Liver Transplants and Other Complex Liver Surgery

By Leslie Bernstein

Two preeminent liver disease experts have joined the Columbia faculty to create one of the first fully multidisciplinary liver disease centers in the nation. Dr. Jean Emond, who helped to develop live-donor liver transplantation, and Dr. Robert S. Brown Jr., a gastroenterologist and hepatologist and former medical director of North Carolina’s largest liver transplant program, are codirectors of the new, comprehensive New York Presbyterian Hospital Liver Disease Center. In its first six months, the center transplanted the livers of five children, including a 14-week-old infant, and one adult. The pediatric transplants used organs from live donors in a procedure developed in the late 1980s by Dr. Emond and his colleague, Dr. Christoph Broelsch, at the University of Chicago. The center’s first transplant, performed in January 1998, replaced the scarred and cirrhotic liver of a 1-year-old girl, Juliana Reid, who was suffering from biliary atresia, a rare but devastating congenital condition that affects about 400 newborns in the United States every year. These children have no bile ducts, causing bile to back up into the liver. Juliana’s father, Leonard, was chosen as the preferred donor because his blood type matched his daughter’s. The change in Juliana has been dramatic: A child who was severely jaundiced and had failed to gain weight is now thriving, which is typical of successful liver transplants. Without intervention, Dr. Emond, professor of surgery, estimated that Juliana would have died within six months; now she is expected to live a normal life span. Her father is also doing well and was able to return to work about six weeks after the operation. Like all transplant patients, Juliana is being carefully monitored, especially during the first year following the operation, when high doses of the immunosuppression medicines cyclosporine and prograf place transplant patients at highest risk for infection and rejection of the donor organ, says Patricia Harran, a nurse practitioner who joined the center after seven years as senior coordinator of NYU’s liver transplantation program. Dr. Emond favors live-donor transplantation over organs donated from deceased patients, even though live-donor transplantation requires major surgery for both donor and recipient. “There are three principal advantages,” he says. “First, live-donor transplantation is always done electively, instead of under urgent, emergency conditions; second, the liver is healthy; and, finally, donor and recipient are relatives, decreasing the risk of rejection.” Still, this is the most technically difficult of all transplantation procedures, he says, because of the myriad vascular connections surrounding the liver. The procedure begins with removal of about 20 percent of the donor organ in an operation that takes approximately three and a half hours. Then, in a four-and-a-half hour operation, the diseased liver is replaced with the donor organ. “The liver is remarkable,” Dr. Emond says. “It is the only organ in the body that can regenerate completely. So the donor’s liver will grow back, and, in the case of a child, the transplanted piece of liver will grow as the child grows.” By using a living donor, not only is the recipient assured of receiving a healthy organ of matching blood type, but the recipient does not need to take a place on a waiting list of 9,000 people in the United States awaiting liver donation. That is why another procedure using live donors, known as auxiliary liver transplant and considered appropriate for adults, is under intense clinical study at the center. The center’s first auxiliary transplant involved a 50-year-old man who donated a portion of his liver to his twin brother. Dr. Emond placed the healthy organ next to the cirrhotic one; once the healthy liver is fully functioning, which is expected to take about three to six months, he will do a follow-up operation to remove the diseased liver. The focus of the new liver center is on patients and families, Ms. Harran says. “We offer boutique services to meet patients’ needs. I see patients and follow up on their progress, so I develop a relationship with them. It is very good for the patients, and it is rewarding professionally as well.” In addition to the codirectors and two nurse practitioners, the center’s staff includes social workers, anesthesiologists, radiotherapists, and faculty consultants from a number of disciplines, including psychiatry, infectious diseases, cardiology, rehabilitation medicine, and nephrology. Dr. Emond came to P&S from the University of California, San Francisco, where he directed the pediatric liver transplantation program. Dr. Brown, assistant professor of medicine, trained in pediatric and adult liver transplantation at UCSF under Dr. Emond and others; he also holds a master’s degree in public health. Most recently he was medical director of the liver transplant program of the University of North Carolina, Chapel Hill, where he helped build it into a thriving facility and conducted research on the clinical and cost outcomes of liver disease. While transplantation is an important part of its mission, the center also offers many other treatments for liver disease, including the Kasai procedure, an alternative method to treat biliary atresia. Within the next five to 10 years the center will develop a training program for medical students and residents, and Dr. Emond also hopes to train physicians from throughout the world to perform transplants and other complex liver surgery. “We also hope to become leaders in research,” Dr. Emond says, “including testing innovative techniques, surgical tools, clinical outcomes research, and basic research related to liver biology.” The center expects to do 12 to 15 transplants in its first year. Dr. Emond projects that, once it is fully up to speed, the center will do 50 to 100 transplants a year. Dr. Emond and Dr. Brown also hope to raise public awareness of the need for donor organs. “Between 900 and 1,800 people in this country die every year waiting for a transplant,” Dr. Emond says, “and more than half of all families refuse to donate a loved one’s organs. We need greater awareness of the benefit of organ transplantation.”

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