Bruzzone Paolo
Ann Ital Chir. 2014 Nov-Dec;85(6):616-7.
Since 2001 independent Organ Donor Facilities(OFOs) have been proposed within Organ Procurement Organizations (OPOs) with the aim of reducing organ procurement costs 1, cold ischemia time of donor organs and the flight-related risk 2 for donor surgeons, perfusionists and coordinators. An independent OFO has been established in 2001 in St. Louis 3, half away between the 2 Transplant Centers (TCs) (Washington University School of Medicine and St. Louis University) and now includes a two-bed intensive care facility, a complete laboratory, a cardiac catheterization facility, a Computed Tomography (CT) scanner and an operating room. All brain-dead (BD) patients within OPO (Mid-America Transplant Services), after family's informed consent, are transferred, if necessary by an OPO owned and operated airplane, to this facility, where undergo multiorgan harvesting. By doing so the organ acquisition charges (OACs) apparently decreased, as well as delay in recovery, which can affect organ viability and move families to withdraw consent; also risks and tiring of transplant surgeons were reduced. This independent OFO successfully procured in 2001 not only livers, but also pancreas, kidneys, hearts and lungs 4-6. Cold ischemia time was reduced and there was no Primary Non Function (PNF) of harvested organs, but only kidney delayed graft function (DGF). In the past, heart donors were moved to the recipient's hospital. With the development of multiorgan harvesting, usually donor surgeons are sent by the TCs in order to evaluate liver, pancreas, heart and lungs, while the only local surgeons is the "nephrectomist", that in local hospital is not a transplant surgeon. To move a donor, although hemodinamically stable, is always a risk. Finally, the decrease of OAC must balance the extra expenses to create and operate independent OFOs. In all the papers published by the members of this OFO, the control group of the retrospective analysis consisted of less selected BD donors, requiring more vasosuppressor support, which can be a study bias. It has been proposed that OPOs should organize "recovery teams" for multiple TCs but most transplant surgeons, in case of marginal donors, would like to inspect the organ prior to starting recipient surgery or would send their own team to harvest organs. According to literature, there are no other independent OFOs in US, probably because there is no need for them, and increasing their numbers would not increase organ donation rate. Considering Europe, we do not have information about the existence of independent OFOs: this may be a consequence of logistical organization and minor distances, as well as the higher concentration of TCs. However, the acceptance of such a procedure from donors' families may be less enthusiastic in Europe than in USA, particularly from minorities. In Italy would not be acceptable that the maintenance of BD donors and more generally the operation of independent OFO would rely on non-physicians, to save costs. Finally it is not clear from the reviewed papers who pay for transportation of the donor's body from the independent OFO back to home, but donor's family should not be charged for these expenses. At least 5 donors were lost during transportation, confirming that moving of BD donors remains a risky procedure. The potential economical and organizative benefits of independent OFOs could be counterweighted by the perceived (by relatives and public opinion) commodification/ reification of BD patients. Anyway, the authors of these papers should be congratulated for their innovative proposal. However, a prospective randomized trial would be needed to draw more definitive conclusions on the real benefits of independent OFOs.
自2001年以来，器官获取组织（OPO）内部提议设立独立器官捐赠设施（OFO），目的是降低器官获取成本、减少供体器官的冷缺血时间以及降低供体外科医生、灌注师和协调员与飞行相关的风险。2001年在圣路易斯设立了一个独立的OFO，位于两个移植中心（华盛顿大学医学院和圣路易斯大学）中间位置，现在包括一个有两张床位的重症监护设施、一个完整的实验室、一个心导管插入设施、一台计算机断层扫描（CT）扫描仪和一间手术室。OPO（中美洲移植服务中心）内所有脑死亡（BD）患者，在获得家属知情同意后，如有必要，由OPO拥有并运营的飞机转至该设施，在那里进行多器官获取。这样做显然降低了器官获取费用（OAC），以及恢复过程中的延迟，恢复延迟会影响器官活力并促使家属撤回同意；同时也降低了移植外科医生的风险和疲劳程度。这个独立的OFO在2001年成功获取了肝脏、胰腺、肾脏、心脏和肺脏。冷缺血时间缩短，获取的器官没有原发性无功能（PNF）情况，只有肾脏出现了延迟移植功能（DGF）。过去，心脏供体被转至受体医院。随着多器官获取的发展，通常由移植中心派遣供体外科医生去评估肝脏、胰腺、心脏和肺脏，而当地医院唯一的外科医生是“肾切除医生”，他并非移植外科医生。转移供体，尽管血流动力学稳定，但始终存在风险。最后，OAC的降低必须与创建和运营独立OFO的额外费用相平衡。在这个OFO成员发表的所有论文中，回顾性分析的对照组由选择较少的BD供体组成，需要更多血管活性药物支持，这可能是一种研究偏差。有人提议OPO应为多个移植中心组织“获取团队”，但大多数移植外科医生在面对边缘供体时，希望在开始受体手术前检查器官，或者会派遣自己的团队去获取器官。根据文献，美国没有其他独立的OFO，可能是因为没有需求，增加其数量也不会提高器官捐赠率。考虑到欧洲，我们没有关于独立OFO存在情况的信息：这可能是后勤组织、距离较短以及移植中心更集中的结果。然而，欧洲供体家属对这种程序的接受度可能不如美国热情，尤其是少数族裔。在意大利，依靠非医生来维持BD供体以及更普遍地运营独立OFO以节省成本是不可接受的。最后，从查阅的论文中不清楚谁来支付将供体尸体从独立OFO运回其家乡的运输费用，但不应向供体家属收取这些费用。运输过程中至少有5名供体死亡，证实转移BD供体仍然是一个有风险的程序。独立OFO潜在的经济和组织效益可能会被亲属和公众认为BD患者被商品化/物化所抵消。无论如何，这些论文的作者提出的创新提议值得祝贺。然而，需要进行一项前瞻性随机试验，以就独立OFO的实际效益得出更明确的结论。
