What's Your Perspective?

  • A Transplant Surgeon’s Story of Surviving COVID-19

    Dr. Kato

    Tomoaki Kato, MD, MBA
    Columbia University - College of Physicians & Surgeons

    Throughout my career, I have been challenging the status quo and trying to come up with new strategies to solve problems. This is probably not unusual in a transplant surgeon’s mentality. We all fight for the state that was once considered incurable not too long ago. Since the field is relatively new, there is still room for innovation. My routine surgeries are liver transplant and hepatobiliary surgery. I have personally performed more than 1,000 liver transplants, which I never thought that would become my single most performed surgery when I was a surgical resident (I thought appendectomy or cholecystectomy would be the one….).

    Liver transplant never bores you; you always find something new every time. But I’ve also taken on further challenges. The first was multivisceral transplantation; I learned this in Miami under Dr. Andreas Tzakis, who was the pioneer of this procedure. We spent countless hours trying to perfect the procedure, and now we witness patients who underwent transplant in their childhood becoming adults and having productive lives. Another one was ex vivo surgery. I started to do a few cases in Miami and further developed this procedure to the current level with the help of Dr. Jean Emond and colleagues after moving to Columbia University in 2008. Now we are seeing survivors past 10 years from ex vivo procedures.

    This year I have faced a very tough challenge, distinctly different from the ones I have had in the operating room. When we were told to prepare for the  COVID-19 crisis in mid-March by the New York State leadership, we were still fully operational in our transplant programs, but we were not wearing proper PPEs. About a week after performing a living donor liver transplant, I started to feel sick. I immediately knew this was not the regular flu because the level of muscle pain was something I’ve never experienced before. But I was still in a bit of denial. I even tried to set up a multivisceral transplant for a child because the organs offered were perfect size match (matching the size is a key to success in multivisceral transplant). The patient’s family declined the offer due to the COVID situation, and soon after I learned that I was positive for COVID-19.

    The first few days after the diagnosis, I stayed home taking hydroxychloroquine and azithromycin. My oxygen saturation was about 94 to 95%, but I had no shortness of breath. One day, I was taking a shower and suddenly I developed a hacking cough due to the humidity. My saturation dropped below 90% and I decided to go to my hospital. The first day in the hospital I was stable with oxygen. I had no idea what I would be facing in the next few months.

    My respiratory status deteriorated overnight and I was moved to ICU for intubation. As is the case with many COVID patients, I was in a “happy hypoxia” state. Even a few minutes before intubation, I was able to text my friends. As a matter of fact, I texted a transplant anesthesiologist to come up and intubate me, which he did.

    I was totally sedated for the next 3 weeks on a mechanical ventilator with no recollection of what was going on. What I describe from here is what I heard from my colleagues. My inflammatory parameters went through the roof over the next couple of days. My CRP value was over 90 and ferritin level, which is known to correlate the severity of the COVID, was over 9,000. I received Tocilizumab and was started on Remdesivir. I went into septic shock due to gram negative bacteremia; I was put on full pressor support and then started on ECMO and CVVHD. It seems that ECMO stabilized me. I came off ECMO in about a week and was weaned off the ventilator the next week.

    All of my colleagues scrambled to help me. Hepatologist colleagues spoke to the pharma to get the medicines for me and surgeons and nurses underwent blood tests to be plasma donors for potential convalescent plasma therapy. Our transplant ID specialist was on my case all the time directing the care. Junior surgeons who I trained spent many hours at my bedside giving me company when I was having an emotional breakdown struggling with PTSD. My NP, PA, pediatric transplant specialist, and OR nurses came to my bedside taking turns to ensure my recovery. I survived because of them, and I just can’t thank them enough. 

    Soon after the extubation, I was found to have intracranial bleeding. For that I was transferred to the neuro intensive care unit. There were a couple of small parenchymal bleeding with septic emboli and subarachnoid bleeding. It is most likely from anticoagulation of ECMO, but could have also been from COVID itself. I underwent a cerebral angiogram and it showed no abnormalities. Then, I was transferred to neuro step down unit and then the rehabilitation unit.

    I gained consciousness when I was transferred to neuro step down unit. I remember the morning I woke up and saw Hudson River from the window, and the nurse told me that I was in New York, Columbia University Medical Center. Until then I was dreaming all the time. I don’t know at which point I started dreaming, but those dreams are so vivid that I can still describe them to the detail. I saw a white light. It came from far away and surrounded me. I thought I died. All other dreams were weird ones. One time I was trapped in a conspiracy plot of an artificially created pathogen in a different country.  I was getting sick during the flight coming back from the country and was intubated in the airplane by a young women who was not a doctor or nurse but knows how to intubate because she was involved in the activity of putting people to sleep and infecting those people with the pathogen. When she learned that there was no doctor on the plane to intubate me and I was at a verge of death, she stepped up and helped me. I sent a message over the internet revealing the secret of the country and I was chased by gang mobs. Another time I was a bystander watching the Battle of Waterloo. The day after Napoleon was defeated I was arrested by the coalition army with the suspicion that I was a supporter of Napoleon. I called my lawyer and obtained an “international bystander” status from a court in New York (which was supposed to give me an immunity…).  I made a case with the fact that I was born in Japan and then moved to the U.S. with a busy life as a transplant surgeon; how could there have been time to support Napoleon….? The last one was the one mixed with the reality. This was probably around the time I woke up in the medical ICU and then transferred to the neuro ICU. In my dream, I was in a weird hospital in the Middle East. The hospital was run by nurses who request tips whenever they do things, so they have incentives to keep patients in the hospital. The hospital staff often fall asleep and do not wake up. One time my ET tube got clogged and I was banging the wall for help. They did not come until I was about to faint, so I broke my restraints and extubated myself. Somehow my colleagues were working in the hospital. I was screaming to get me out of the hospital. After screaming all night, I woke up in Columbia Hospital in the neuro stepdown unit. 

    I stayed a total of 2 months in the hospital and was discharged home. Now I am having outpatient OT/PT and slowly starting to get back to work. I’ve learned a lot from my experience. People told me I would be a better doctor in the end; I think that was true.

    When I woke up, I was still on CVVH with a rectal tube and needed to have a feeding tube placed. The first couple of attempts of feeding tube placement were not successful; the tube went to the wrong tract. At that time I had no swallowing function, so to place a tube in the esophagus is harder. I finally got a tube in but I refused the tube for a while, despite the fact that I have persuaded many patients in my life to get a tube without knowing how painful it is.

    Soon after the extubation, I could not talk and there were very thick secretions covering my larynx and vocal cord. I wanted to tell the doctors and nurses about it but I couldn’t. It took a while when one doctor finally understood me and put her finger all the way down to pull an almost gum-like material out. I’ve seen many patients trying to verbalize and struggle. I learned that not being able to verbalize clearly does not mean they are not thinking clearly. Some other minor things are, and all who experienced it would agree with me, how terrible the diaphasia diet tastes, rectal tubes for conscious patient is inhumane, air-conditioning of the hospital needs improvement, etc. 

    The news that I was down with COVID went around the world very quickly. It seems that all transplant surgeons knew it within a week. Some texted me, some sent me an email, and others told me afterwards that they knew. I am so overwhelmed by the support I have had from transplant community. It is so nice to have many friends who care. I take this opportunity to thank everyone who rooted for me.

    My illness scared many of my colleagues in the hospital. The hospital was filled with COVID positive patients. My colleagues volunteered to be redeployed to the front line and took care of them despite the shortage of PPE. The Columbia Medical Center ended up becoming one of the busiest hospitals for COVID care. Almost all OR rooms were converted to ICUs, and many other pop-up ICUs were created. Many surgeons became ICU attendings, and the surgical consult service became tracheostomy service (at the peak, we did 20 tracheostomies per day). Now things are slowly getting back to normal.

    I am very proud of my colleagues who stood in the frontline, and I am terribly sorry for those who lost their lives to COVID. This has been such an unusual time; it seems it will continue for a while. I hope we get back to our normalcy soon and to our mission to save lives with transplants, and at that time, I’m sure I will be telling my patients, “I know it’s painful because I’ve been there.”

  • Growing the Pipeline of Future Transplant Surgeons

    Dageforde Photo JPGLeigh Anne Dageforde, MD, MPH
    Massachusetts General Hospital

    Transplant Surgery is an amazing field so let’s get students and residents involved early!

    From my perspective, transplant surgeons have one of the most exciting careers in medicine. We have a unique role in turning the devastating experience of death into a life-giving opportunity for multiple patients. Our practices are a combination of time spent in the clinic and the operating room. We do day surgeries and large complex operations. Our patients require equal parts medical knowledge and surgical skill. Some of our patients are rescued from the brink of death after lingering in the MICU with a high MELD awaiting their liver transplant. Others come from home for their preemptive living donor kidney transplant. We treat patients of all ages with diverse social situations and backgrounds. Our role in the field can be customized by organ-type and interest. Many of us follow our patients for years building lasting relationships with them and their families reminiscent of a relationship with a primary care physician. Transplant research is novel and cutting edge, and more work needs to be done. What a great field!

    If all this is true, then why is the demand for an abdominal organ transplant fellowship so low?

    Transplant surgery is one of the least competitive fellowships for US trained general surgery residents, and the number of applications for transplant surgery fellowship has been decreasing in recent years 1,2. The reasons for this are felt to be multifactorial. Fewer students rotate on transplant surgery with the new curriculums mixing clinical care with educational lectures, and some students may not even be at a center with transplant surgery.   Also, students can now match directly into surgical subspecialty residencies thus bypassing the opportunity to “recruit” general surgery residents to the field. Some general surgery residency programs see the “service-education” balance fall too heavily towards service and have reduced the resident time on transplant rotations. NPs and PAs are utilized to organize the complex care required of transplant patients both in- and out-patient.  For trainees there are work-life balance concerns 3 as well as questions about available jobs after training 4. Innovations in transplant surgery such as normothermic perfusion and organ procurement centers may improve the transplant operative schedule and address surgeon burnout 5. Still, it should be a priority of us as transplant surgeons to recruit highly qualified, excellent future surgeons to be our partners and eventual replacements!

    To recruit an ongoing stream of future transplant surgeons, Dorry Segev, MD, PhD and Jean Emond, MD organized the ASTS Pipeline Taskforce. Our Taskforce is working to reach students and residents very early in their career to improve their exposure to transplantation. We have developed the Pipeline Award to recognize surgeons committed to sharing their love of the field and are conducting research to better understand career choices by general surgery residents. We are partnering with the Behind the Knife podcast to provide listeners with pertinent clinical information about solid organ transplantation. Listeners also have the opportunity to hear 13 diverse transplant surgeons share about both their career and life outside the hospital.

    Behind The Knife/ASTS Podcast Series

    Access the Podcast at: http://behindtheknife.libsyn.com/. The BTK/ASTS Miniseries was published in October 2019, but the podcasts are still available. Please promote among students and residents by encouraging them to listen to high-yield transplant information for the ABSITE and Boards.

    Behind The Knife/ASTS Podcast Miniseries Session Guide


    Session 1

    We explore a vascular access case and the pre-transplant evaluation for both liver and kidney transplant. We also explore the most common indications for transplantation.

    Dr. Arika Hoffman, a kidney transplant and vascular access surgeon, talks about her practice at University of Nebraska medical center. She also shares about balancing life with her kids with her busy clinical schedule.

    Dr. Vincent Casingal is Chief of the Division of Abdominal Transplant and the surgical director of the kidney transplant program at Atrium Health’s Carolinas Medical Center in Charlotte, North Carolina. He talks about life as a transplant surgeon without a transplant fellow.

    Session 2
    In this session we explore what to look for when patients are called in for the liver or kidney transplant operation. The induction immunosuppression medications and their mechanisms of action are discussed.

    Dr. Joshua Mezrich, transplant surgeon at the University of Wisconsin Hospital and author of recently published book, When Death Becomes Life, shares about memorable patients and what drew him to transplant surgery.

    Dr. Majella Doyle is a Professor of Surgery at Washington University in St. Louis where her practice includes pediatric liver transplant surgery, adult liver/pancreas/kidney transplants, HPB surgery, and living donor nephrectomies.  She was born and trained in Ireland and discusses advice for young residents interested in a career in transplant surgery.

    Session 3
    This session highlights some of the most common post-transplant complications that residents and students caring for liver and kidney transplant patients may encounter.

    Dr. Lisa McElroy just completed her fellowship at University of Michigan Summer 2019 and is now on faculty at Duke. She discusses finding a job and the transition from fellowship to practice.

    Dr. Adeel Khan had a circuitous route to his current position at Washington University in St. Louis due to visa issues.  He gives advice to others interested in transplant surgery who may also encounter difficulty with their visas. He is busy building his robotic HPB practice in addition to his job as a multi-organ transplant surgeon.

    Session 4
    Session 4 examines long-term outcomes after transplant and immunosuppression medications. Also, we discuss post-transplant complications including infection, PTLD and rejection.

    Dr. Satish Nadig works at the Medical Un South Carolina and is an NIH funded basic science researcher who shares his advice for future transplant surgeons.

    Dr.Daniela Ladner is an Associate Professor of Surgery at Northwestern University where she Director of the Northwestern University Transplant Outcomes Research Collaborative. She is an R01 funded health services researcher.

    Session 5
    This unique episode discusses organ donation – both living and deceased donors.

    Dr. Robert Montgomery is the director of the NYU Langone Transplant Center. He was a recipient of an HCV+ heart transplant and discusses his own experience as a patient and the research opportunities for future transplant surgeons.

    Dr. Charles Rickert is a PGY-4 general surgery resident at MGH. He is currently applying for solid organ transplant fellowships after having completed his research time studying immunology and zenotransplant. He was a non-designated altruistic living kidney donor during medical school.

    Session 6
    In this transplant “Grab Bag” session we talk with transplant surgeons about the intersection of transplant and global/international surgery as well as transplant surgery and medical student/resident education. We also hear about multivisceral organ transplant and uterine transplant.

    Dr. Jeffrey Punch at University of Michigan started the living donor kidney transplant program in Ethiopia.

    Dr. Peter Liou is a resident at Columbia where he is pursuing a career in multivisceral organ transplantation.

    Dr. Liza Johannesson at Baylor in Dallas, Texas shares about her experiences as a Uterine transplant surgeon.

    ASTS Pipeline Taskforce members:
    Dorry Segev, MD, PhD; Kelly Collins, MD; Leigh Anne Dageforde, MD, MPH; Mike Englesbe, MD; Jacqueline Garonzik Wang, MD, PhD; Jaime Glorioso, MD; Cutler Quillin, MD; Amit Tevar, MD; Anthony Watkins, MD

    References

    1. Quillin RC, Cortez A, Bongu A, et al. The Transplant Surgery Pipeline. ASTS Winter Symposium. https://onlinelibrary-wiley-com.ezp-prod1.hul.harvard.edu/doi/epdf/10.1111/ajt.14572.

    2. Schlottmann F, Gerber DA, Patti MG. International medical graduates and unfilled positions in abdominal transplant surgery fellowships in the United States. Transpl Int. 2018;31(5):566-567. doi:10.1111/tri.13120.

    3. Balch CM, Shanafelt TD, Sloan JA, Satele DV, Freischlag JA. Distress and career satisfaction among 14 surgical specialties, comparing academic and private practice settings. Ann Surg. 2011;254(4):558-568. doi:10.1097/SLA.0b013e318230097e.

    4. Reich DJ, Magee JC, Gifford K, et al. Transplant surgery fellow perceptions about training and the ensuing job market-are the right number of surgeons being trained? Am J Transplant. 2011;11(2):253-260. doi:10.1111/j.1600-6143.2010.03308.x.

    5. Lindemann J, Dageforde LA, Brockmeier D, et al. Organ procurement center allows for daytime liver transplantation with less resource utilization: May address burnout, pipeline, and safety for field of transplantation. Am J Transplant. 2018;11(4):1109. doi:10.1111/ajt.15129.

    Go comment!
  • The Value of Upper Extremity, Face, and Uterus Transplantation: A Workshop with the Leading Programs in the U.S. and Funding Institutions

    Andreas TzakisAndreas Tzakis, MD
    Cleveland Clinic

    ASTS, in collaboration with AST, the American Society for Reproductive Medicine (ASRM), and the American Society for Reconstructive Transplantation (ASRT), is organizing a workshop on face, hand, and uterus transplants to take place at the Uniformed Services University on November 8, 2019. Invited are leaders of private and public funding and regulatory organizations. Presentations will be made by the leading active programs in the United States.

    This workshop is a continuum of a symposium convened in Baltimore in 2017. It aims to update our guests on the current state of VCA. Indeed, significant progress has been made since then toward:

    • Establishing the indications
    • Standardizing the procedures
    • Quantifying and presenting the results using common functional dashboards
    • Accumulating more data on cost benefit analysis
    • Collaborating with third party payers to develop reimbursement plans

    VCAs differ in regard to the clinical problems they address, the organs transplanted, and the qualifications and background of the caregivers. Face and hand transplants have a longer history and slow buildup of the experience. Possible candidates nationwide are numbered in the hundreds. Uterus is the most recent. Experience is building more rapidly, and possible candidates are numbered in the thousands.

    Although spotty, coverage of the medical cost has been provided for exceptional cases. These include military service-related injuries as well as with Local Coverage Determinations (LCDs). In general, reimbursement has been an extremely difficult problem.

    One serious obstacle has been the small number of clinical cases performed. Historically, data is sparse and not standardized. Collaboration among centers is highly desirable.

    Abdominal wall transplants, although VCAs, will not be discussed in this workshop because they have been packaged with intestinal or multivisceral transplants.

    The latest addition, uterus transplants, are also very different. They have been segregated from VCAs and are now included with the other solid organs.

    Indeed, the uterus is a solid organ rather than a composite tissue graft. Whereas transplant surgeons play a consulting role in VCAs, in uterus transplants transplant surgeons and gynecologists play a vital role in the development and performance of these procedures.

    The active clinical programs (Baylor Hospital, University of Pennsylvania, and Cleveland Clinic) already share clinical information through regular meetings and conference calls. They have agreed to form a consortium. Sharing will include a database and tissue repositories in order to expedite learning and research as well as training of new staff.

    Pursuing Current Procedural Terminology (CPT) codes for VCAs to enable tracking has been a priority but is a very elaborate process. It has now been reinvigorated thanks to the personal interest of ASTS President Dr. Lloyd Ratner.

    We hope that this workshop will bring face, hand, and uterus transplants closer to acceptance in clinical practice.

    Uterus Transplant: A personal perspective on the occasion of the International State of the Art International meeting in Cleveland (September 6-7, 2019)

    The 2nd Congress of the International Society of Uterus Transplantation is planned to take place in Cleveland on September 6th and 7th, 2019. More than 100 participants are expected to attend. More than 50 uterus transplants and more than 15 babies born as a result worldwide. Lively and informative discussions are eagerly expected.

    My introduction to uterus transplants started when I was a junior staff surgeon at the University of Pittsburgh. A novelist approached me at the direction of Dr T. E. Starzl; his heroine, a renowned transplant surgeon, had to perform a uterus transplant. He did not disclose the plot. The question was: how would she do it?

    I went to my anatomy books and conceived the operation for him. The book was published successfully. I was included in the credits and did not give it a second thought for several years.

    Then, a young woman in her 20’s presented to me at the University of Miami in need of a multivisceral transplant, a transplant which would include all abdominal organs. She had a prior hysterectomy and no children. Would it not be nice to restore everything back to normal?

    A seminal event had just occurred in my own life and made me sensitive: my wife gave birth to our daughter… I will never forget the day our daughter was born. It was a pivotal event, the happiest day of my life, and had an everlasting effect!

    Indeed, I don’t know anything more valuable to my wife and I than our daughter. The thought of adding a uterus to my patient’s multivisceral transplant was insistent. Prudence prevailed and I abandoned the thought for this particular patient. It would be too much risk for an unknown procedure. But what about doing a uterus transplant for patients who could not have children because of lack of a functioning uterus?

    I had to study it.

    Having resolved the anatomical considerations, at least in theory, I had to study the immunology of the uterus, particularly because of its role in the tolerance of the offspring by the mother.

    There were 3 volunteers on the team, eager to participate in the studies: Werviston (Tom) DeFaria, Akin Tekin, and Takis Tryfonopoulos, all surgeons with passion for research. We obtained mini swines, which Dr. David Sachs was kind enough to provide. We designed a heterotopic variant of the operation in order to study the uterus, rejection, its treatment, and the longevity of the graft. The feasibility, at least in animals, was demonstrated.

    By good fortune, while working on the mini swine model, I received an Honorary Degree from the University of Gothenburg in Sweden, home of my good friend Michael Olausson and also Mats Brannstrom, the Chairman of Gynecology who was working diligently with his team, including Michael, on uterus transplants. They were ahead of us!

    It was the beginning of a collaboration that took us to Nairobi, Kenya, and Homestead, Florida, for experiments on primates and then to Gothenburg for the first clinical trial at the Sahlgrenska University Hospital.

    This was a great inspiration, particularly because at that time I was relocating to the Cleveland Clinic, an institution with an excellent record in transplant research and an exceptionally good gynecological program led by Dr. Tommaso Falcone.

    Dr. Falcone expressed some skepticism in the beginning. It took a visit to Gothenburg and meeting the recipients of the transplants to persuade him. It was clear that this was an operation that these women really wanted in their quest to have their own children. Once persuaded, Falcone and his team were perfect partners.

    Contrary to most other programs, our preference for these transplants has been that they should be performed with uteri from deceased donors in order to avoid any risk to a living donor.

    We performed our first uterus transplant on February 24, 2016. It was the first attempt in the U.S., which unfortunately failed due to a fungal infection which caused a rupture of one of the arterial anastomoses.

    As a result, there was a very elaborate review of our trial.

    In the meantime, the excellent team at Baylor Hospital in Dallas, Texas, led by Drs. Testa and Klintmalm, with the assistance of Drs. Michael Olausson and Liza Johannesson of the Gothenburg team, performed the first successful uterus transplants in the U.S., which resulted in the births of 2 healthy babies. These were the first babies in the U.S. born from transplanted uteruses.

    We resumed our program as soon as all necessary precautions were taken to avoid another infection. We have now performed an additional 6 transplants, 5 of them successful. One of them resulted in the delivery of a beautiful, healthy baby this July.

    That baby was the first born from a deceased donor in the U.S. and second in the world, confirming the efficacy of this approach.

    Uterus transplantation is evolving rapidly, even in today’s heavily regulated environment. We hope it will be a valuable option to the many women who cannot have children simply because one non-vital part of their body is missing.

    Go comment!