Liver transplantation: Issues for the next 20 years

The growing numbers of potential transplant recipients on waiting lists is increasingly disproportionate to the supply of cadaveric donor organs. The hope for the next 20 years is that supply will satisfy demand. This requires both a reduction in indications for the procedure and an increase in the transplants performed. A multi-pronged approach is needed to increase cadaveric organ donation, generating enthusiasm for donation among both the general public and hospital staff. Accurate assessment of marginal grafts with stringent criteria known to predict graft function will diminish wastage of organs. Methods of rehabilitating marginal grafts during extracorporeal perfusion will increase organ availability. Supply of non-heart beating donors can be greatly expanded and protocols developed with ethical consent to optimize their initial function despite warm ischemia. Splitting livers that fulfill selection criteria, thus providing for two recipients, should be universally applied with acceptable incentives to those units who do not directly benefit. A proportion of recipients, though not those transplanted for autoimmune disease, will be spared the side-effects of immunosuppression thanks to immune tolerance. Protocols for close monitoring of those patients for rejection during treatment withdrawal must be carefully observed. In addition to gene therapy, it is highly likely that hepatocyte transplantation will replace orthotopic grafting in patients without cirrhosis, especially for inherited metabolic diseases. It is much more difficult to envisage that heterologous stem cell transplantation or xenotransplantation will have clinical impact in the next 20 years, although research in those areas has obvious long-term potential.     

COMPARATIVE EVALUATION OF NO-SCALPEL VASECTOMY AND STANDARD INCISIONAL VASECTOMY

No-scalpel vasectomy employs a refined method of dissection and delivery of the vas deferens. We compared no-scalpel vasectomy with standard incisional vasectomy in 176 patients over a 33 month period. The haemorrhage rate was 1.08 per cent for no-scalpel vasectomy compared with 11.9 per cent for standard vasectomy (p < 0.005). The infection rate was 3.26 per cent for no-scalpel vasectomy as against 14.28 per cent for standard vasectomy (p < 0.01). There was a 37.5 per cent reduction in operating time and a substantial reduction in pain during and after the procedure when no-scalpel vasectomy was performed and also there was no failure of vasectomy. No-scalpel vasectomy is a satisfactory alternative to standard vasectomy with fewer complications and increased patient acceptability.KEYWORDS: Male sterilization, Vasectomy