In Their Own Words:
I became very interested and very involved with transplantation while I was a resident, serving sort of extra time on the transplant service because it was exciting. You know you were on the fringe of science; it was sort of like being at Hopkins or some of the other centers in cardiac surgery during the early fifties when they were doing the pioneering work in cardiac surgery. You just sensed that you were at the forefront. In order to be successful in a career, you have to have a feeling of excitement. If you are not excited about what you are doing, you’re in the wrong position. And it was very easy to become excited about transplantation because of it’s... You knew it was going to be a clinical tool. You knew it had the challenges of immunology, it wasn’t just pure mechanics. – James Cerilli, MD
James "Jim" Cerilli, MD, a charter member of the ASTS, served as its 7th President. Dr. Cerilli graduated with a medical degree from Johns Hopkins University in 1958 and went on to serve at the Walter Reed Army Medical Center in the early 1960’s. Completing his general surgical residency at the University of Colorado in the mid 60’s, he became interested in transplantation, then a clinical science in its infancy. Dr. Cerilli went on to the Ohio State University where he founded the transplant program in 1967. In addition to interests in clinical outcomes and surgical education, Dr. Cerilli was among the first transplant surgeons to address important social issues in organ donation.
James Cerilli: My name is Jim Cerilli and I am retired. I currently live in Hilton Head Island, South Carolina.
Thomas Peters: How and when did you first become interested in transplantation surgery?
James Cerilli: I became interested really in transplantation when, when... probably when I was in the military, as early as 1960. I spent two years doing research at Walter Reed and they assigned me to an area doing renal physiology, about which I knew absolutely nothing and I developed an interest in renal physiology.
When I went to my residency, I was actually going to go into cardiac surgery. When I went out to the University of Colorado, Tom Starzl had just taken a position there and it met the criteria really that I wanted, namely to be at the... I wanted to be part of a rapidly developing, innovative new field in transplantation that combined science with clinical development. And all of the ingredients were there when I went to Colorado, namely a hardworking, innovative clinician in Tom and a field in transplantation that was about to, you could tell, explode as both a science and a clinical. I just wanted to be part of it, so to answer your question; I became really interested in transplantation in the very early sixties.
Thomas Peters: After Colorado, how did you maintain that interest in that clinical role?
James Cerilli: Well I became very interested and very involved with transplantation while I was a resident, serving sort of extra time on the transplant service because it was exciting. You know you were on the fringe of science; it was sort of like being at Hopkins or some of the other centers in cardiac surgery during the early fifties when they were doing the pioneering work in cardiac surgery. You sort of, you just sensed that you were at the forefront. In order to be successful in a career, you have to have a feeling of excitement. If you are not excited about what you are doing, you’re in the wrong position. And it was very easy to become excited about transplantation because of it’s... You knew it was going to be a clinical tool. You knew it had the challenges of immunology, it wasn’t just pure mechanics. And I was in the right place really to become part of it.
So I took a year of Fulbright Scholarship, a Fulbright Fellowship I went to, Copenhagen and did more research in transplantation plus other things and came back. And I guess you might say I was Tom Starzl’s and Tom Marchioro’s in a way first transplant fellow, although the concept of fellowship was not applied to training. It was sort of you were just there and there was no criteria for training.
And we can get into that a little bit later because it’s kind of an interesting story how the first people who did transplantation did it. They weren’t trained, nobody trained them, and they trained themselves. You just learned, it was on-the-job training and you learned the dog lab and you learned on patients. And some of the developmental early stages of transplantation might not have really have been able to happen in today’s regulatory environment. A lot of things went bad, badly. Patient survivals in the beginning were terrible, but the excitement of the leadership at several institutions drove it. And it drove it without opposition so to speak, there was nobody looking over your shoulders. And I am not sure transplantation could ever develop as rapidly as it did in the sixties if you moved it up to this decade. There would have been too many brakes put on the process, too much glue would be put into the wheels. It was just a fast-moving, exciting time.
Thomas Peters: After Colorado, where were you?
James Cerilli: Well we can get into that now. I took a year, well not quite a year with Tom. At that time, ALG was just beginning... Anti-lymphocyte globulin was just beginning to be developed. Again, you could never do what we did in the sixties today because it was a product that was sort of made home-brew. Everybody had a good conscience; their goals were absolutely beyond reproach. They were trying to advance the science, but most importantly advance the clinical discipline. There was no monetary drive, not at all. It was purely “Let’s make this work. Let’s make it better.” And the fact that you went out and basically made a drug, you just did it and you did it for the right reasons.
Thomas Peters: Was there an IRB [institutional review board] in that process?
James Cerilli: Well in some places there was and in some places to be perfectly candid, there wasn’t. And you know IRB’s are... You can sell most things to an IRB unless there is evidence to the contrary that what you are going to do is wrong. If you are starting with a clean slate, its hard for them to really turn it down, when the alternatives of a patient is to die.
When I took the training with Tom, and Tom knows this, I spent nine months there and I never got closer to doing a transplant than holding a retractor. He and I would like to pay homage to Tom Marchioro, who was a Past President and friend who has died can’t be with you at some point, was another pioneer in transplantation, you know deserves much of the credit for helping this field progress.
But I can say now that when I went to Ohio State to initiate a transplant program, I had never done a whole transplant. I had done multiple transplants in dogs. Tom at that time was developing ALG and I understand this program had to work. He had to prove ALG and I understand you don’t want things to go technically wrong. So Tom did most of the surgery, Tom didn’t… And Marchioro did little to none. But you can only stay that way for long if you are an aspiring young surgeon and anxious to own mark on the field.
So I went to Ohio State because I had an interim colleague from Hopkins who knew me, he was at Ohio State and recruited me there. So I went there under Bob Zollinger who had a reputation as a real fire horse. And I went there with a great deal of trepidation, fear and sweat on my brow to initiate a program in the late sixties with great doubts in my mind, but feeling that I had an opportunity to make a contribution to the field and we just did it.
Thomas Peters: Once you had the program going in Ohio, what would a typical day be like in your professional life?
James Cerilli: Well at the beginning, I ultimately had... Other opportunities, I mean other responsibilities. I was also directing a cancer education program, that’s where my salary came from, was a federal grant. So I had some responsibilities in that, but most of it was getting a research lab going and writing research grants. It was getting an organ procurement organization going and begging for money from the hospital to try to get the people and the equipment to get that off the ground. It was going around and trying to convince nephrologists that they should ultimately send me patients. I helped to train a corps of nurses as to what the problems will be when the transplant patients came through an operating room. So it was very much of a developmental first-level day, there was nothing routine, everything was new.
And also it was an atmosphere of a great deal of skepticism in those days. Today there is an excitement and acceptability and nobody questions the role of transplantation, but that really wasn’t true back then. There was a great deal of skepticism about whether or not transplantation should even be done. The costs were prohibitive. There was little to no reimbursement. The hospitals basically paid for it out of, you know profit and losses. You’ve got to remember as I’m sure you do, patients stayed in the hospital three months routinely. You can spend a lot of money in three months when you get nothing in return. So it took a dedication to both hospital administration and the whole facility to make this work because at the beginning, the prognosis wasn’t that rosy.
Thomas Peters: Shifting gears a little bit, you were instrumental in the formation of the American Society of Transplant Surgeons. Can you recall for us some of the early days of the ASTS, please?
James Cerilli: Well the ASTS was formed as an idea of former President Fred Merkle from Chicago. And I can remember the discussions about whether or not this organization really was necessary. Were there enough people in the field to talk to each other? Do we need a formal organization to do it? What are we going to talk about, what are the goals? And I even had my skepticisms; I said “Well what’s the point? I can pick up the telephone and talk to you or whoever and learn what I need to know.” Then all of a sudden, a groundswell of unanimous views that we had to have a society, but it caught on very quickly. And I can remember the excitement of the meetings and as was mentioned previously by a person that was interviewed, the collegiality and the. . .
What drove the system then was science. It was science that made the system move. Competition, one program wanted to advance it more rapidly than another program. It wasn’t money that drove the system. It wasn’t hospitals saying “Do fifty transplants.” It was a group of dedicated people who really weren’t paid a lot in the beginning to want to make this discipline work and it was the science that was the motor and the rest sort of followed.
But the ASTS grew as… We used to have our parties as you probably recall at Fred Merkle’s house, we could all fit in his backyard and he would bring the Chicago Symphony there. I’m not making any secrets, it was a drunken brawl. But it contributed to the collegiality of a closely knit, very, very hardworking group of people and it helped keep us together.
Thomas Peters: You ultimately led the American Society of Transplant Surgeons. Can you tell us some memories from your Presidential year?
James Cerilli: Well I wanted to make. . . Do something that would last, not just put in twelve months and when I walked out the door or off the podium, it wouldn’t be much different than when I walked on. So I thought, “What are the arenas that need development?” And one of the arenas, the problems we had was getting patients.
And one of the reasons there was problems getting patients is it was my view that the nephrologists had an inappropriate perception of what the results were. They would always quote the bad end, the bad results, like we won’t send patients to transplantation. And yet I knew from my associations with the Belzer program and the Minnesota program, the Starzl program, that the results were a lot better than were being quoted and while they were in the literature, they were never really amalgamated into a piece of data that you could sell, because everybody sort felt, “Well that’s Starzl tooting his horn” or “It was Dr. Najarian tooting his horn” or it was somebody always tooting their horn. But if we could put this together as a meaningful piece of information, we could sell it as a non-personal piece of information. So I started the standards committee and asked Oscar Salvatierra to chair it to bring this data together and that helped.
And the other was that I felt that it was certainly clear based on my own personal experience of how I got started, that we needed to formalize the educational process. And I knew there was no better person that John Najarian to lead that and so we started the education committee and he did a great job. It really began putting some teeth or some standards into who can be a transplant surgeon, what are the training requirements and it wasn’t easy. I mean it wasn’t easy at all to begin to bring together a totally amorphous system in which you did exactly what you wanted to do. You could take somebody off the street and if he was a surgeon, he was a transplant surgeon. I mean you could walk in and you were, and that could not be sustained. It could not be sustained because untrained people don’t do things well and training and education was the core and the foundation of this field developing the way it should develop. And so I thought education really... And the formalization of its standards held the future for transplantation.
Thomas Peters: In describing what you did with the ASTS, you did it without staff?
James Cerilli: Different days, everybody who was President just sort of pushed the administrative responsibilities onto their own administrative staff that they could control, you know at the parent institutions. And it was smaller; the breadth of responsibilities, true responsibilities was much smaller than it is today. And I must admit I was, I’m not sure surprised was the word, but to see the size of the administrative staff that is currently associated with the ASTS and I’m sure it’s a very necessary additional to the society because there are so many more responsibilities. From obtaining grants to dealing with gosh-knows-how-many facilities for standardization of training, keeping track of…
There are just so many things that we didn’t have to do. So the breadth of interest and responsibilities of the society has grown enormously. We were focusing on the immunology and the clinical science and this does so much more than we did.
Thomas Peters: In your Presidential address that you gave in the early 1980’s, you mentioned a topic which was the third rail and that was financial incentives in organ donation. You were really the first person to publicly address that topic. Could you tell us a little bit about the genesis of those thoughts that you had and what your thoughts are today?
James Cerilli: Well I still have the scars from the talks I gave on it if you would like to see them.
Thomas Peters: So do I.
James Cerilli: I think transplantation has done a wonderful job and the society has done a wonderful job. The science... And this may be a little lengthy answer, but I think it’s important. Science has improved tremendously, the education has become more formalized, the communication within the system has become formalized, but there was a problem.
And the problem is that we are probably one of the very few, if the only medical discipline what cannot apply its discipline to its fullest extent because we don’t have the supplies to do it. You want to do a hip implant, you pick up the telephone and you order a hip implant. You want to do cardiac surgery; you call up the operating room. You can... The supplies to do any other clinical discipline are available with a phone call and with dollar bills, that’s about all you need.
That is not true with transplantation and what is most discouraging is that that has not improved much over the last thirty years. The percentage of donors, people who are willing to donate, while it has improved a little, has not kept pace with the advancement of the field that we see in education, if we just do it on a percent of incremental improvement. The clinical application of the field, the training, its just not anywhere near it. So there is a problem that existed and it’s a problem that’s getting worse.
Now what’s getting worse? People are dying waiting for transplants and the number of people that are dying waiting for transplants is increasing rather than decreasing as the list grows. And there is nothing, at least that I am aware of, and it’s possible that I am not aware of data because I don’t follow this on a weekly basis. But the prognosis for this getting better I sense is not great. So new ideas that may not be acceptable on the surface sometimes have to be applied to a serious problem, particularly a problem that is getting worse and new ideas are not very easily accepted.
For instance, brain death was not easily accepted. Everybody today accepts brain death. But I can remember the ethicists, many people in Congress, large numbers of the medical community being against brain death. Yet there would be people lined up in the ICU units, be declared brain dead when they really weren’t dead. There was this enormous fear of brain death and right now it is almost the foundation of the applicability of cataract transplantation. It has become accepted.
We couldn’t get standardized donor surgery because who wanted to get up at two o’clock in the morning, travel 100 miles in a snowstorm, spend ten hours and not get paid for it? Now you hate to put things in monetary terms, but as a result of that, many centers had difficulty getting experienced people, committed to a program on the donor side because it just was too much of an intrusion on their professional lives. And it is very understandable, this does not mean they are monetary, it just means that they have their own careers to develop and it was very much of an intrusion.
And I remember very clearly that when the concept of plain donor surgeons came out, there were many people who were against it because they said, “You will be taking organs from people whose organs should not be removed because the donor surgeon is going to be promoting it and he is going to get paid for it.” And the title I gave to my talk was Chicken Little; the sky is going to fall down. Well the sky never fell down when we did brain death. The sky never fell down when we paid donor surgeons. The sky didn’t fall down when we started giving some compensation, like the final 24 hours in the care for the donor family for a cadaver donor, even though there were people that thought they would. So I don’t think the sky will fall down if there were controlled, carefully monitored by experienced, multi-disciplinary people we put in a financial incentive system for cadaveric family donation. Why? Because the problem is getting worse and new ideas need to be tried.
Thomas Peters: Let’s shift gears a little bit. Over your left shoulder is a chimera. Can you tell us a little bit about that beautiful piece?
James Cerilli: Well I was always devoted to transplantation, but I am not much one for symbols. I don’t know, I’m just not much of one for symbols. But when I retired, I wanted something around me to help remind me of a long career and so I decided I would try to find a bronze statue of the chimera. Well you are not going to find it with much luck in this country.
So every time we’d go to Europe, we would sort of explore the places that would sell bronze statues. And in Florence, in a small place that sold bronzes, down a dingy hallway, covered in dust, my proprietor who was absolutely amazed that anybody even knew what a chimera was, much less asked for one, he brought this out and I said “I’ve got to have it.” So I bought it and it sits in a very prominent place in my study, which I sit in every day and its right there in front of me. And I must admit, it brings back many, many fond memories.
Thomas Peters: It’s heavy, how did you get it back here?
James Cerilli: We had it shipped.
Thomas Peters: Um, you did an awful lot of surgery in your active career. Any operating room scenes that were particularly outstanding, humorous or otherwise interesting that you can tell us about?
James Cerilli: I don’t think there was ever any humor any my operating room. I don’t say that facetiously, just like there was no music. It was a very focused atmosphere. There were some memorable moments. I always enjoyed the children that I operated on, but it was a… They were… The children were my worst moments and my best. In the early days when mortality rates were much higher than they are now and we all lost patients, if an adult you knew you weren’t going to be able to save him, you just… You became immune to that. But when a child would get ill and I knew was going to die, I couldn’t go to the hospital. I just couldn’t do it. You know you did it peripherally, so the emotional commitments to children were some of the saddest times.
But I did one of the first, if not the first, successful infant nine months old and that success was probably one of the most gratifying because that child lived a long time, ultimately required re-transplantation. So children were some of the saddest moments in my life in terms of professionally and it was also some of the most gratifying.
Thomas Peters: Could you have imagined at the time you were growing the division at Ohio State, what transplantation would evolve to?
James Cerilli: Not in your wildest dreams.
Thomas Peters: Tell us what your… your prognosis might have been and how it’s different from what really did happen?
James Cerilli: Well I never thought that multi-organ transplantation would be so widely applied. My fault, my narrowness of vision or maybe my lack of background in it, but I never really thought that it would have such huge applicability. Maybe I never saw the patient need. So the enormous growth of liver transplantation I would never have anticipated.
I never thought pancreas transplantation would become as clinically successful as it did. I thought Islets and did some Islet research, would probably be the leader of the science and the leader of the clinical direction. And while they both have progressed, it’s clear that at today in the year 2009, whole organ pancreas is being applied greatly, more greatly and more frequently. So I did not in any… My wildest anticipations thought that the numbers would be done and so successfully, lack of vision on my part.
Thomas Peters: Where do you think transplantation will be in ten years?
James Cerilli: Well that’s an impossible question for somebody who has been out of it as long as I have. You have to define what the problems are today to know where it might be fifteen years from now, because you can’t improve on things that need minimal improvement. And while obviously immunosuppression does need… Hopefully they will solve the organ supply problem. Maybe it’s through use of hepatocytes for all I know rather than doing whole organ livers. Maybe it Islets, I don’t know the science well enough.
I would hope that the problem of organ supply would be solved because I view it right now, if you can compartmentalize what the issues are in transplantation, appropriate recipient, appropriate donor, appropriate education, appropriate… Just make compartments of them and one of those compartments is organ supply, I think organ supply right now is our problem.
Thomas Peters: Oh, thank you for reminding me. Okay, you may have heard me say earlier on to one… And I forgot to ask Bill Pfaff about this and I failed at that. We want to begin as part of this project to have our honorees talk a little bit about two or three of our colleagues who are dead. So there is Belzer, there is Corry, there is Kaufman, there are others.
James Cerilli: Marchioro.
Thomas Peters: Your... And so what we would do though is extract this part from your piece.
James Cerilli: Okay.
Thomas Peters: And then have a piece on Tom, since he can’t speak for himself. So let’s do at least Tom and…
James Cerilli: Okay.
Thomas Peters: And maybe one or two others, if you wouldn’t mind?
James Cerilli: I would be delighted to do that, I really would.
Thomas Peters: Yeah.
James Cerilli: I would appreciate the opportunity.
Thomas Peters: Yeah, so you can... It’s yours.
James Cerilli: Well Tom Marchioro was part of transplantation from its onset, working at Colorado and then the University or Washington. And I worked with him for many years, very closely. And he was a true… Both a mentor of mine and an idol of mine. He was an incredible technical surgeon and I don’t think with the exception of Tom Starzl that I know, I don’t know any of his peers. Tom did liver transplants, pancreas transplants, thymus transplants, kidney transplants, spleen transplants, lung transplants, did all kinds of thoracic surgery, open heart surgery and Tom could do anything technically and do it well.
But the most important thing that from my perspective, and I’m not talking about his science or his… It was his tremendous dedication to the patient, but his ethics. Tom set a standard in transplantation ethics that I hope would serve as an example to others. It was always, “Is this the right thing to do? Maybe we shouldn’t be doing this because this is not in the patient’s interest.”
If there were things… You’ve got to realize, I’m sure you do. You’ve got to remember the days in the sixties when things that would never be done now, I mean things were tried because we just didn’t have any idea whether or not they would work or not. You know, chimpanzee transplants, baboon transplants, we didn’t have any idea at all. Twenty hours, twenty-four hours for a liver transplant, in surgery. This you just can’t imagine how difficult and bad things would be. So the question of patient selection and is it appropriate to choose this patient knowing the mortality rates were 30%, 40%, is it right? But Tom set a standard for ethics and a standard for the technical aspects of transplantation that I… That helped mold my career.
And I hope that he… Tom went to the University of Washington and established a successful program and I hope he gets remembered fondly.
Thomas Peters: Okay.
James Cerilli: Well the only other one I’d like to mention maybe is Fred Belzer. Fred was a scientist and a knowledgeable scientist who focused on an area, namely organ preservation that made monumental advancements and made transplant, cadaveric transplantation, practical. Because in the beginning and I remember literally taking out a cadaver organ at two o’clock in the morning and racing to the operating room to put it in before it turned into mush. And Tom… Excuse me, Fred took that urgency out of the process and made it practical. And from organs that would last a couple of hours or less, he converted it to lasting days. So he made transplantation applicable on a wide basis.
Instead of just being done by some people who were crazy enough to get up at two in the morning, get an organ, race across town and put it in right away because it would never have survived as a clinical discipline if that’s the way it had to be done. And he had a lot of success and he had his failures. But he stuck with it and I think he’s… His contributions will never be forgotten, nor should they be.
And also, I will tell a little vignette. He was a very, very bright clinician. I organized a symposium on organ preservation at Ohio State. And I prided myself as being a very good technical surgeon with very few technical complications, and I have very, very few. So I happened to have done a living related donor that day that Fred shows up at this presentation and they match. And I said, “Fred, let’s make rounds.”
And going around and I did this A match donor and it was… I did it in the morning and finished around eleven. It was about five o’clock in the afternoon and Fred says, “I don’t know, the urine output looks a little low.” And so he says, “I think you have got an arterial stenosis.” I said “Oh Fred, I don’t get arterial stenosis. I have never had one.” He said, “I think you have got an arterial stenosis.” Well he was right, arterial stenosis. Re-operated on the patient the next day and that’s exactly what he had. He was an acute clinician, very, very bright fellow.
Thomas Peters: Okay. Well did you have another…? Did you have another story you wanted to relate?
James Cerilli: Well everybody always talks… Everybody always talks about the good things and how well things are and how good results are and I think the current generation of transplant surgeons needs to know that these good results were built from a fire of disappointment. From years of struggling and failures at multiple centers and whose leaders because of their perseverance… And I will repeat that, because of their perseverance and belief in the discipline, put those failures behind them and kept moving forward. So that this generation of transplant surgeons can enjoy I think a much a more clinically acceptable disciple.
Thomas Peters: You know, there are very few surgeons under the age of 45 who have seen an unmitigated, accelerated acute rejection that within hours becomes associated with coagulopathy, with encephalopathy, with all of the… with hemorrhage, with all of the things that people…
James Cerilli: That’s right.
Thomas Peters: At your stage saw far too often.
James Cerilli: That’s correct.
Thomas Peters: They have never seen a disrupted arterial anastomosis, even though it was technically done well when the operation was performed. And I don’t know that they are better for it or not. I don’t… They don’t understand what the physiology of rejection can really result in, it can kill you.
James Cerilli: That’s right.
Thomas Peters: Yeah.
James Cerilli: They have never seen the process.
Thomas Peters: Yeah.
James Cerilli: Good times, great times, a wonderful life.
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