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Byers “Bud” Shaw Jr., M.D. |
Below, Dr. Shaw talks about Morgan Smith-Dennis, organ transplantation and the strides that have been made in organ transplantation since Morgan’s transplant at 14 days old on June 18, 1986.
In Dec. 19, 1981, Dr. Shaw performed his first transplant. Twenty-two years ago in July 1985, he launched UNMC’s liver transplant program. To date, more than 2,330 liver transplants have been performed at UNMC’s hospital partner, The Nebraska Medical Center.
At the time of his transplant, Morgan Smith-Dennis, who recently celebrated his 21st birthday, was the youngest liver recipient to receive a transplant at the medical center. He still holds the title here, as well as being considered one of the youngest in the country to have received a liver transplant.
In 1986, when you got the call from a hospital in Kansas City about Morgan Smith-Dennis, what was it that made you and your team decide to take his case?
I don’t think there was a question of not doing it. It was a child who was desperately ill and needed a liver transplant. We didn’t consider that he was too small. The difficulty in a child that size at that time would have been finding a donor organ. The difficulty with a donor organ in that age group is a lot of the donors that could provide a liver small enough … often have been quite ill before they die so the quality of organs is not likely to be that good. In Morgan’s case, we took one that we thought would be adequate quality and that organ took forever to work properly. … Morgan suffered from many weeks of marginal liver function. We weren’t sure during that period if this thing would ever take off and work.
Can you explain the nuances of doing a transplant on a 14-day old?
The connection for the artery is the smallest one — probably a millimeter to a millimeter and a half. You’re talking about a blood vessel that’s maybe as big around as a refill cartridge of a ball point pen and we had to use 10 power magnification to be able to do it — and we used tiny little stitches that look thinner than a human hair.
What is the average time a transplant surgery would take now?
Four or five hours. In the 20 years, particularly in the past 15 years, we’ve really made the operation routine and streamlined the steps considerably, so 10 to 12 years ago, the average time would be half of what it was in 1985.
Of those who’ve had transplants, what is the average percentage of survival?
About 15 percent might not be alive at the end of the first year. The 85 percent to 90 percent who survive at least one year are still alive at 10 years. Most problems occur in the first two months. One of the most common reasons for needing a liver transplant now, compared to 20 years ago, is hepatitis C. The risk of recurrence is quite substantial. The biggest long-term threat is hepatitis coming back and destroying the new liver. We think one out of every four patients are going to get in trouble later. That’s going to have a huge impact on the 10-year survival.
Can you talk about the advances in liver transplantation since 1986?
Quite a few things have changed. If you just look at Morgan as a patient, if he were to show up today … for one thing, we would have the ability to take a larger person’s liver and cut down a small piece and use it and probably get better function from it.
The preservation solutions that we use to keep the liver from being damaged during the time when it’s outside the donor and not yet in the recipient are much more reliable at protecting the liver. That reduced the risk of the liver not functioning well. It used to be up to 10 percent or 12 percent of the livers we used wouldn’t work and we’d have to re-transplant the patient (with another liver). Now, that’s less than 3 percent.
Better immunosuppressive drugs have been one of the biggest improvements. All we had back then were cyclosporine and prednisone. Now we have nearly a dozen different drugs from which to choose. We can often combine different drugs to allow us to use lower doses of each and still achieve adequate prevention of rejection with fewer side effects. The options we have now are much more reliable at preventing rejection of a transplanted organ. Morgan probably faced a risk of developing an episode of rejection during the first six weeks to two months after his transplant of about 55 percent to 65 percent. Of course, we were almost always able to treat the rejection successfully, but if he got a transplant today, the likelihood that he would have a rejection episode is probably on the order of 10 percent or 12 percent — drastically lower.
Technically, we’re better at doing the operation. These days, in only a year or two, we can train a new surgeon to do the procedure quicker and better than I could do it in 1985, even though back then, I was one of the most experienced liver transplant surgeons in the world. We’ve figured out lots of ways of improving the actual operation so the time spent in the operating room is a lot less, the blood loss is a lot less and complications afterwards are considerably less.
When you think of the lives you and your team have impacted over the years, what do you think about?
You’re asking somebody who’s been involved in this since 1981. And I think you go through a long period of time, maybe as much as 10 years where you are quite enthralled by the success. I think what happens at some point is you start to get more and more discouraged by your failures. When you’re involved in something like I was, where the overall success rate was good — still there were quite a few people who did not survive. If you think about it, there aren’t very many fields in surgery where you would do an operation on somebody and they’d have an 80 percent to 85 percent chance of surviving the first year. Liver transplantation, when I first started, was probably on the order of 75 percent or 80 percent. When you’re exposed to that year after year, you have to develop mechanisms where you cannot basically obsess about the failures. It causes a toll over time. I think you begin to get more and more aware of the body of failures you’ve had. Very few of us sit back and feel complacent based upon all of the success. A lot of what causes you to lose sleep and spend extra hours thinking about how to make things better are all the failures.
I’ve also noticed another change that maybe comes with the territory. When we first started 25 to 30 years ago, liver transplantation was not felt to be something that should be offered to patients. The results were so bad that it was done only in the most desperate situations, as a last ditch effort to save someone who was near death. I spent a lot of the first half of my career giving lectures both to professional societies and to community organizations presenting the evidence that not only were the results from liver transplantation very good, but also that the people who got them could lead normal, productive lives. That was a hard sell over the years, but once you sell that and the public begins to believe and accept it, public expectations become very high. Maybe too high, when you consider that despite the success, it is still a risky undertaking. People forget that without transplantation, liver failure is still a death sentence. So these days, patients and their families are much less tolerant of any complications. We all assume everything is going to be perfect, and when it is, as often is the case, well, we take it for granted. And when something does go wrong, and recovery is delayed, everyone is perhaps far more disappointed than is realistic.
In the end, we get our reward from grateful patients. Taking success for granted may have lessened the sense of accomplishment somewhat over the years, but, like I said, it probably comes with the territory.