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Not Only A Good Liver

"Not Only A Good Liver" © 2021 Jay Hoppenstein, MD, FACS. Used with permission.

I received my first request from the transplant coordinator to participate in the retrieval of a liver from a patient hospitalized in West Palm Beach, Florida, late one Texas summer’s evening. My instructions were to leave immediately for Love Field and meet the transplant team which consisted of the transplant coordinator, the transplant fellow, and two surgical scrub nurses with their heavy bag of specialized surgical instruments necessary for the harvest procedure. All of the medical personnel arrived wearing what they had on when they were summoned – scrub suits. On my drive to the private jet facility I experience both excitement and apprehension, familiar feelings I recalled having in my own practice when confronted with a challenging and difficult surgical case. There was hardly an operation I had not done during my training or in my private surgical practice; however, the complete removal of a liver from a living patient, though declared permanently brain dead, was a new and daunting experience. I realized that I would be working with a surgeon and nurses I did not know and in an operating room that I had never seen before. Several lives would depend on the success of this procedure – one that would end and four others who would receive healthy organs and live. Everyone’s performance had to be flawless.

Shortly after the arrival of Baylor’s first, exceptional, liver transplant surgeon, Dr. Gorin Klintmalm, in the 1980s, the general surgeons on staff were asked to form a support team to assist in the harvesting and implantation of the donor liver organs. A dozen surgeons volunteered and were arbitrarily divided into two teams of six surgeons from which a rotating call list was devised. A member of each team was called by the transplant coordinator when a matched donor organ was made available for a recipient patient. One surgeon would depart, usually by Lear Jet, to assist the transplant fellow in the retrieval of the organ, and another would remain to assist Dr. Klintmalm in the removal of the patient’s diseased liver and implantation of the new one. Timing was critical in the early days of liver transplantation because an extended preservation solution had not been introduced at that time, requiring the harvested liver be implanted within a few hours following its removal from the donor. The actual hepatectomy of the diseased liver was not begun until the liver to be transplanted was removed from the donor, certified to be satisfactory and taken aboard a waiting jet for its transport to Dallas by the organ retrieval team. The clock was always ticking.

Compassionate corporations donated the use of their idle jet aircraft for the humanitarian use of the transplant team. The pilot, copilot and a flight attendant greeted us as we boarded the sleek Lear Jet – the sports car of airplanes. Once buckled into our seats the plane lifted off of the runway quickly and headed east. Sandwiches and beverages were served for those who wanted any during the two and a half hour flight to West Palm Beach but most took the opportunity to recline their seat and take a nap knowing that we would be up for the rest of the night.

The doorway to the flight deck remained open and the pilots could be seen and overheard throughout the flight. I watched as they signaled the otherwise dark and deserted private landing strip for the runway lights to be activated. Two rows of lights suddenly blazed from the blackness below us like a dancer’s stage, illuminating a strip of concrete. We found an ambulance waiting for us on the runway after we landed. Disembarking the plane we were immersed in the heavy, humid warmth of a typical Florida’s summer’s night. All of us crowded into the “treatment” area of the ambulance, thankful for the air conditioning and the relief it brought during our 20 minute drive to the hospital.

We were taken to the emergency room entrance of the hospital and scurried across the soft asphalt whose heat could still be felt radiating upwards into our faces, even at that time of the night. Our team passed through the automatic ER doors and followed directions to the ICU where the donor was being maintained. He was a pleasant looking 42 year old man who had suffered a ruptured brain aneurysm, and was now on total life support. We reviewed his chart, examined his laboratory values and assessed the condition of his vital organs. He was a suitable donor. The transplant coordinator called Dallas to give the signal that we would begin removing the patient’s organs soon so that the recipient with liver failure in Dallas could be readied to receive the new liver.

In the early days of liver transplantation the implantation procedure took about 12 hours, almost equally divided between two stages of the operation: the removal of the diseased organ, often the most difficult part of the whole procedure, and the construction of the five anastomoses for the implanted liver. Unquestionably, liver transplantation was the most difficult of all elective abdominal surgical procedures.

The harvesting of organs from a biologically alive but “brain dead” patient is not unlike any other operation on an ill, living patient. The donor is cared for and treated with the same respect and consideration. The donor is anesthetized after which the transplant surgeons perform the dissection to remove the targeted donor organs. The family of the donor made the decision as to which and how many organs were to be donated. This night they consented to the use of all tissues that could benefit patients in need of healthy organs or tissues. That included his two kidneys, two corneas, his liver and his heart.

Unequivocally, cardiac transplantation was the most dramatic of organ transplantation procedures, though it is not nearly as technically difficult to harvest a heart as it is to remove a liver. The heart, however, has a much narrower window of time that it can be “preserved” prior to implantation than any other organ. The cardiac procurement team arrived by helicopter at the hospital and marched into the operating room ready to take the heart. The liver surgeons had been working for several hours by the time the heart surgeons streamed into the OR. Impatient, the cardiac surgeons were eager to take their organ and leave but were hindered by the necessity to keep the beating heart intact until the liver was ready to be removed. In that way all of the organs were optimally perfused with oxygenated blood until the last few seconds when the heart and the liver were removed, almost simultaneously.

The liver and the heart share one contested bit of anatomy: the vena cava between the top of the liver and the atria at the base of the heart. Each transplant team needed as much of the few centimeters of this vessel as possible to make the implantation of the donor organ into a recipient, easier. After the donor’s chest had been opened exposing the contested structure, there was a dispute between the heart and liver teams as to how much of this critical tissue each required before it was divided. The vascular clamps were poised, one on each side of the intended line of division, each surgeon nudging the other’s clamp a millimeter up or down like hockey players do with their sticks before a face off. The tension in the operating room was at its highest. Finally, a compromise was agreed upon, the clamps placed and the vena cava divided.

Moments later the heart was taken and the cardiac surgeons were away. The tension in the OR perceptibly subsided and the operating room personnel breathed a sigh of relief as they left. The anesthesiologist turned off his machines and noted the time. The liver was quickly removed, infused with normal saline, inserted into a doubled, sterile plastic bag which was then placed into an ice filled Styrofoam cooler, not unlike those used to cool drinks at a picnic. The lid was then taped securely closed.

The kidneys were removed quickly by the liver team and were later sent to a renal transplant center. The donor’s incisions were closed just as if he had been living. We picked up our precious cargo, changed into clean scrub suits and dashed down the empty night time hallways of the hospital, our footsteps echoing from the tiled walls, reverberating like the sound of a pack of dogs in chase. Shortly, we burst through the ER automatic doors onto the driveway of the receiving area expecting to see our ambulance waiting for us. But it wasn’t.

What did greet us was the heat and humidity. It was oppressive. Our glassed fogged, immediately, and the clamminess of the Florida climate became intolerable. As the tension of the past few hours began to subside, our fatigue became noticeable. Someone carrying the heavy liver container set it down and, as we waited, we observed through the ER window the transplant coordinator, telephone handset in one hand and a small black book in the other, frantically calling to obtain transportation for us to the airfield. Enviously, we looked at the square cement helicopter pad, not far from where we stood, painted with a large red cross from whence the cardiac surgeons had arrived and departed. One by one members of the transplant team peeled off to seek comfort in the air conditioning of the ER waiting room. I, too, sought relief from the smothering atmosphere. Once inside I noticed through the condensation streaked window our Styrofoam box resting in the center of the ER driveway – our precious organ, alone and unguarded. Outside, I was enveloped by the humidity, almost too thick to breathe, as I retrieved our treasure.

The coordinator had no success in getting us a ride to our waiting plane. Just then, a Yellow Cab arrived and stopped about where the organ container had been. An elderly woman feebly got out and tottered toward the ER. Our resourceful coordinator sprang out the door, commandeered the cab before he had a chance to leave and summoned everyone to get in. We had a ride to the airstrip. We squeezed into the cab, a couple of the more slender among us sat on the laps of others. To our dismay, there was no room for the organ container! The cab driver opened his trunk and we were forced, reluctantly, to put our priceless organ container beside a dirty extra spare tire and other filthy junk that filled the wretched space. We closed the trunk and left for the airport.

The cabbie, who spoke little English, had no idea where the airfield was located; neither did we. The coordinator stopped a couple of times to use payphones found beside the road, called to get directions and eventually guided us to the obscure airport where our jet awaited to whisk us and our cargo home to the implantation team waiting in the Baylor operating suite. None of us, except the women, had taken any currency when we hastily departed Dallas in our scrub suits. The coordinator had to scrounge a few bills and coins from the nurses who had brought their purses to collect enough money to pay the cab driver’s fee, just barely.

The sky was still black when we departed and the darkness followed us as we traveled deeper into the night on our journey westward. Sandwiches and drinks that had been declined on the outgoing trip were greedily devoured on our return flight. Despite the lateness of the hour and the exhaustion everyone felt, the liver team was too energized to sleep at first. There was the chatter about the satisfaction of having done a good job and the prospect of returning home. The transplant fellow had called Dallas to say that it was a good donor who had a good liver. He was told that the recipient was having his liver removed and would be ready for the implantation as soon as we arrived. The clock was ticking.

An hour into the flight the conversation amongst us dwindled as sleep overtook the exhausted team leaving the sound only of the engines’ soft roar and the occasional remarks which drifted back from the cockpit. I reflected on the night’s procedures, its drama, its hope for a better life for four people and its sadness. I could not help but think about the good donor and his good family. Would they be as pleased as we were that he had a good liver or were they more likely grieving for the loss of a good man?

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