Harder Than Hearts

Transplantation of a human heart is without a doubt the most dramatic feat of modern surgery. Yet while the heart is only a pump, the liver, by contrast, is an immensely complex processing factory, with dozens of functions involving the chemistry of metabolism. Transplantation of a liver is far more difficult than that of a heart, and so far equally rare. Eight patients who have received new livers at three U.S. medical centers within the past year are now alive. In the early days of liver transplantation, survival for a month was considered remarkable. Last week one of the patients made medical history by reaching the first anniversary of the operation.

One of the two most common causes of irreparable, irreversible liver damage is a congenital abnormality of the bile ducts called biliary atresia, which behaves like a malignancy and usually proves fatal within 18 months of birth. The other cause is cancer itself, which may strike at any age.

Heroic Incisions. Take the case of Tommy Gorence, 16, a 6-ft, 195-lb. high school basketball player from Oneonta, N.Y. Last February he was elbowed in the abdomen and doubled up with severe pain, but he shook it off. A second elbowing put Tommy into the University Hospital in Syracuse, where surgeons trying to sew up his lacerated liver discovered that it was cancerous. Since the cancer was found to be incurable, Tommy was referred to Boston's Peter Bent Brigham Hospital for a possible transplant.

In Children's Hospital, across the street from the Brigham, a twelve-year-old boy died June 17 from head injuries suffered in an auto accident. His parents, who refuse to be identified, consented to the transplant. While three surgeons removed and cooled the liver to retard deterioration, Dr. Francis D. Moore (TIME cover, May 3, 1963) and his Brigham team prepared Tommy Gorence to receive it. It was, says Moore, "a very arduous job because of the whopping size of Tommy's liver." Just to get at it entailed making three heroic incisions, two horizontal and one vertical. This was typical of the immense problems involved in liver-transplant surgery (see diagram).

Bypassed Duct. After the incisions were made, the real technical difficulties began. Moore and his chief assistant, Dr. Alan Birtch, clamped off the portal vein, which delivers blood to the liver for chemical processing, and the inferior vena cava. The hepatic artery, which delivers blood for the liver's own oxygen needs, was so damaged by pressure from the cancer as to be useless. Moore and Birtch decided to use in its place the right kidney artery. That meant removing the right kidney, but a single healthy kidney is all the body needs.

There was also the problem of the bile ducts. The donor liver had come with its gall bladder and ducts attached. Rather than attempt a dangerously delicate joining of the common duct to the duodenum, Moore decided to attach the new gall bladder itself to the duodenum, allowing the bile to bypass the common duct. The entire operation took eight hours. Not until Tommy Gorence was sitting up and eating well, apparently making a good recovery, did the Brigham publicize the case. Tommy made good progress for four weeks, then ran into difficulties with a lung infection, a common complication of transplants.

Less Suppression. Denver, where the first such operation was performed in March 1963 by the University of Colorado's Dr. Thomas E. Starzl, remains the liver-transplant capital of the world, with six recipients surviving. The early operations five years ago, says Starzl, were tragic. Although surgeons were sure that the procedure would work, the longest survival among the first patients was 23 days. In most cases, death resulted from infection, to which the patients were especially susceptible because of generous use of drugs to suppress the mechanism by which the body rejects foreign protein.

Starzl stopped operating while he and his colleagues worked on a less hazardous method of immunosuppression, using antilymphocyte serum or globulin extracted from horses into which human white blood cells had been injected (TIME, July 26). Only when the technique was developed satisfactorily did he begin transplanting again. In his second series, Starzl operated last year on Julie Rodriguez, now 21, who suffered from cancer of the liver. Julie has had to be readmitted for additional treatment, but has now survived for a record twelve months. Starzl has no hope of curing her cancer, which has spread. What is certain is that Julie has an effectively functioning transplanted liver. Starzl has also discharged two-year-old Randell Wayne Bennett of Mesquite, Texas, and Eddie Miller, 44, of West Helena, Ark., and has three other patients, more recently operated on, still in Colorado General Hospital.

Six other Denver patients have died, after as long as five months following surgery, from a variety of complications usually involving blood clotting. In no case has it been clear that rejection of the transplanted liver was the single direct cause of death. "If a patient can make it for six or eight months," says Starzl, "he has a good chance of living a very long time." Without a liver, for which there is no artificial substitute, no one can live longer than about 36 hours.

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