La greffe repose sur le don d’un organe qui, dans le cadre du don cadavérique, est issu d’un donateur qui n’a pas la conscience de donner. Le donneur et le receveur ne se connaitront jamais, et ce don prend le sens d’une réduction à la donation. Tout se passe comme si le donateur redonnait une chose dont il n’était pas propriétaire ; ce procès prend dès lors la forme d’un sacrifice ou redondance du don, au sens où celui qui a reçu redonne à son tour et sans retour. Il illustre également le concept d’hospitalité qui peut être mobilisé autant par le greffé, que par le soignant. Durant cet intervalle requis par la greffe, au sein de ce rituel symbolique et technique, le greffé est soumis à une réalité chaotique inconcevable et imprévisible. Ainsi, le mot peut manquer et l’écriture, par exemple, peut pallier cette carence, sous la forme d’ateliers ; expérience qui fut menée durant cette recherche et qui sera poursuivie. Sans s’opposer à la démarche des ateliers et outre l’avantage d’une mise en œuvre plus simple, le récit narratif s’est imposé pour trois raisons. - C’est une forme d’action, la plus élémentaire, la première possible après une longue période où toute action était devenue improbable. - C’est une façon de donner une cohérence au parcours subi et, même s’il s’agit d’une construction narrative, celle-ci participe à l’individuation du greffé, condition préalable pour envisager de nouvelles actions. - Enfin, ce récit peut être restitué au médecin qui a vécu l’acte de greffer, contrairement au malade. L’hypothèse est que cette hospitalité faite au récit permet d’une part, de renverser le schéma habituel – le soignant est dans la position de celui qui reçoit, non de celui qui donne –, d’autre part, de donner crédit au récit. Et, de proposer que la phase de réhabilitation, en rapport avec les actes thérapeutiques lourds, débute par ce type de récit où le malade parle et le soignant écoute, sans autre finalité, pour ce dernier, que d’accepter et de recevoir. / The transplant bases of the donation of an organ which, within the framework of the deathly donation, arises from a donor who is not conscious to give. The donor and recipient will never know each other, and this donation takes the senses of a reduction in the donation. It’s as if the donor gave a thing which he didn’t own ; this process takes from then on the form of a sacrifice or a redundancy of the donation, meaning that the one who received becomes the one to give, with no return expectations. It also illustrates the concept of hospitality which can be mobilized by the transplanted and the caregiver. During this interval required by the transplant, within this symbolic and technical rite, the transplante is subjected to an inconceivable and unpredictable chaotic reality.The transplanted can be wordless, and the writing, for example, can mitigate this deficiency, in the form of workshops. Such an experience was carried out during this research and will be pursued.Without opposing the approach of workshops and besides the advantage of a simpler implementation, the narrative was imperative for three reasons :- it is the first possible form of action after a long period of inactivity.- It helps the transplanted to give a coherence to the tranplantation. Even if it is narrative construction, it participates in the individuation of the transplanted, a precondition to envisage new actions.- Finally, this narrative can be restored to the doctor who experienced the act to tranplant, contrary to the sick person. The hypothesis is that this hospitality made for the narrative allows on one hand, to reverse the ususal plan – the caregiver is in the position of the one who receives, not of the one who gives - , on the other hand, to give credit to the narrative.And, to propose that the rehabilitation phase, related to the heavy therapeutic acts, begins with this type of narrative where the sick person speaks and the caregiver listen to, without no other purpose, for the latter, than to accept and receive.

Introdução: A doença hepática crônica na infância aumenta o risco de deficit neurocognitivo e linguístico, que pode persistir mesmo após o transplante de fígado (TxH) bem-sucedido. O objetivo da pesquisa foi verificar se há atraso no desenvolvimento linguístico em crianças com idade entre 2 anos e 7 anos e 11 meses, pré TxH e pós TxH. Método: A casuística foi constituída por 76 crianças, sendo 31 pré TxH e 45 pós TxH. O grupo controle (GC) foi composto por 60 crianças. Para verificar as habilidades linguísticas, foi aplicado o Test of Early Language Development-TELD-3. Para complementar, foram coletados dados clínicos e socioeconômicos. Resultados: O desempenho das crianças na fila de espera do transplante foi significativamente inferior ao do GC (p < 0,001) e ao do grupo pós TxH (p < 0,001), com valores abaixo da média, de acordo com o TELD-3. O grupo pós TxH apresentou média inferior à do GC (p=0,031), entretanto, com valores na média, de acordo com o TELD-3. Na análise de regressão, para o pré TxH a idade apareceu como fator de risco (OR=1,075; p=0,050) e para o pós TxH, a renda mensal (OR = 0,999; p=0,055). Conclusões: Constatou-se atraso das habilidades gerais de linguagem em crianças pré TxH, sendo a idade o único fator de risco apontado para o atraso linguístico. Para o grupo pós TxH não foi observado atraso linguístico. Entretanto, o desempenho foi inferior ao do GC e o único fator de risco indicado foi a renda familiar mensal. É necessário que as crianças sejam acompanhadas por equipe multiprofissional no momento pré TxH e no pós TxH imediato, para minimizar os deficit linguísticos e otimizar seu desenvolvimento / Introduction: Chronic liver disease in childhood increases the risk for neurocognitive and linguistic deficits, which may persist even after successful liver transplantation (LT). The objective of the present research was to check for delayed language development in children aged 2 years to 7 years and 11 months, pre and post liver transplant. Method: The sample consisted of 76 children, 31 pre LT and 45 post LT. The control group (CG) consisted of 60 children. For checking the language skills the Test of Early Language Development-TELD-3 was administered. In addition, clinical and socioeconomic data were collected. Results: The performance of children on the waiting list for transplant was significantly lower than the control group (p < 0.001) and the post LT group (p < 0.001), with values below average according to TELD-3. The post LT group had lower scores than the CG (p = 0.031), however with values on average according to TELD-3. In the regression analysis for the pre LT group, age appeared as a risk factor (OR = 1.075; p = 0.050) and for the post LT, monthly income (OR = 0.999; p = 0.055). Conclusions: General language skills were delayed in the pre LT group, with age appearing as the only risk factor for the language delay. Language delay was not observed in the post LT group, however the performance was lower than the CG, the only risk factor indicated was monthly family income. To minimize the linguistic deficit and optimize their development, children pre LT and immediately post LT, should be assisted by a multi-professional group

No description available.

Fibrolamellar hepatocellular carcinoma (FL-HCC) is a malignant liver tumor which is thought to be a variant of conventional hepatocellular carcinoma (HCC). It accounts for a small proportion of HCC cases and occurs in a distinctly different group of patients which are young and usually not in the setting of chronic liver disease. The diagnosis of FL-HCC requires the integration of clinical information, imaging studies, and histology. In terms of the treatment options, the only potentially curative treatment option for patients who have resectable disease is surgery either liver resection (LR) or liver transplantation (LT). When performed in a context of aggressive therapy, long-term outcomes after surgery, particularly liver resection for FL-HCC, were favorable. The clinical outcome of patients with unresectable disease is suboptimal with median survival of less than 12 months. The aim of this review is to update the available evidence on diagnosis, treatment options, outcome predictors, and recent developments of patients with this rare disease and to provide a summarized overview of the available literature.

The face of transplantation has changed in recent decades. The improvement can be observed not only in terms of survival, but also the improved quality of life after this demanding procedure. This is one of the reasons why quality of life is one of the factors to consider (Durant, 2019). This is also due to the fact that in today's modern society one does not only want to survive, but wants to live fully. He wants to benefit his family and the society in which he lives. He wants to do his hobbies. Everybody wants to be active physically and also mentally. Today, quality of life is considered an indicator suitable for assessing physical, mental and social health (Chrastina, 2015). Methodology: The aim of this work is to evaluate how patients after liver transplantation perceive different domains related to quality of life and whether the results are different depending on the time elapsed from transplantation. For the purposes of the research was chosen a quantitative method using a questionnaire. A standardized WHOQOL BREF was used. The questionnaire contains 24 closed questions, which contain four domains and two questions themselves. Two separate questions assess the overal quality of life and overall health. The questionnaire was supplemented by two questions, which were aimed at obtaining...

Purpose: To evaluate the efficiency of a multimodality approach consisting of transcatheter arterial chemoembolization (TACE) and radiofrequency ablation (RFA) as bridging therapy for patients with hepatocellular carcinoma (HCC) awaiting orthotopic liver transplantation (OLT) and to evaluate the histopathological response in explant specimens. Materials and Methods: Between April 2001 and November 2011, 36 patients with 50 HCC nodules (1.4–5.0 cm, median 2.8 cm) on the waiting list for liver transplantation were treated by TACE and RFA. The drop-out rate during the follow-up period was recorded. The local efficacy was evaluated by histopathological examination of the explanted livers. Results: During a median follow-up time of 29 (4.0–95.3) months the cumulative drop-out rate for the patients on the waiting list was 0, 2.8, 5.5, 11.0, 13.9 and 16.7% at 3, 6, 12, 24, 36 and 48 months, respectively. 16 patients (with 26 HCC lesions) out of 36 (44.4%) were transplanted by the end of study with a median waiting list time of 13.7 (2.5–37.8) months. The histopathological examination of the explanted specimens revealed a complete necrosis in 20 of 26 HCCs (76.9%), whereas 6 (23.1%) nodules showed viable residual tumor tissue. All transplanted patients are alive at a median time of 29.9 months. Imaging correlation showed 100% specificity and 66.7% sensitivity for the depiction of residual or recurrent tumor. Conclusion: We conclude that TACE combined with RFA could provide an effective treatment to decrease the drop-out rate from the OLT waiting list for HCC patients. Furthermore, this combination therapy results in high rates of complete tumor necrosis as evaluated in the histopathological analysis of the explanted livers. Further randomized trials are needed to demonstrate if there is a benefit in comparison with a single-treatment approach. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

In recent years, the transplant community has explored and adopted tools for quantifying clinical insight into illness severity and frailty. This dissertation work explores the interplay between objective and subjective assessments of physical health status and the implications for liver transplant candidate and recipient outcomes. The first aim characterizes national epidemiologic trends and the impact of Centers for Medicare and Medicaid quality improvement policies on likelihood of waitlist removal based on the patient being too frail to benefit from liver transplant (“too sick to transplant”). This aim includes more than a decade (2002–2012) of comprehensive national transplant waitlist data (Scientific Registry of Transplant Recipients (SRTR)). The second aim will assess and define objective parameters of liver transplant patient frailty by measuring decline in lean core muscle mass (“sarcopenia”) using abdominal CT scans collected retrospectively at a single U.S. transplant center between 2006 and 2015. The relationship between these objective sarcopenia measures and subjective functional status assessed using the Karnofsky Functional Performance (KPS) scale are described and quantified. The third aim quantifies the extent to which poor functional status (KPS) pre-transplant is associated with worse post-transplant survival and includes national data on liver transplantations conducted between 2005 and 2014 (SRTR). The results of this dissertation will help providers in the assessment of frailty and subsequent risk of adverse outcomes and has implications for strategic clinical management in anticipation of surgery. This research will also to serve to inform national policy on the design of transplant center performance measures.

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第20564号 / 医博第4249号 / 新制||医||1022(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 増永 慎一郎, 教授 妹尾 浩, 教授 鈴木 実 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Background and Aims: Morphometric features such as the Milan criteria serve as standard criteria for liver transplantation (LT) in patients with hepatocellular carcinoma (HCC). Since it has been recognized that these criteria are too restrictive and do not adequately display the tumor biology, additional selection parameters are emerging. Methods: Concise review of the current literature on patient selection for downstaging and LT for HCC outside the Milan criteria. Results: The major task in patients outside the Milan criteria is the need for higher granularity with patient selection, since the benefit through LT is not uniform. The recent literature clearly shows that beneath tumor size and number, additional selection parameters are useful in the process of patient selection for and during downstaging. For initial patient selection, the alpha fetoprotein (AFP) level adds additional information to the size and number of HCC nodules concerning the chance of successful downstaging and LT. This effect is quantifiable using newer selection tools like the WE (West-Eastern) downstaging criteria or the Metroticket 2.0 criteria. Also an initial PET-scan and/or tumor biopsy can be helpful, especially in the high risk group of patients outside the University of California San Francisco (UCSF) criteria. After this entry selection, the clinical course during downstaging procedures concerning the tumor and the AFP response is of paramount importance and serves as an additional final selection tool Conclusion: Selection criteria for liver transplantation in HCC patients are becoming more and more sophisticated, but are still imperfect. The implementation of molecular knowledge will hopefully support a more specific risk prediction for HCC patients in the future, but do not provide a profound basis for clinical decision-making at present.

La transition est un sujet qui demeure d’actualité, et ce, malgré qu’elle fasse l’objet de plusieurs recherches, et ce, depuis des décennies. Or, certaines transitions semblent être moins étudiées, alors qu’elles nécessitent aussi une attention particulière afin d’améliorer la qualité et la sécurité des soins, de même que le continuum inter établissement. D’ailleurs, la transition d’un centre hospitalier pédiatrique à un centre hospitalier pour adultes auprès de jeunes patients ayant eu une transplantation hépatique est l’une de ces transitions. Cette étude avait pour but d’explorer la perception de jeunes adultes ayant eu une transplantation hépatique, de parents et de professionnels de la santé quant à la transition d’un centre hospitalier pédiatrique à un centre hospitalier pour adultes. Afin d’encadrer cette étude, le cadre théorique de Meleis (2010) a été retenu. Un devis qualitatif descriptif et exploratoire a été utilisé. Des entrevues semi-dirigées (n=10) ont été réalisées avec de jeunes patients (n=7), ainsi que des parents (n=3), et un groupe de discussion a été réalisé avec des professionnels de la santé (n=5). Une analyse thématique des données collectées a permis d’identifier sept thèmes, soit 1) les différents types de transition; 2) les émotions associées à la transition; 3) les caractéristiques individuelles; 4) la préparation à la transition; 5) l’approche des professionnels entre le centre hospitalier pédiatrique et le centre hospitalier pour adultes; 6) les besoins de chacun et enfin, 7) les pistes d’amélioration proposées par les patients, les parents et les professionnels de la santé. Les résultats de cette recherche permettent, notamment, d'approfondir la compréhension relative au processus de la transition d’un centre hospitalier pédiatrique à un centre hospitalier pour adultes. Ils permettent également d'ajouter une nouvelle perspective de la transition du point de vue des jeunes patients, des parents et des professionnels de la santé, en plus de proposer d'éventuelles recherches de plus grande envergure. En somme, cette présente recherche, de par sa nature descriptive exploratoire, permet d'offrir une compréhension davantage approfondie du processus de transition vécue par ces jeunes adultes ayant eu une transplantation hépatique en vue d’améliorer la qualité et la sécurité des soins, de même que le continuum inter établissement. / Transition is a topic that remains topical, despite the fact that it has been the subject of much research for decades. However, some transitions seem to be less studied, even though they also require special attention in order to improve the quality and safety of care, as well as the inter-institutional continuum. The transition from a pediatric to an adult hospital for young liver transplant patients is one such transition. The purpose of this study was to explore the perceptions of young adult liver transplant patients, parents and healthcare professionals regarding the transition from a pediatric to an adult hospital. Meleis' (2010) theoretical framework was used to frame this study. A descriptive and exploratory qualitative design was used. Semi-directed interviews (n=10) were conducted with young patients (n=7) and parents (n=3), and a focus group was conducted with healthcare professionals (n=5). A thematic analysis of the data collected identified seven themes: 1) the different types of transition; 2) the emotions associated with the transition; 3) individual characteristics; 4) preparation for the transition; 5) the approach of professionals between the pediatric hospital center and the adult hospital center; 6) the needs of each; and finally, 7) the avenues for improvement suggested by patients, parents and health professionals. In particular, the results of this research will provide a better understanding of the transition process from a pediatric hospital center to an adult hospital center. They also add a new perspective on the transition from the perspectives of young patients, parents and healthcare professionals, and suggest possible areas for further research. In sum, this research, by its exploratory descriptive nature, provides a more in-depth understanding of the transition process experienced by these young adults who have had a liver transplant in order to improve the quality and safety of care, as well as the inter-institutional continuum.