Dr. Joseph Melancon: Kidney, Pancreas, and Liver transplantation - [Video Transcription]
- Personal Introduction
Hello, my name is Joseph Keith Melancon and here at Georgetown I perform kidney, liver, and pancreas transplantations. My patients have end organ damage. They can have either kidney organ damage, liver organ damage, or pancreas organ damage. I am the director of Kidney and Pancreas Transplantation. So, my focus is primarily on transplanting patients with end stage renal disease or type I diabetes. The reasons for end stage renal disease vary, but the two most common reasons in the United States are hypertension and diabetes. These patients once they have end organ damage are going to have one of three options. These options are hemodialysis, peritoneal dialysis, or renal transplantation. The patients that are sent to me are usually on dialysis already and they are looking for another option. Transplantation is going to be able to extend their lives and also improve their quality of life. So, these are the patients that come to me that have end stage renal disease. The patients that have diabetes that come to me have end organ damage. So, their diabetes is not well controlled medically in other words with Insulin therapy. Those patients continue to develop the complications of diabetes even with the best medical therapy available. Those are the patients that would require pancreas transplantation. Those are the two groups of patients that I would see at my clinic. - Do you see children?
I see pediatric patients that have end stage renal disease. Pediatric renal disease is a little different because there are many congenital defects that will lead to end stage renal disease in children. These patients actually can be transplanted a lot earlier because of the way we allocate organs in this country. We preferably allocate them to children because they have such a benefit in the quality and the duration of their lives with a transplant. These patients I will see and transplant a few months to a year after my first consulltation in the clinic. - How long will the transplant last?
A kidney transplantation typically will take approximately three hours. It takes about an hour prior to that to position them and get them ready for transplant. So, from the time that they leave the side of their loved ones, it takes about four hours. The actual operation lasts about three hours. This is the same in a pancreas transplantation. A pancreas transplantation will last about three hours as well. - How long will it be before I can return to normal activity / return to work?
Patients after organ transplantation typically need to be in the hospital approximately one week. The reason for this is not just for convalescence or recovery after the transplant, but also because of the immunosuppressive therapy. It takes four to five days for the medication to build in the system to a point where it is safe to leave the hospital. So, our patients are typically in the hospital for seven to eight days. - How long until I can return to normal activities?
Most of our patients feel very well after approximately two weeks. However, their strength will not be back to normal levels and I usually counsel my patients that they should not return to work for approximately six weeks. - What is the benefit to coming to Georgetown University Hospital for a kidney or pancreas transplant?
What has impressed me about Georgetown are the excellent outcomes. So, the outcomes after transplantation for all the major organs are some of the best in the country. That is one of the things that really brings patients to us. The other thing that is really impressive about the program here at Georgetown is that it is truly multidisciplinary and that all major organs are transplanted here at this institution. Again, that is a rarity. We have intestinal transplantation, pancreas transplantation, kidney transplantation, liver transplantation, living donor kidney transplantation and liver transplantation at one center. You have a truly multidisciplinary team that can take care of any sort of abdominal organ dysfunction. That is unique even among major transplant centers in this country. The fact that you have minimally invasive liver surgery as well as liver transplantation and minimally invasive donor nephrectomies again is one of the feathers in the cap of this institution. - How does the team approach at Georgetown benefit the transplant patient?
One of the things that I have enjoyed here at Georgetown are the dynamics of the transplant team. I find that they are very efficient in getting the patients from the first meeting to the transplantation. Again, in large transplant centers this remains a problem because especially at lower socioeconomic levels patients find the healthcare industry to be very cumbersome. They often times will fall out at certain levels of interaction and won’t get all the way to the level of transplantation. I think the team here at Georgetown is very aggressive and they make the transition from first meeting to transplantation as easy of any that I have ever seen. - How did you get involved with transplant medicine?
The reason that I am a transplant surgeon is because my best friend in college required a transplant. He had to receive a kidney and pancreas transplant. That was my first interaction with anyone ever having an organ transplant. I already knew at that point that I wanted to be a surgeon, but after that interaction of seeing him in the hospital and seeing his quick recovery from his very bad kidney disease and diabetes really goaded me to go on and become a transplant surgeon. - Have success rates improved in transplant medicine?
One of the most miraculous things that we have seen in the field of transplantation is the fact that the medications have improved markedly. Transplant is actually a very young field. The first successful transplant was done in 1954. So, in a very short period of time we have gone from a field that was primarily experimental to an operation that is done routinely in many major medical facilities across the country. So even in my lifetime in medicine, I have seen this field explode. That has been primarily because the immunosuppressive medications have improved. The rejection rates after transplantation are now so low that we routinely even think about. Most of our patients do not even have rejection and when they have rejection it can be well treated with the medications that we have available. I think that the remarkable success of the operations today are primarily due today to the great advances in technology like our immunosuppressant therapy. The actual training of transplant surgeons have improved over the last few decades and the operations are now done in very similar routine fashion throughout the country. - Are there many people on dialysis now who could improve their lives with a transplant?
Access to transplantation continues to be a problem in this country. Many great studies have been done and I have interacted with some of the physicians that do this type of research. Primarily people at lower socioeconomic levels have more of a problem accessing our health system overall especially very specialized medical therapy like transplantation. The government has many programs in place to help people with end stage organ dysfunction. However, there remains a problem in patients accessing the system. The problems are myriad. From the first consultation with a transplant program all the way to them finishing their work up. All of these things remain a problem for people at low socioeconomic levels. We are not quite sure exactly why that remains such a problem, but it is something that I am committed to trying to alleviate in my career. - How many transplants have you done?
I have probably done somewhere around 500 kidney transplants, approximately 150 pancreas transplant, and maybe 40 liver transplants. - How do you perform a transplant?
For a kidney transplant, we make an incision in the right flank or left flank. Basically, this is lower in the abdomen to one side or the other. It is in a little bit of a different location to where the kidneys are located normally. It is in the same region, but just a little bit lower in the abdomen. We need to move over all of the peritoneal cavity or abdominal organs and get to the major vessels to make incisions into those vessels. We can then perform the transplant. Again like I said earlier, it takes about three hours to do this. A pancreas transplant is done in a very similar fashion. Now a liver transplant is what’s called an orthotopic liver transplant. In other words, we place a new liver in exactly the same place where the old liver had been previously. So comparing a liver transplant to a kidney transplant or kidney/pancreas transplant, you have to actually remove the old organ to put in the new organ. That is what makes a liver transplant so much longer. It usually takes around six hours to perform a liver transplantation. - What is the most common misconception of many of your patients?
When I meet patients, one of the things that I really want to get across the them is that transplantation is a gift of life. Once you have end organ damage, this disease will eventually cause the death of the patient. Unfortunately, this knowledge is not usually held by the patient. I really want to get across the them the fact that they need to have a transplant in a certain period of time. Usually a shorter period of time that they may have thought prior to our initial meeting. So, I want to impress upon them the urgency of the situation. For whatever reason, this knowledge is something that they don’t typically have before they meet with me. One of the things that I really want them to understand is that they need to avail themselves to any outlet that they could to expedite their transplantation. In other words to living donation if this is going to be an outlet for them. They need to be on the list as soon as possible for a deceased donor transplant. I really urge them to move urgently to be transplanted. - Can the transplant wait?
Many patients especially patients that need kidney transplants because there is a therapy (dialysis) that can keep them alive for many years don’t often understand that their lives are shortened while they await transplantation while on dialysis. I really impress upon them the fact that transplantation can be life extending if they qualify. - Is transplantation a last resort?
Transplantation is really the only way that we have for patients with end organ damage to regain their lives at it was prior to their organ damage. In other words, there are lots of temporizing things that we can do as physicians. In this country, we are very good in treating tertiary types of problems. However, there is no method currently available for patients to regain their health like transplantation. Of course, our patients need to take medications for the rest of their lives. However, they can go back to a normal quality of life especially if they are treated and transplanted early in their disease process. In other words, the earlier the intervention the better. The healthier you are coming in, the healthier you will be after transplantation. It is something that we really try to aggressively pursue in patients that quality at the earliest possible intervention.