Surgical Revival
A high-profile death caused a slump in the once-booming levels of live donor liver transplants, but Dr. Giuliano Testa is helping restore faith in the procedure
By Caleb Hannan
Holding his surgical knife like a paintbrush, Dr. Giuliano Testa stood over a man in his early-50s lying unconscious on the stainless steel operating table, his abdomen glistening orange from the sterilized disinfectant. Testa’s first incision arced just below the rib cage in the shape of a frown. Another vertical cut completed the "Mercedes incision,” named for its resemblance to the German car-maker's iconic hood ornament.
Tall and raven-haired, Testa used the searing heat of an electric knife to cut through muscle, ignoring the smoke and accompanying smell of burning flesh, until he’d exposed his target: the plump, reddish-brown mass of the man's liver. The smooth, healthy look of the organ was a welcome, if unsurprising, site. There was nothing wrong with the man’s liver, a good sign considering Testa was about to remove more than half of it to save another life.
Testa had spent the past year at the University Hospital in Essen, Germany, studying the relatively new procedure known as live-donor liver transplantation (LDLT). He'd scrubbed in and assisted on a few operations here and some during his time as a surgical resident at the University of Chicago's Medical Center. But today, on a hot July morning in 1999, Testa was operating for the first time as lead surgeon.
In an adjoining room lay the patient's younger sister, being opened in a similar fashion by one of Testa’s colleagues. Her liver was shriveled and lumpy, the remainder of an organ ravaged by cirrhosis and cancerous tumors. Without the operation, Testa wasn’t sure she’d live to see Christmas.
Testa reached into the man's abdomen with both hands and pulled out the three pound right lobe, a feeling he described as similar to holding a baby. Moving it into the next room in his hands, Testa fit the lobe into the space previously occupied by the sister’s diseased organ, reattached the veins and bile duct, and stitched her close.
After eight-hours of surgery, Testa was left exhausted and thrilled. At age 37, he thought himself to be youngest of a small and prestigious group of surgeons who had performed adult-to-adult LDLT. The successful operation represented the culmination of eight years of training that had brought him from his native Italy to Chicago to Dallas to Germany.
He left the hospital that night excited by the possibilities, both for him and the procedure. “At the time I really thought it was the beginning of a revolution in transplant surgery,” says Testa. “I was an actor in something that was changing the world.” For Testa and LDLT, everything seemed to be coming together.
Today, the revolution Testa spoke of is in the midst of a painful transition. Now back in Chicago as the director of the liver transplant team at the University of Chicago Medical Center, Testa has been witness to every stage of LDLT’s American odyssey. He’s watched its meteoric rise flame out thanks to one spectacular death and the fallout that ensued. As LDLT becomes increasingly rare, Testa plays the role not only of surgeon, but as ambassador for a controversial procedure at its lowest point.
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The liver is the largest gland in the human body and the second largest organ (after the skin). It’s responsible for producing bile to digest fat and enzymes to detoxify the blood. When the regular function of a liver is threatened – by hepatitis, cirrhosis, or a congenital disorder – transplants become the final safety net for ailing patients.
The first LDLT in the United States was performed at the University of Chicago (U of C) in November 1989. Surgeons transplanted a portion of liver from a Texas fourth-grade teacher into her 21-month-old daughter suffering from biliary atresia, the primary cause of pediatric liver failure. Last year, with her mother looking on, the young recipient graduated high school. The success of the operation and the more than 1,000 that have followed have helped contribute to a pediatric mortality rate close to zero.
Liver function is relative to the size of the recipient, so only 20 percent of the liver, from the donor's smaller left lobe, is required for a child. For an adult-to-adult LDLT, 60-75 percent of the liver is removed via the right lobe. The recipient receives the bigger half because a dissected liver loses some of its functionality.
"I prefer using the word harvest, instead of remove," Testa says, "because the liver is just like the crops in the field; when we harvest them they end up growing back."
With 17,000 Americans on the waiting list and less than half receiving a healthy transplant, the demand for livers vastly outnumbers the supply. In large part, the disparity is due to an epidemic of Hepatitis C which began during the formative years of the baby-boomer generation. "There's about a 20 to 25 year lifetime before the Hepatitis C will start a failure of the liver," says Dr. Enrico Benedetti, chief of transplant surgery at the University of Illinois Medical Center. "[The epidemic began] in the '50s, ’60s, and ’70s, which means that in the late ’90s we had the peak." As a result of this epidemic and the lack of deceased livers, about one in five American dies waiting for a transplant.
