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Newswise — In a first for Children’s Hospital Los Angeles, two surgical teams have performed synchronous liver transplants on two pediatric patients, using portions of the same donated liver. The dual surgeries saved the lives of both children: a 2-year-old with metabolic liver disease and a 10-year-old with acute liver failure.
The concurrent pediatric liver transplants had little precedent, having been performed only a few times in the U.S., says Kambiz Etesami, MD, FACS, Chief of Abdominal Organ Transplantation and Surgical Director of the Liver Transplant Program at CHLA. The program—co-led by Medical Director Beth Carter, MD—is one of the largest for children in the country and is the national leader in pediatric liver transplant survival rates.
The dual surgeries required 30 to 40 staff members divided into two sets of operating teams. “I split the liver and did the smaller child’s case,” he says, “and Dr. Shannon Zielsdorf did the older child’s case.”
We spoke to Dr. Etesami to learn what it took to turn this complex undertaking into a lifesaving success.
How were you able to do two liver transplants at the same time?
It was a combination of timing, skill, and tenacity from our team. We had both kids listed for transplants. The older child was in acute liver failure. When you have acute liver failure, it’s a much more dire circumstance. If you don’t get a liver very soon, you can die. But the younger child had the primary allocation for this donated liver.
I accepted on behalf of that child, and we asked the organ procurement organization—the people who allocate these lifesaving organs—if they would be willing to give us the remaining half of the liver for our patient with acute liver failure. And they said yes.
Why did you choose to do the two transplants together instead of separately?
You don’t want to do these cases sequentially. The first case may take too long, and then by the time you get to the second case, that other half of the liver has been sitting on ice. The longer you keep these organs on ice, the more complications you run into once you put them in.
How did you determine how to divide up the liver?
Both kids had imaging—CT scans and such—as did the donor. So we knew the exact dimensions of the liver and what we could fit into our patients. We looked at the liver, decided that it had the appropriate dimensions and anatomy, and we cut it. I knew the 2-year-old would need the smaller half, and the 10-year-old could take the other half. The younger child got the left lateral section, and the older one got the right tri segment—the right lobe, essentially.
Had you ever done two concurrent transplants with another surgeon?
No. I had done cases where I took the smaller half, and one of my colleagues on the adult side took the larger half and did a transplant concurrently on an adult, but never at the same time for two kids in the same pediatric hospital. That’s very uncommon. As far as I know, it’s a first for Children’s Hospital Los Angeles, and it’s only been done one or two other times in the U.S.
Why is it so rare?
First, two children must need a liver at the same time with the same blood type, and the dimensions of the donated liver have to be workable. Second, you need the expertise of two separate surgical teams and two separate anesthesia teams. You need the operating room staffing and the physical room availability to do it.
Usually it’s not even considered because it’s extremely complicated to coordinate. It’s an allocation issue as well. When you take half a liver, the other half gets allocated down the wait list to other patients. We just had a circumstance where both of our patients at the same time were near the top of the list. So all of these things have to come together.
Discuss the logistics of the two surgeries.
A lot of staff had to be consolidated to make both happen. We were in two separate operating rooms at the same time. I had my team, and Dr. Zielsdorf had hers. We needed two separate anesthesiology teams, two separate nursing teams, two surgical teams, fellows—and then postoperatively, two beds in the Pediatric Intensive Care Unit, one for each patient.
So multiply by two what you need for one liver, and that’s what you need to make this happen. We’re talking probably 15-20 people per team, including the efforts of Dr. Andrew Costandi, Chief of Anesthesiology, as well as his colleagues who helped coordinate the OR and complete both surgeries.
What makes CHLA a place where these kinds of rare liver transplants can happen?
It’s not just about available operating rooms and logistics. You need a dedicated team of individuals who want to do these things and are capable of doing them. At CHLA, we perform more pediatric liver transplants than the vast majority of hospitals in the country and have the very best outcomes, so we have the extensive experience needed in these kinds of scenarios.
Ultimately, it’s the willingness and dedication of the teams of physicians, surgeons, anesthesiologists, intensivists, nurses, and coordinators to take that extra leap and make lifesaving moments like this possible. It’s really rewarding to be part of it.
