein and artery and activates the counter. The time from when the kidney loses irrigation until it is placed on ice with preservation fluid should be minimal. Peri makes an incision at the level of the navel and Alcaraz introduces his hand to remove it. On the screen, a white glove gently grasps the elusive organ. He extracts it to an ice tray and asks: "Time?" "2.57", someone answers. "We have taken three minutes. Before it was more pink and now it is grayish. "

While Peri closes and sews, Alcaraz removes the fat from the kidney, seals capillaries and polishes the entrance to the artery and vein. And he keeps it in an ice shirt with a gauze full of hail.

The anesthetist awakens the donor and moves her to Resuscitation. On the way, still asleep, she crosses paths with her son, who waits in an adjoining room.

At noon, the second round. The patient is already asleep. On the stretcher, the robot Da Vinci with its four arms like legs of spider raises the voice: "Da Vinci is ready". "Others too," laughs a nurse. The robotic transplant is done at the Clínic since 2015. It is a more precise and clean technique: only incisions to insert the arms, also on the side, and a small cut to insert the organ.

The kidney, with its ice shirt on, is inserted into the belly. Alcaraz controls the robot's controls several meters away from the patient, before a console. Isolates the iliac vein from the circulation and makes a tiny cut in the vessel to sew it to the renal vein. A stream of heparin in the hole to prevent clots and start to weave. The urologist dances with the needle, stitch by stitch, until the veins are joined. The same with the iliac artery and the renal artery. Remove the mesh that isolates them from circulation and the blood runs again. Break the ice shirt and the operating room is silent. "Good perfusion", he appreciates smiling. The ureter, still loose, begins to urinate. Good sign. The kidney is working. It's almost 3. Alcaraz takes off his gloves and leaves.

"Donate must be another activity in the ICU"

From his office in Geneva, Dr. José Ramón Núñez (Ávila, 1958) monitors transplants around the globe. He is responsible for the WHO Donation and Transplant Program. Recently, he has been visiting Barcelona to participate in a day of the Catalan Transplant Organization.

Question. What has the Spanish model that receives so much praise?

Answer. A good organization and a public system, fair and free. People are equally generous around the world, but when they detect that there is no equity, they are wary.

P. Spain has once again become a leader in transplants and donations. Is there still room for improvement?

R. It is necessary to detect 100% of potential donors and that among the people admitted to the ICU, donation should be considered as a right, as a process more at the end of life. We must promote donation as another activity within the ICU.

P. What happens in other places?

R. There are 124 countries and the realities are completely different. But as soon as the Spanish model is applied anywhere in the world, the donation rises dramatically. Although it is true that there are social or professional realities that are difficult to transfer. For example, in India, the criterion of brain death – the patient is dead and his heart beating – was not shared by the professionals. In Africa it is a utopia to talk about transplant programs because their priority is that women do not die in childbirth, that children do not die at birth, and that they do not become infected with malaria. It is a question of the sanitary reality of the countries. The free health of Spain does not exist anywhere.

P. When he took office in the WHO, he undertook to combat organ trafficking. How do you wear it?

R. Traffic moves 1,000 million dollars a year. When we manage to block it in one part of the world it moves to other areas. We make efforts to detect it, but my priority is to enhance the legal transplant to reduce traffic.

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