In their own words:
The American Society of Transplant Surgeons evolved from the Southeast Organ Procurement Foundation. It was based on the same concept, but a larger audience. The Southeast Organ Procurement Foundation was the southeast, the American Society of Transplant Surgeons was national, and so it was a very logical extension. And there were people doing great things that SEOPF did not have access to, which they now did through ASTS and vice versa. And the groups worked cohesively very well and it became the society to belong to if you were a transplant surgeon and then very wisely brought in the medical component, the physicians because after all, it’s their patients and they wind up taking care of them usually over a lifetime. So it was a very wise move and it had all of the immunology, all of the basic science. It was a well thought-out group and grew beyond anybody’s wildest imagination at the time.
Stanley Mandel, MD, graduated from the Medical College at the University of Virginia in Charlottesville, and thereafter trained in general and vascular surgery. Taking an appointment at the University of North Carolina in Chapel Hill, Dr. Mandel was designated by his chair as the surgeon responsible for development of a new field in general surgery, namely organ transplantation. Within days of arriving in Chapel Hill, the challenge of transplantation was met head-on by Dr. Mandel who performed the first successful kidney transplant at that institution, having never seen a human kidney transplant before. Serving that medical center for nearly four decades, Dr. Mandel has retired from active vascular and transplantation surgery but remains Medical Director of the University of North Carolina Hospital Operating Rooms. Dr. Mandel is a past President of the Southeastern Organ Procurement Foundation and has served numerous transplant related organizations over the course of his career.
Stanley Mandel: My name is Stanley Mandel. I am from Chapel Hill, North Carolina at the University of North Carolina. I got started in transplantation in 1969. I had finished the residency program at the University of Virginia and they had not performed any transplants during my time there. I had spent a year in the lab working on organ preservation; we figured out that cold preservation could keep a kidney going for probably up to 24 hours. But my only operative experience was putting kidneys in the neck of a dog and then we would have the kidney available for biopsy and we could see how the kidney performed. But I had no training in clinical transplantation; there was none at the University of Virginia at that time.
I did have my residency and extended residency in thoracic surgery, so I knew how to sew some blood vessels together. And the first job I had and the only job after residency was at the University of North Carolina in Chapel Hill. I got there of July 1st and finished the residency on June 30th. And when I got there, the chairman said, “Do you know how to sew blood vessels together?” And I said, “Sure, I have done that in thoracic.” And he said, “Well why don’t you take over the transplant program? We have tried one, it hasn’t worked and we need a transplant surgeon.” So I said, “Well I’ll do that, but I need to get some training.” And he said, “Well you don’t need to worry, we only have three people on the list and you’re not going to get called and we’ll send you someplace where they know how to do that and you’ll learn how.”
So I put my head on the pillow on July 1st and sure enough at 11:00 at night, I get a call from Johns Hopkins and they have an ideal donor. You know, heart-beating-cadaver 21-year-old male, it was Mel Williams because in those days, surgeons were also the procurement agencies, there were no OPA’s. And Mel said, “It’s a perfect donor, you need to take it.” And I said, “I guess I should, but…” And so I agreed to take it with some anxiety and so now I had to find somebody to tell where to put the kidney because I knew I couldn’t put it in the patient’s neck.
I looked around and I found a thoracic surgeon in the hospital who had had training in Texas and I said, “Look, I need to put this darn thing in, I don’t know a thing about it, please help me.” And he said he would help me with one proviso. And I said, “You name it, it’s yours.” And he said, “I’ll help you put the kidney in but I’m not going to help you take care of the patients because that’s the most difficult part of the operation," which probably to this day is still true. So he helped me put the kidney in and sure enough, the perfect donor of course, let the clamps off, the kidney pinked up and made urine but now I knew I had to take care of the patient and I didn’t know where to go.
I remembered that Duke had probably started before we did in ’69, so I called a friend at Duke and I said, “Look I put this kidney in, it’s making urine. What’s next because isn’t there this thing called rejection?” And he said, “Well yeah." He said, "Well what you do is you give this Imuran stuff and the steroids.” And I said, “Well what in the world do they do?” And he said, “Well steroids will kill all of the white cells that are there.” And I said, “That makes sense.” I said, “What about Imuran?” He says, “That will kill the white cells that are trying to be made.” I said, “That makes sense.” “Now what happens if that doesn’t work?” And he said, “Well you give more steroids.” I said, “Well what happens if that doesn’t work?” He said, “Take the kidney out.” (Laughs) And that was my training and that was the first successful transplant at University of North Carolina and then the program was built from there until today where it’s a multi-organ transplant program.
Randall Sung: And what was your life like back then, especially with patients?
Stanley Mandel: Well it was busy, you know you did everything. You spoke to the families when you needed, when you had a donor. You had to procure the kidneys yourself. You had to transplant them yourself. There wasn’t a transplant service, so I kept the patients on the vascular surgery service because that’s where the expertise for…And there really wasn’t any vascular surgery services; I was it with one other person. But we did everything.
If there was an organ procurement at another center and of course North Carolina is spread out and we would go, we would go to that center in the state. We would have to do that procurement locally. UNC had a couple of their own planes, so the UNC Air Force would fly to a local hospital, I would procure the kidneys, take them back to UNC and then transplant them. And we would share among the centers that were in business at that time. And we were members, one of the founding members of SEOPF, which I was familiar with because I was at University of Virginia as a resident when SEOPF was formed.
Randall Sung: How was that formed? Were you familiar with that?
Stanley Mandel: Oh yeah. It was like the Atlantic Coast Conference, but it wasn’t totally logical, the Atlantic Coast, because it was the southeastern organizations, many of which I could name, but it looked like that and then it had some illogical members based on geography. Like we had one institution from New Jersey because they had a pathologist who knew how to read the slides and tell you whether you had rejection or glomerular nephritis or something else. But basically it was a group of people who had a common interest who met regularly, started meeting in Richmond for lunch. And the leaders in transplant at that day came and other school started being added, but it was the beginning of an organized group of people with a common purpose and it was clinical care, research, education, it really was a wonderful group. And I remained the representative from the University of North Carolina when I got down there.
Randall Sung: And how did that wind up evolving into…?
Stanley Mandel: Today’s situation?
Randall Sung: Yeah.
Stanley Mandel: Well UNOS kept growing because it fulfilled all of the needs that one would want. You had a database of recipients, you had scientific exchange, you had the people who were involved in transplantation, multiple specialties and it was obviously a very successful model and people wanted to belong. And so we started figuring out how we would grow. And we would add, if you were on a contiguous state, if you bordered on one of the states, you could join. Well of course, you take that model forever eventually you would reach the Pacific Ocean. But we had in it somewhere between 12 and 15 institutions, they functioned very well and they knew each other and I think that was the…
You knew the people; you didn’t get called at 4:00 in the morning from somebody you never heard of with some questionable description of the organ. If I got called, it was by the transplant surgeon and then I met him at the meetings and we would go four or five times a year to Richmond or maybe more and then we started meeting annually at the American Society of Transplant Surgeons, so it was a great group and very successful.
Randall Sung: What were some of your biggest obstacles in developing kidney transplantation?
Stanley Mandel: Well of course you know people really…You had to get people to understand what you were doing. First the organ shortage was always there. You know people to accept the fact that the organs could not go with them after death, so organ procurement was always a big problem. Dealing with the fear of what the legal implications might be, a heart beating cadaver and brain death is the same as death of a patient. And then by and large, the big…
To me, after getting over that you know I had a love/hate relationship with immunosuppression my whole life. I loved it because I knew I could not do the operations without it. I hated to see some of the results. It was…And a lot of times I’d use the metaphor, it was like napalm. You could wipe out the enemy but you wondered what was standing when you finished. So to me, that was an albatross around my neck forever and that’s one of the reasons I always promoted and would even today if I was still doing it, live, related transplant.
There aren’t any immunosuppressive drugs that matches live, related and you look at the results and they were there. And we had good results with the cadavers, but you knew with a greater degree of predictability what would happen with a live, related donor. And with kidneys, I pushed hard before I put somebody on the cadaver list to make sure that there was no opportunity for a live, related donor.
Stanley Mandel: SEOPF the initials, which is a wonderful organization, stands for Southeastern Organ Procurement Foundation. It was the original group of people who came together with a common purpose, education, exchange of scientific material, a camaraderie that allowed people to understand what was going on at that time and it just was a good thing and very much needed.
Randall Sung: What are some of your most memorable moments as a transplant surgeon?
Stanley Mandel: Well two or three I guess. Certainly one was, I think we did the first diabetic in the state of North Carolina, not the first diabetic in the country, but that was a big deal because in those days, people were afraid to transplant diabetics for all of the reasons that are obvious, all of the underlying comorbidities and how they would do. And we did the first diabetic and the patient did very well. So the fear of operating, doing kidney transplants in diabetes was certainly alleviated. That was, I thought a very historic event for me.
The other was a rather unusual circumstance. We had, and I think I have already spoken about the advantages of live, related donors. We had twins, two girls, they were twins and they were both under-age. And the parents and the family all agreed they wanted me to transplant the kidney from the normal twin to the one who had end-stage renal disease. But of course there was no precedent in the state of North Carolina for an under-age child to give permission for an operation they did not need. And so the question was how were we going to get around that entanglement?
So by some historic law or judgement by the courts, I was sued in a friendly suit by the family for $1, which was what the judgement was that I was mandated by the state of North Carolina to transplant the kidney from the healthy twin to the one who needed it and if I did not, I’d be in contempt of court. So that was the first, certainly in North Carolina, under-age twin transplant that had occurred and that to me was sort of a unique circumstances. And I think if you dig up the legal document, you see that I have been sued for $1 to allow twin transplantation. So that, you know was another meaningful thing. You know I guess you remember those things forever.
I’m trying to think if there was a third. I remember one night I was waiting for a kidney transplant recipient to come in and the kidney was there and we were waiting and this patient came in late. And you know, it was like a two hour trip and it took them eight or nine. And I said to the patient, I said, “Where in the world have you been? We have been waiting for you for six or seven hours?” And he said, “Well I went to church.” I said, “You know transplantation is serious business.” And the guy looked at me in the eye and he said, “Well I tell you what, God is serious, too.” (Laughter) So I backed off, we transplanted him and he did fine so I guess it was good thing he stopped off for four or five hours.
Randall Sung: Any particularly embarrassing moments or moments, you’d rather not remember?
Stanley Mandel: Well I remember going on one of the local television programs, you know to talk about organ procurement and it was one of these programs where they had guest stars. And so I was there and there was a monkey trainer and a woman who was doing some other thing and the three of us were sitting there and of course I was going to talk about organ transplantation, the monkey trainer was going to talk about what tricks his monkey did and I forgot what the woman was doing. And the monkey kept pulling the woman’s skirt up during the interview. And I was having trouble concentrating on what I was doing, so I thought that was kind of embarrassing for all of us because there was the admixture of transplantation and then this predatory monkey and me. And I guess it was moderately embarrassing. (Laughter from group)
Randall Sung: What has transplantation, how has it affected your life?
Stanley Mandel: Well of course it provided a lifetime of professional achievement and endeavor and allowed me to meet a lot of wonderful people. I didn’t only do transplant, in those days you did more than one thing. So I did a lot of general surgery and vascular and trauma.
But if you ask me, the most important thing it did for me personally, which is what I think you have asked, it showed me the importance, the value of health. Because no matter how rough it got, no matter what my problems were, seeing the people who needed the transplant and what they went through and what they were dealing with put my own problems in perspective.
Now I’ll admit you know when I got home I complained about the same things we all complain about. But it puts your life, all healthcare does and certainly the rigors of transplant puts things in a proper perspective. To me, that’s been the most valuable lifetime lessons, for me personally, above and beyond the professional enhancement.
Randall Sung: How do you…? How do you see the evolution of transplantation? How do you view it over the past decade?
Stanley Mandel: Well…
Randall Sung: What do you think is going to happen?
Stanley Mandel: Well certainly, things that I thought would never be able to be transplanted have now joined the list of the kidney. And based on our program in renal transplantation at the University of North Carolina then expanded to liver and heart and lung and heart and heart-lung and so now it’s multi-organ and that certainly, clearly the trendline. I think it’s going to be less invasive; kidneys are now taken out laparoscopically than through big, open holes. I think the next big bridge is to really get to an innocuous immunosuppression or do away with immunosuppression by some science because as long as you deal with napalm, you are burning down some of the forest to get where you want to go. Now you cross the problem of rejection, take that off the list and then the field is unlimited only by organ donation.
And then the other point I think is that somethings will not be whole organs, the pancreas will be cellular and maybe people can generate enough liver cells so you don’t have to do a whole organ transplant. I won’t see that in my lifetime, but I believe the time will come when you’ll be able to inject pancreatic cells and cure diabetes and so forth. And I don’t know about small intestine and things like that. Perhaps in the absence in rejection, there isn’t an organ you can’t transplant. And there are a lot of other things we didn’t talk about, bone and bone marrow and things like that. But again in the final analysis also after rejection you’ve got to work on organ procurement and changing a cultural bias perhaps that one does, one can take your organs with them which of course you cannot. But you deal with emotion and not science when…And I respect that. I have never in my lifetime, nor would I ever…If somebody said to me, “You know, doctor, I just can’t do that,” I never pushed it and that was my shortcoming perhaps as a procurement agency in my own right. I never said, “Well you really should.” You know I to this day believe that we should respect people’s beliefs, even though it may not make sense to us, that’s their belief, that’s their religion. I was not in the business of saying, “Well you really don’t understand.”
Randall Sung: Can you talk a little bit about what the ASTS was like?
Stanley Mandel: The American Society of Transplant Surgeons evolved from the Southeast Organ Procurement Foundation. It was based on the same concept, but a larger audience. The Southeast Organ Procurement Foundation was the southeast and the American Society of Transplant Surgeons was national and so it was a very logical extension. And there were people doing great things that SEOPF did not have access to, which they now did through ASTS and vice versa. And the groups worked cohesively very well and it became the society to belong to if you were a transplant surgeon and then very wisely brought in the medical component, the physicians because after all, it’s their patients and they wind up taking care of them usually over a lifetime. So it was a very wise move and it had all of the immunology, all of the basic science. It was a well thought-out group and grew beyond anybody’s wildest imagination at the time.
Randall Sung: What were the meetings like back then?
Stanley Mandel: They were good; you know it was a smaller group. We were holding…The meetings of the ASTS were held in Chicago at the Drake. It was a wonderful three or four days. You would go up there and go to some scientific meetings, meet friends, learn new things, set up some clinical studies, run down the park along the lake, get out at night and have a few drinks with your buddies. And that’s the way it should have been, you know and a lot of that has been lost today. But in those days, it was a group of people working together and respecting each other and that mutual respect allowed patient care to be improved because knowledge was shared and people understood what one group could do that they could not and how they had to get there. It was a good…It was a good society.
Randall Sung: What is your view of today’s generation of transplant surgeons?
Stanley Mandel: Well they don’t know each other as well and there are certainly a lot more of them. But I would venture to say that the people at one institution don’t really know, unless they are right next door. But it’s not as close and cohesive a group. They have a little bit of the entitlement mentality, “Well of course I’m a transplant surgeon,” so I think there is a little less humility. Perhaps the old always says that about the new. (Laughter) I think they’re a lot more adept at looking at different ways, less invasive ways of doing things than we were.
And I think they have a very strong appreciation, hopefully based on the heritage they got from our group about the fact they cannot move forward unless they are holding hands with basic science because as I have said earlier in this discussion, immunosuppression is the bridge that you have to cross if you really want to go to the next level. And unless they are holding hands with science, the fact that you can sew the organ in is not enough.
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