Judith Lattin's life had become a very dark landscape. What she thought was a simple case of stress-induced intestinal trouble in her 20s had been the beginning of the end of her liver. At 48, she sat stunned in a doctor's office listening to the news that an autoimmune disease had scarred that all-important organ beyond recovery.
For the nine years that followed, Lattin fought the consequences of liver failure, enduring procedures to control a bleeding esophagus, an enlarged spleen and major vein blockages. In one unnerving incident, she became completely disoriented and confused, unable to get up and walk to her bedroom door. Her life became an unpleasant regimen of medications, with uncomfortable side effects, that could not always control or compensate for her condition. Once a trusted accounting professional, Lattin found her world contracting to a distressing equation: She was not sick enough to be high on the list for a transplant, but she was sick enough to be told she should live very close to the hospital where her doctors practiced. Then came the day, almost eight years into her wait, when those doctors told her that the complications of her liver disease made them uncomfortable with a transplant—that they thought she wouldn't survive it. But she did have one more option, they said.
They recommended she go to Stanford Hospital & Clinics to meet with its liver transplant team. It was a group of expert and experienced surgeons whose training originated with Thomas Starzl, the American physician who pioneered successful liver transplantation. For Lattin, that changed everything. At her first meeting with Stanford's chief of clinical transplantation, Waldo Concepcion, "He said, 'Yes,' they could do it, and there was hope. I saw light at the end of the tunnel again," Lattin said. "When you've been told that surgery is not an option for you, that's basically a death sentence. It can be a very uncomfortable death. I had seen that as inevitable for me."
A different kind of donation
Stanford was also willing to do something else that many others would or could not: use a piece of Lattin's sister's liver as a transplant. Instead of having to wait on the list for a deceased donor liver, Lattin could get that life-saving transplant as soon as Stanford's team approved the donation from Lattin's sister, Christine Webb. She was nine years younger and in good health, a strong candidate for the procedure. But Lattin wasn't so sure it was a good idea.
"She has three children, and a husband, and I just felt it was too dangerous," Lattin said. She was not unjustified in her fear; the history of liver transplantation from a living donor was not without incident. The drive to make it work, however, grew from the continuing challenge shared by all forms of organ transplant: more people in need than organs to give. Campaigns to raise awareness are a common occurrence, yet the number of available deceased donor livers has been stable at about 6,000 each year for the last decade, while the waiting list has climbed steadily, now averaging between 16,000 and 18,000. One in seven die before receiving a new liver. There is no equivalent of kidney dialysis or cardiac-assist devices for the liver.
At about 3 ½ pounds, the liver is the body's largest solid organ by weight. Its functions are crucial. It detoxifies the blood, stores vitamins, breaks down fats and sugars, generates hormones, and, most vital when surgery is involved, it produces the substance that clots blood. And, it is the one organ in the body that responds to loss by expanding to restore its original volume. That remarkable quality is what enables someone to give away as much as 60 percent of a liver without repercussion—if a surgery is done well. For that to happen, surgeons must control bleeding in an organ that's rich with blood vessels and pumping through 1 ½ quarts of blood each minute.
But Christine Webb, told very carefully and frankly about all the possible complications, was not dissuaded. "My sister didn't want me to be in harm's way, but I didn't want her to have to wait. I wanted to help her." Webb had the support of her children and husband. Yet she couldn't convince Lattin, until one night on the phone. "Judy," she said, "you need to stop trying to talk me out of this. This is my purpose in life. This is my reason for being alive, to give you this piece of me." After that, Lattin said, "I just accepted that this was something that she had to do."
Experience and expertise and endurance
Because Lattin and Webb were about the same height and size, such a transplant would not have to leap any great physical disparity. Nor do donated livers have to be a perfect match of tissue—only blood type must match, said Webb's Stanford hepatologist Glen Lutchman, MD.
Stanford put Webb through a tough evaluation, Webb was assigned her own donor advocate and both women were asked to lose weight. "It's a challenging, difficult surgery in a person who is healthy, who doesn't need surgery," said Stanford transplant division chief Carlos Esquivel, MD, PhD. "The risk of life-threatening hemorrhage is ever present, but we do this because there aren't enough organs to go around."
It's experience, however, that distinguishes Stanford's liver transplant team. Only the most senior surgeons are allowed to do this type of operation, Esquivel said. The surgery to remove the diseased liver and the surgery to remove the donor liver portion take place simultaneously, followed by the surgery to connect the transplant. Esquivel, Concepcion and their colleague, C. Andrew Bonham, MD, all worked the sisters' surgery day. Bonham is the youngest of the three and free with his admiration. Esquivel, he said, "has been doing this longer than any other surgeon who's still doing it. He's seen it all and done it all." Said Esquivel, "I cannot say enough about our transplant team, every single one of them is a star."
Concepcion spent hours meticulously clearing out old blood clots from a vein, just half of an inch across, that connects the intestine to the liver. It was that vein that had given Lattin's previous doctors pause. "He said he'd be my roto-router, my plumber," Lattin jokes. It took time, Concepcion said, "but you have to make it work because with a living donor liver, you don't have the veins that come with a deceased donor. You do this with trepidation, but you think of the benefit."
Making it safe and successful
"I have a lot of faith in God," Webb said, "and I also had faith in the Stanford medical team that took care of me. I knew that they were some of the best in the world, and that they don't go into these surgeries lightly at all. I knew they would leave nothing unchecked, so I really trusted them."
The team uses instrumentation and tools to reduce blood loss and it carefully calculates just how much liver to take. Every step has been developed to be protective of the donor and recipient. "We're kind of obsessive-compulsive when it comes to managing these patients," Bonham said, "to reduce the risk of complications."
The living donor procedure emerged in the late 1990s. There have been a small handful of deaths, the most recent in 2010; those deaths, Bonham said, have helped make transplant "the most highly regulated aspect of medicine. We have three to four government agencies we have to answer to." Stanford performs three to five living donor transplants each year and 50 to 60 deceased donor liver transplants each year; its government-reported results place it in the top ranks for safety and survival. In addition to the wisdom gained from doing many procedures, advances in imaging used by Stanford surgeons also have improved safety, said Walid Ayoub, MD, who has been Lattin's pre- and post-transplant hepatologist. With that imaging, "surgeons can see all the vessels ahead of time. They have a road map of the liver that allows them to stay clear of large veins and partition the liver safely."
Lattin was in the hospital for several days. Webb was released after four. Lattin lives carefully, following the rules for her medication, diet and exercise. "It's a matter of being compliant, and, uh, if they need you to take this medicine, and maybe you don't like the taste of it, because it's a liquid or something, too bad. You have to take it." It's a little thing, those rules, given all the other changes in her life. "I have energy to do things," she said. "I have just so much more of a joy for life. I waited nine years for a transplant and I didn't realize just how much I had declined until after transplant when I started to feel so much better, and then I just started to do things."
Webb needed all the three months her Stanford doctors told her she would to make a full recovery. "I don't think of myself as a supreme athlete by any stretch," she said. "I'm just a normal person and I feel like I passed with flying colors. There's not a feeling in the world that is better than when doctors come to you and say, 'You saved two people.' I saved my sister but I also saved the person who will now get the deceased donor liver my sister won't need. It really brings it home when you think about it that way."