Liver Transplant: Battle Against the Odds

The condition of Patrolman Edward C. Callahan, 36, father of two, was listed as critical even before the famed neurosurgeons at Massachusetts General Hospital had fully assessed the damage to his brain. Callahan had been shot in the head while trying to stop a holdup at a suburban Boston supermarket, and his fight for life mounted into agonizing suspense--not only for his family and for the surgeons who were caring for him but for another family and for other surgeons in another hospital on the other side of town.

Humane Apology. Surgeon in Chief Francis D. Moore of Peter Bent Brigham Hospital (TIME cover, May 2) heard of Callahan's condition, promptly phoned M.G.H. Chief of Surgery Paul Russell. What were the chances of Callahan's recovery? Not good, said Russell realistically. Had the patrolman suffered any injuries besides the head wound? No. Was there any reason to believe that his liver was damaged or diseased? No. Then, with the inevitable apology, Dr. Moore asked Dr. Russell if he would discuss with Callahan's wife, in case her husband should die, the possibility of releasing his liver for transplantation to a man who was otherwise doomed. Dr. Russell agreed.

The deathwatch went on while the M.G.H. surgeons did everything possible to pull Callahan through; they even dropped the temperature of his entire body to decrease his brain's need for oxygen. But he showed no sign of regaining consciousness. On Monday, when all hope had faded, Dr. Russell tackled his most difficult task. He told the wom an who was about to be widowed what his colleagues wanted. Ermalinda Callahan replied without hesitation: "Go ahead if it will help someone else."

As soon as Dr. Moore got the word, the Brigham team raced into action. The patient was Joseph J. Bingel, 58, a Dorchester construction worker. Brigham surgeons had operated on Bingel in August and found cancer of the liver--a cancer that was too big to be cut out, yet so far as the surgeons could tell, one that had not spread. So Bingel was just the right patient to receive the Brigham's first liver transplant. Twice, before Patrolman Callahan was shot, the Brigham surgeons had thought they had a likely donor, but in each case doctors and patient alike were disappointed because the liver proved to be diseased or injured. Now, for a third time, Patient Bingel was wheeled into the operating room and prepared for surgery.

Cool Container. At 5:30 p.m. Callahan died. "When we were absolutely sure that life had left him," says Dr. Russell, "Mrs. Callahan signed the release." A phone message went to the Brigham even as the patrolman's lifeless body was wheeled into an operating room. There Drs. Nathan Couch and Anthony Monaco made a long vertical incision on the right side of the abdomen. Within three minutes they cut down to the portal vein, which drains into the liver; they then injected a frigid solution to cool the precooled liver down still more. They completed their work in 24 minutes and dropped the liver into a cold saline solution in a sterilized container.

With its lid clamped down to protect the liver against contamination from the air, the container was put in an ambulance. It got to the Brigham at 6:36. There Patient Bingel had been under anesthesia since 6 o'clock. The choice of anesthetics was important because some of the best modern drugs undergo chemical changes in the liver. This would put an extra burden on a transplanted liver, and anyway, Bingel was not going to have any liver at all for a couple of hours. So Anesthesiologist Leroy Vandam chose old-fashioned cyclopropane, which acts fast, then switched to ether.

The Brigham team weighed the surgeons' discarded sponges to measure the patient's blood loss and thus make sure that he got enough, not too much, transfusion blood. Before it was all over, Bingel got 18 pints, all freshly drawn from donors who had waited in the hos pital most of the day.

It was 6:05 when Surgeon Moore made his incision, a wide, inverted horseshoe across Bingel's abdomen, with a long, curving extension up the right side of his chest. Unlike transplanted kidneys, which are set in the flank, the liver was to go just where nature had placed Bingel's own. "We felt it wouldn't work right unless it was in its normal place," said Dr. Moore.

Time might have been saved at this stage if Surgeon Moore had had more advance notice: he could have done the preliminary work of cutting Bingel's own liver free from its many muscular and ligamentous attachments. Now it was dangerous to rush. The region around the liver used to be terra incognita to surgeons; only recently have Dr. Moore and others explored and mapped it in detail. And although human organ transplants have been made possible by experimental operations on dogs, the details of canine anatomy are sufficiently different from man's to be of little help at this stage.

At last, Surgeon Moore was ready to tackle the blood vessels. Biggest and therefore easiest to handle was the in ferior vena cava, the great vein that drains all blood from the lower body and is attached firmly to the liver. It was cut in two places, one above and one below the liver. More difficult were the hepatic artery, which supplies blood to the liver itself, and the portal vein, which carries blood from the intestines to the liver for purification. Dr. Moore cut them as close to the liver as possible to leave long ends for later connections.

Simultaneously, other surgeons installed shunts of plastic tubes to carry the blood that should have passed through the inferior vena cava to the jugular veins in Bingel's neck. A second group stood ready with a heart-lung machine in case Patient Bingel needed it. (He didn't.)

Finally, Dr. Moore removed the cancerous liver, so enlarged that it weighed more than 8 Ibs. (normal is about 31 Ibs.). Out of the cooled container came Callahan's liver, with its long leads of blood vessels. Dr. Moore stitched these to the ends of the same vessels in Bingel's abdomen. At 9 o'clock Bingel's blood was switched to follow its normal pathways--through his newly acquired liver. What remained was to hook up the gall bladder and close the sweeping surgical wound. That took until 12:35 a.m.

Two-Hour Limit? This was not the first transplant of a human liver. That was done last March in Denver, where surgeons and physicians from the University of Colorado Medical Center and the nearby VA Hospital have pooled their talents in a transplant team. By now the Denver group has done four transplants, with one patient living 22 days after the operation, when he died of pneumonia. The Boston and Denver teams have traded reports of their progress, and their methods are remarkably similar, though they differ in some details.

Denver's Dr. Thomas E. Starzl and William R. Waddell feel strongly that a liver should be hooked up to its new blood supply within two hours of being disconnected from its original host. They have not yet been able to make the transplant as fast as that, and neither did Dr. Moore. But the Callahan-Bingel transplant had an advantage in that the liver had been precooled for 40 hours, which gave its tissues time to adjust to a lower metabolic rate.

Since man can live only about 36 hours without liver function, and three of the Denver patients lived longer than that, it is clear that the transplanted organs have worked. So did Joseph Bin-gel's, for eleven days. Then he died.

The M.G.H. and Brigham doctors were not discouraged. The attempt to save Bingel, helped by a widow's understanding, had been a noteworthy feat of medical and surgical cooperation. It failed, said Dr. Moore, "because all transplant patients face the problem of the organ's getting used to its new host--the host and the liver have to learn to live together." Renewed attempts to teach them to live together were certain to be made soon. Even as Joseph Bingel died, a gathering of transplant experts convened in Washington to figure out improved methods of increasing those chances.

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