An abbreviated history of liver transplantation

摘要

INTRODUCTIONThe birth of the field of liver transplantation (LT) had a difficult gestation. Not putting too fine a point on it, the blood-soaked operating room floors and drained blood banks, weary surgeons after marathon operating sessions with overall poor outcomes in the very first cases led to great skepticism about whether to support further efforts for this procedure. The rationale to press onward despite these early challenges was beautifully summarized by Thomas Starzl in the following quotation: “The mortality from the failed early trials and that which occurred later did not mean that LT was causing deaths. These patients were under a death sentence already because of the diseases that had brought them to us.”1 Indeed, Starzl’s early cases in Denver, CO, were desperate ones, for whom another favorite Starzl quote rang painfully and poignantly true. For a worried Claudius outed by Hamlet as his father’s killer, “Diseases desperate grown By desperate appliance are relieved, Or not at all.”—William Shakespeare Hamlet, Act 4, Scene 3. Desperate diseases, like Hamlet, end-stage liver failure, and hepatocellular carcinoma (HCC) are best healed by desperate measures, or they won’t be cured at all. For Claudius, this meant hatching a plot to get Hamlet out of Denmark and have him killed. And for Starzl, this meant not giving up on LT until it was perfected. LT was indeed born out of necessity and our ability to treat only a few liver diseases, and even then, only when these diseases were recognized early, and therapy was successful. What seems routine now at many centers across the world, achieving better than 90% early survival with only a few long-term maintenance medications necessary (and rarely over time in some, with no ongoing anti-rejection medications at all) was once thought of as a pipedream and not worthy of further government investment or reimbursement by private insurers. To again quote Starzl, “It was all nothing but a kind of a wild science fiction at the beginning, but as realistic as the dream of putting a man on the surface of the moon was at that time. They both did not sound like anything very rational, but they both turned out to work at around the same time.” And here, we are surely aware that the patriarch of LT was not referring to the strange hallucinating dreams that opium smokers in the 1870s experienced from the especially long stems that opium pipes had. Although, come to think of it, some adjuvant was needed for the emotions of all concerned with the patients and their loved ones. What follows is a summary of “how we got there” in short form, as volumes could be and have been written on this subject. LT surgery has transformed care for patients with life-threatening liver diseases and given hope and opportunity to patients transplanted around the world. The creation of a specialty of “Transplant Hepatology” was also one of necessity as there became a need for expertise in managing patients with complications of advanced liver disease, in assisting surgeons in the medical management of complications from the transplant surgery, and afterward in helping manage immunosuppression and recurrent liver disease. The growth of important consultative expertise in anesthesia and critical care medicine for perioperative care drastically improved outcomes, along with the involvement of other specialties of internal medicine including infectious disease, cardiology, hepatopulmonary syndrome specialists, hematologists, and blood banking experts among others. The multidisciplinary nature of best care models for transplantation also grew to include dieticians, social workers, psychiatrists, psychologists, and specialists in addiction medicine. Some of the milestones achieved along the way and their timeline is shown in Table 1. Together we have realized that the miracle that Starzl set out to achieve, transforming the outcomes of this procedure from extraordinary to ordinary in less than half a century, has co