In the nation's first liver transplant from a living donor, surgeons at the University of Chicago Medical Center on Monday removed a section of the organ from an elementary school teacher from Texas and transplanted it into her 21-month-old daughter.
Dr. Peter F. Whitington, director of the university's pediatric liver transplant program, said physicians would not know until today if the tissue taken from Teresa A. Smith's liver was "functioning" in the body of her daughter, Alyssa. The child was in "critical but stable" condition at the conclusion of about eight hours of surgery.
The mother's spleen, an important circulatory and immune system organ, ruptured while liver tissue was being taken and had to be removed. She was also in "critical, but stable" condition. Without a spleen, she will be at increased risk of suffering serious bacterial infections for the rest of her life, but she is expected to make a full recovery.
The liver is a complex organ that performs dozens of vital functions such as detoxifying potentially harmful substances and processing sugar, proteins, fats and bile.
Transplanting livers from live donors, which has been performed several times in other countries, is likely to spark controversy in the United States because it requires that the potential risks to a parent or other family member, including major complications or death, be balanced against the potential benefits to a young child, who might die if a dead liver donor could not be found.
Surgeons and medical ethicists emphasized that the risks to the donor from the experimental surgery were substantially greater than those of donating a kidney or bone marrow, which are common medical procedures. "There is a quantum difference (in difficulty)," said Dr. Ronald W. Busuttil, the chief liver transplant surgeon at the UCLA Medical Center.
In addition, unlike kidney and bone marrow transplants, there is a dearth of medical evidence that liver tissue from a related donor is more likely to function in the long term than tissue harvested from a cadaver.
The potential risks of the surgery were underscored by the rupture of the mother's spleen.
"We certainly didn't expect a problem with the spleen," Whitington told reporters " . . . I don't believe this was a matter of nerves or jitters. This sometimes happens." The fragile organ is next to the left lobe of the liver, which was the section of liver removed from the mother.
The parents, who live in Schertz, Tex., near San Antonio, were not available for comment. But the mother said in an interview Oct. 25, made available by medical center officials, that she and her husband "both felt comfortable with the idea of donating. It was an obvious decision for me. Once you've given someone a big piece of your heart, it's easy to throw in a little bit of liver."
The groundwork for the pioneering surgery was established through a series of recent articles in medical journals and widespread discussions at the medical center. University surgeons and ethicists have argued that the shortage of organs from cadavers justifies offering the option of liver donation to parents. To safeguard prospective donors, they established a detailed medical, ethical and psychiatric review process.
Similar surgery has been performed in Brazil in December, 1988, in Australia in August and in Japan earlier this month.
While some liver transplants physicians and ethicists gave the University of Chicago program a cautious endorsement, others questioned whether it was possible to obtain "informed consent" for the procedure.
"The major ethical dilemma is whether the critical organ shortage justifies the risk to the mother," said Dr. John Lake, the medical director of the liver transplant program at UC San Francisco. This "is a true ethical dilemma that is unresolved in most people's minds.. . . Most programs are going to see what the experience is at the University of Chicago before embarking on this procedure."
Dr. Christoph Broelsch, chief of the liver surgery service at the University of Chicago, has pioneered techniques for using segments of livers from dead donors. This allows the liver to be used for two recipients, such as a child and an adult, or two infants, or to be cut down to fit a smaller recipient.
Broelsch's teams also removes part of the liver from patients to treat liver tumors. In the last 35 such cases at the university, there have been "no major complications," such as serious bleeding or infections, officials said.
After a portion of the liver is removed, the remaining tissue can regenerate. But it is more difficult to remove a segment of the liver from a live donor than from either a tumor patient or a cadaver. This is because the function of the liver that is removed and the part that remains must be carefully maintained.
Alyssa Smith was born with biliary atresia, a lack of development of the bile ducts, which is the most common cause of liver failure in children. Her parents first brought her to the University of Chicago in November, 1988, according to medical center officials.
After a medical evaluation, Alyssa's name was entered on the national waiting list for liver transplants and the family returned to Texas. A potential liver became available in July but it was damaged and could not be used.
In August, Whitington contacted the family to see if they were interested in the living donor program, medical center officials said. The parents, after learning that their insurance company would cover the experimental procedure, agreed to go forward. Both parents were evaluated, but the mother was selected based on "size" considerations.
The surgery was performed while the child was "pretty healthy," Whitington said. This was to maximize the chances that the surgery would succeed and to minimize the pressure on the parents to donate.
"I think they are very strong people and I admire them for their willingness to step forward first," Whitington said Monday.
From 25% and 50% of infants needing liver transplants die while awaiting the procedure, according to some estimates. But other medical experts said these figures were overstated.
UCLA's Busuttil said the comparable figure at UCLA, one of the busiest pediatric liver transplant centers in the world, was about 10%. "If I had a small child that needed a liver desperately, I would be able to find a (larger) donor and would cut down that liver before I would consider taking a segment of a relative's liver and putting it into the child."
The policy at the University of Pittsburgh, the busiest pediatric liver transplant center, is not to perform liver transplants using live donors because of concerns about the risks to the donors, said Dr. Joel Frader, a pediatrician and medical ethicist at the medical center.
As of Monday, 727 Americans were on waiting lists for liver transplants, including 138 children age 5 or younger, according to the United Network for Organ Sharing in Richmond, Va. In 1988, 1,680 liver transplants were performed in the United States. The average wait for the transplant was about two months.
Steinbrook reported from Los Angeles and Shryer from Chicago.
LIVER TRANSPLANT FROM A LIVING DONOR
Surgeons at the University of Chicago on Monday removed the left lobe of the liver from Teresa Smith, 29, of Schertz, Tex., so that it could be transplanted into her 19-month-old daughter, Alyssa. Alyssa has biliary atresia, a severe and usually fatal childhood liver disease. The surgeons also had to remove the mother's spleen, which ruptured during the surgery.