Politics a Strange Bedfellow in World of Liver Transplants

‘Sharp was a pioneering effort by one of the great surgeons of the world and would have succeeded if there had not been highly orchestrated criticism.’

Dr. Thomas Starzl

Liver transplant surgeon

Almost 2 1/2 years after top UC San Diego Medical Center officials helped scuttle an ambitious liver transplant program at Sharp Memorial Hospital, they now plan to start a similar program this spring.

Some university officials, including the dean of the medical school, insist that their program is being undertaken correctly at a major university teaching center, whereas the Sharp program was too ambitious for a community hospital. Five of six patients who underwent liver transplants at Sharp in late 1983 and early 1984 subsequently died.

But other physicians familiar with both programs, including the University of Pittsburgh surgeon who pioneered such transplants, say that criticism of Sharp was based more on medical politics than on technical shortcomings.

They say that deaths unfortunately occur as an institution begins using complicated new medical procedures. If the Sharp program had initially chosen patients with fewer medical complications, and had it been given institutional and community support at the outset--instead of a barrage of criticism--San Diego would have an ongoing liver transplant program today and many people with terminal liver illnesses could have been saved, these doctors assert.

For the first time since the Sharp program’s demise, those involved in the liver transplant controversy spoke at length about such programs in San Diego, providing a rare glimpse into the clash of powerful medical institutions--and the egos of top doctors.

The Sharp program was headed by Dr. Marshall J. Orloff, himself a UCSD professor of surgery, who built the medical school’s department of surgery during 14 years as its first chairman, and who is a world-recognized expert on liver diseases.

But Orloff, a controversial figure in university politics for many years, had been turned down by UCSD medical administrators when he proposed setting up the transplant program at the medical center in 1983.

The issue of whether San Diego could have had an ongoing program for the last 2 1/2 years revolves around the reasons for the rejection of Orloff’s proposal by UCSD in 1983 and whether he was subjected to unfair scrutiny at Sharp before his program had a chance to prove itself.

“Dr. Orloff doesn’t have the luxury of fighting the battle (with UCSD administrators) again, but he should have the reward of obtaining dignity about what happened in the past,” said Dr. Thomas Starzl, the University of Pittsburgh surgical professor who first performed liver transplants a quarter-century ago. Starzl has trained practically every surgeon doing such transplants nationwide, including Orloff, the head of UCLA’s department, and the young surgeon, Dr. Oscar Bronsther, who will head up the UCSD program.

“Everyone wants desperately for the UCSD program to succeed,” Starzl said. “But it is wrong for anyone to make invidious comparisons with Sharp. Sharp was a pioneering effort by one of the great surgeons of the world and would have succeeded if there had not been highly orchestrated criticism at the time.”

The dean of UCSD’s medical school agrees that public outcry led by UCSD was a key factor in the program’s demise but defends the harsh criticism of Sharp’s poor survival rate as justified.

“I kept my mouth shut about their (Sharp) knocking people off until 5 out of 6 had died,” Dr. Robert G. Petersdorf said in an interview. “I was the only one who had the guts first to come out and say something. My comments effectively stopped the program. I did not tell them to stop it, but when an individual of my stature and seniority spoke out, people listened.”

Petersdorf said he went public only because Orloff was a UCSD professor on leave while undertaking the Sharp program. “I felt, as his dean, the school was being involved by virtue of the man doing the transplants,” Petersdorf said.

Liver transplants are among the most difficult of all surgical procedures, often requiring 12 hours or longer for surgeons to remove the diseased liver and replace it with a properly sized, functioning liver from an appropriate donor. Doctors often have as difficult a time locating a donor as actually performing the operation. Until the introduction of recent drugs into the procedure, the recipient’s body often rejected the new organ, and even today rejection can still present problems.

Candidates for liver transplants all have terminal diseases that cannot be treated in any other way than replacing their diseased organs with new livers.

Nationwide, an estimated 30 people per million require liver transplants each year, translating into about 5,000 operations per year. The operation is no longer considered experimental, although it still involves high risks and an often excruciating wait by the potential recipient for a suitable donor.

The origins of liver transplantation in San Diego can be traced to Orloff’s resignation as chairman of the surgical department in 1981 to speed his recovery from heart surgery. Orloff then decided to pursue the idea of liver transplants--at the time done only at Pittsburgh and three other academic medical centers in the eastern United States.

“I had spent 33 years in liver research and felt that I could spend the rest of my life making a real contribution to mankind by doing this,” Orloff said in an interview last week, his first since the Sharp experience.

After many years of frustration, Starzl--a longtime acquaintance and sometimes competitor of Orloff--had begun improving his survival rate of patients, in good part because a new drug, cyclosporine, had become available. The drug helps prevent the body of a transplant recipient from rejecting the new, foreign organ.

In 1983, Orloff became one of only four American researchers (along with Starzl) at the time given permission by federal authorities to use the drug experimentally. As a result, Orloff continued his studies by traveling to Pittsburgh six times, spending several weeks at a time, to perfect the surgical techniques under Starzl.

“I was not a kid starting out,” Orloff said. “I knew the liver as well as anyone. Dr. Starzl was kind enough to put at my disposal the accumulated knowledge of the world’s premier transplant center.”

After participating in a large number of liver transplants--and two pancreas transplants--Orloff returned to San Diego and in the spring of 1983 proposed creation of a program at UCSD Medical Center. Orloff found enthusiasm from department chiefs at the medical school as well as from the school’s human investigations committee, a federally required review body that must approve all medical research planned for human subjects.

But Orloff said that the school’s administration “threw up one obstacle after another, much to my surprise.” Even a direct appeal by Starzl to Petersdorf failed.

“Starzl should be ashamed of himself, coming out here and telling us what we should have done,” Petersdorf said last week of the effort.

The reasons for rejecting Orloff’s request are not entirely clear, even three years after it was made. Orloff said the university cited the high costs of running a liver transplant program. Petersdorf today says only that a variety of reasons existed, refusing to elaborate on what he calls “ancient history,” but insisting that he was willing to consider the idea again within a year.

A prominent former UCSD physician said that Petersdorf and the new surgical department chairman, Dr. A.R. Moossa, could not tolerate the idea of Orloff--a powerful personality--running what would become the future wave of surgery.

“That would have been intolerable to Moossa and to Petersdorf, who had picked Moossa as the new chairman,” said the doctor, who asked not to be named. “They had to turn Orloff down.”

At the time, Moossa also voiced strident criticism of Orloff after Orloff took his transplant proposal to Sharp, saying that the program had moved too fast.

Moossa told a reporter last week, “Don’t rub it in!” when asked about the fact that Orloff remains a full professor of surgery at UCSD. Moossa privately denigrates Orloff’s technical skills to colleagues and reporters and has given Orloff no input into the planned UCSD program--despite Orloff’s continuing liver research funded by federal health grants and his expressed willingness to help out.

“I was against the way the liver transplant program was being prepared, without me as the new chairman knowing all the facts and background,” Moossa said, “not the program per se, but the fact it was being planned and rushed by Dr. Orloff.”

In fact, Moossa shortly thereafter began putting into effect plans for doing transplants at UCSD that will bear fruit this spring.

After being turned down, Orloff found that Sharp and Children’s hospitals together would be willing to take on the program. An announcement was made in August, 1983.

The Sharp program ran into rough waters soon after it started Oct. 31, 1983. In a three-month period, all but one of the six patients died. The sixth and surviving patient, a little girl from Nevada, marked her second anniversary with a new liver this month and is doing well, Orloff said.

“As soon as the first transplant was done, Moossa, Petersdorf, all started criticizing me,” Orloff said. “But I was convinced I was right. I could not have prepared more carefully under Starzl.”

Petersdorf said that, in contrast to the months of training that the new UCSD surgeons have taken from Starzl, Orloff “was in Pittsburgh for only three weeks and never did a liver transplant on a human.”

When told that Orloff had indeed done human transplants at Pittsburgh over a period of several months, Petersdorf dismissed the discrepancy, saying, “I don’t care if he did 100, the fact is, he did very poorly with his program (at Sharp).”

A top Sharp official said, “Look, the dean meant to bag Orloff and wounded Sharp in the process.”

The official, who asked not to be named, said, “Petersdorf’s comments did cause a lot of ruckus and he may think they alone killed the program, but the final crunch came with the Medi-Cal regulations (in May, 1984).”

In August, 1983, when the program was announced, there was immediate criticism that such a complicated undertaking should not be done outside a university medical center. That argument is still made today by Petersdorf and Moossa and such a requirement is part of the Medi-Cal regulations governing state insurance payments for the costly (often six figures) operation. At the time of Sharp’s program, Medi-Cal paid on a case-by-case basis.

But, the Sharp official said, medical officials from UCSD, UC San Francisco, Stanford and other academic centers lobbied heavily with state Medi-Cal officials to require that liver transplants be done at an academic medical center in order to qualify for state reimbursement.

“That essentially caused us to ask, ‘How can we (get patients) without Medi-Cal?’ ” he said. Sharp’s board of directors suspended the program shortly thereafter.

Dr. Glen Cayler, a Sacramento consultant to the state Department of Health Services, said that Sharp was rejected for Medi-Cal because, basically, “it was too much of a community hospital and not enough of an academic research center.”

“It is a most self-serving kind of statement,” Orloff said. “If you look at the history of transplantation, kidney transplants began at a private hospital, the Cleveland Clinic. Heart transplants in San Diego are being done at Sharp, not at UCSD. In fact, the head of the Sharp program is also the head of cardiac surgery at UCSD.

“Sharp physicians are excellent in all fields, and its care system is the equal to any hospital in the city. There is no question that Sharp could have a liver transplant program equal to that anywhere.”

Meanwhile, Starzl, who had helped train several of Orloff’s team of surgeons and nurses at Sharp, returned to San Diego after the suspension and did a post-mortem of the program, at Sharp’s request.

“I really had no hard criticism of Sharp other than that Dr. Orloff was not shrewd in his patient selection,” Starzl said, explaining that Orloff took liver patients who had other complications as well and were older than the average transplant recipient.

“Difficult cases exhaust personnel and diminish the reservoir of good will in the community,” said Starzl, adding that such good will hardly existed in the first place. “If Orloff had been more political, Sharp would be a great liver transplant center today.

“But Orloff had such powerful moral guidelines and the fact that he operated on that principle, I’m quite proud of him. Yet, he almost emerged as some sort of public monster.”

A UCSD physician sympathetic to Orloff said, “You don’t start out such a program by picking people who not only are sick with liver disease but who have other major, serious problems as well.”

“Orloff was under intense scrutiny and had he been able to do three or four more operations, things might have calmed down and he would have been successful,” said the surgeon, who asked not to be identified for fear of incurring Moossa’s wrath.

The current head of Sharp’s trauma center was a surgeon with Orloff during the liver program. “Unfortunately, the box score fed a very critical atmosphere already existing,” Dr. Barry Knotts said. “I think that if Sharp was not prepared, it was in the sense of not realizing what scrutiny and criticism it would face.

“The board of directors needed to understand what several deaths in a new program mean.”

The Pittsburgh-trained director of UCLA’s program, Dr. Ronald Busuttil, said “a program is doomed to failure if you pick cases that will make your initial success rate low.”

Nevertheless, Starzl said that despite Orloff’s willingness to operate on “worst-case” patients, his initial death rate was little different from those at other institutions that picked their first patients more carefully. (In the last two years, the overall death rate has declined everywhere, as the operations become more common.)

Starzl said he lost his first several patients, and that UCLA, which began its program soon after Orloff started at Sharp, lost six of its first nine. “Yet UCLA had institutional and public support and wasn’t subjected to the intense spotlight, so it went forward and is well-respected today,” Starzl said.

Orloff today professes no regrets over the high-risk patients he chose. “I went to bed at night being able to live with myself, knowing I was right, and still do,” he said.

Orloff since has returned to UCSD as a professor of surgery, where he continues to teach students and conduct research. He has published several articles on liver and pancreatic diseases in the last year.

“I am not interested in retribution,” Orloff said. “I want to make it very clear that I hope the new program succeeds.”

Orloff said he would be happy to provide advice to Bronsther and the new team of surgeons recruited by Moossa but has not been asked to do so. Orloff declined to comment on Moossa despite the new chairman’s comments about him.

Moossa, trying little to conceal his continued enmity for Orloff, said, “Orloff is a senior professor who tried three years ago, and now we have a young, different team emphasizing modernity and youth. Let people read between the lines.”