Medicine: A Transplanted Doctor and His…Transplants
The patient was 30 years old and he was dying. His liver—scarred beyond repair by cirrhosis that followed a hepatitis B infection 18 years earlier—was scarcely functioning. He had been hospitalized at the Hadassah–Hebrew University Medical Center in Jerusalem for almost two months waiting for a donor liver before one became available.
“The doctors didn’t pull any punches,” he says. “They told me that the liver was from a hugely obese 75-year-old donor, which meant that it was certainly old and could be fatty. They told me the risks and said straight out it wouldn’t be their first choice. But the fact was there no longer was any choice. Time had run out and there was no more suitable liver available. I talked it over with my wife and my parents. We all agreed I should go for the transplant.”
For this patient the story ended well. Surgery went smoothly. The donor liver was not fatty and functioned well from the beginning. With no complications, the young man was discharged from the hospital 10 days after the transplant.
“We’ve become far more aggressive in our approach,” says Dr. Hadar Merhav, the new head of the organ-transplantation-surgery unit at the medical center. “We are taking sicker patients and applying extended criteria to the organs we offer them. This can have a price in terms of complications, but with mortality on the waiting list as high as it is, and the waiting list for donor organs as long as it is—both in and outside Israel—there is often no alternative, and physicians and patients must face difficult decisions.”
In 1988, Hadassah was designated one of Israel’s two centers for liver transplantation (following designation as Israel’s first heart-transplant center in 1986), but transplant surgery there has slowed dramatically in recent years. In mid-2008, the transplant unit’s longtime head, Dr. Ahmad Eid, moved to Hadassah–University Hospital on Mount Scopus to head its surgery division, and the unit spent several months without significant leadership until Dr. Merhav was appointed.
Jerusalem-born and a graduate of the Hadassah–Hebrew University School of Medicine, Dr. Merhav comes to the job after spending most of the past 20 years in leading liver transplant centers in the United States. And he comes with a vision for Hadassah’s transplant unit.
“First and most pressing, we must increase the volume of transplants performed, and so ensure that Hadassah is a prominent referral center for kidney and liver transplantation,” he says. “Second, I want to venture into transplantation of other abdominal organs, such as the pancreas and small intestine. And third, I’m introducing new techniques to Hadassah’s [and Israel’s] organ-transplant programs—from laparoscopy to robotic surgery.”
Dr. Merhav, 57, became a transplant surgeon almost by chance. He completed a residency in general surgery under Dr. Reuven Pfefferman, one of Israel’s first kidney-transplant surgeons. Then, in 1987, four years after graduating, he attended a lecture by American surgeon Dr. Thomas E. Starzl, the modern-day father of organ transplantation. (Nine years later, the Pittsburgh Transplant Institute, where Dr. Starzl worked renamed itself the Thomas E. Starzl Transplant Institute.)
“From that moment, I was fascinated by the prospect of organ transplantation, especially transplantation of the liver,” says Dr. Merhav. “I had planned a fellowship in noncardiac thoracic surgery, but, instead, wrote to Dr. Starzl. One evening in April, the phone rang. My wife said, ‘There’s this guy Starzl on the phone.’ I grabbed it! He offered me a two-year fellowship starting that July. And that’s how I became a transplant surgeon.”
Following the fellowship and a stint as an attending physician in charge of intensive care, Dr. Merhav was invited by Dr. Nazih Zuhdi to open a liver-transplant program at the 500-bed Baptist Medical Center in Oklahoma City. He returned to Israel in 1995 as chief of liver surgery at The Tel Aviv Sourasky Medical Center. During a seven-year tenure, he launched a liver-transplant program that became, within two years, the second largest in Israel. Then it was back to the United States as an associate professor at the Memorial Hermann–Texas Medical Center’s Liver Center. With his mentor Dr. Luis Mieles, he was charged with reviving its faltering liver-transplant program—which they did.
“In 2008, I was invited to head Hadassah’s organ-transplantation unit,” he says. “It was the right job at the right time. After 26 years, I came back to Hadassah.”
He started his new job in 2009 and, within weekse was involved in an organ-transplant marathon. In the course of 48 hours last July, two hearts, two livers and a kidney were transplanted at Hadassah–Ein Kerem. One of the liver patients was a 24-year-old from Tiberias and the other a 61-year-old woman from Kiryat Arba. The kidney-transplant patient is 28. They and the two heart patients are all now at home in good health.
“This was unusually intense, but transplant surgery at Hadassah is steadily increasing,” says Dr. Merhav. “In the past year, the number of kidneys we have transplanted has increased by 20 percent over the average of the past six years, and continues climbing. Liver transplantation, which is surgically far more complex than transplanting kidneys, has increased at Hadassah by 70 percent over the past six-year average, and we have doubled the percentage we take from the organ pool.”
Not all livers or kidneys come from cadavers. Hadassah has, notes Dr. Merhav, “a vigorous living-donor transplant program. More than half of the kidneys we transplanted in the past 12 months came from living donors. The majority has been harvested laparoscopically.”
Removing a kidney from a donor by laparoscopy—also called keyhole or minimally invasive surgery—requires no more than a three-inch incision. Its advantages are many: reduced pain, reduced bleeding, reduced risk of infection and faster recovery time, “but it’s demanding in terms of maintaining quality of kidney and safety of donor,” says Dr. Merhav. “We’re now in the process of incorporating the Da Vinci® robot into this procedure.”
The Da Vinci® is a computer surgical system designed to replicate the movement of the surgeon’s hands with the tips of microinstruments. “It’s a super-accurate super-tool for laparoscopic surgery,” says Dr. Yoav Mintz, senior surgeon at Hadassah and head of its Robotic Assisted Surgery Service as well as the driving force behind Hadassah’s acquisition of the system a year ago.
As well as the Da Vinci®, Dr. Merhav has introduced other techniques into transplant surgery, in line with technologies that exist in the United States, several of which are new to Israel. “My overall approach is for our surgeons, each of whom has specialized skills in specific techniques, to work in multidisciplinary surgical teams,” he says. “With the skills of different surgeons complementing each other, we can perform complex procedures that individual surgeons could not perform alone. It is this that has allowed us to introduce laparoscopic liver resection and pancreas resection as well as other novel techniques.”
While Hadassah’s transplant unit is vitalized by new leadership, new organization and new surgical techniques, the original bugbear of all transplant surgery, in and outside Israel, remains the shortage of donor organs.
According to figures released early this year by Israel’s National Transplant Center, the rate of consent for organ donation is on the rise—reaching 50 percent for the first time and putting the country on a similar consent level with several American states. Despite this, however, “there are still too few donors in absolute numbers,” according to Dr. Merhav. “Israel remains significantly behind Europe and the United States in the number of donors per million people.”
Hadassah’s knowledgeable and compassionate transplant coordinator, Kyrill Grozovsky, a nurse by training, gets consents even from the devout Muslim and Jewish populations of Jerusalem. But waiting lists nonetheless remain too long, and too many of those listed die while waiting or deteriorate too far to be helped.
Controversy smolders over ways to encourage people to sign up to be organ donors. Israel’s 2008 transplant law gives registered potential donors preference if they themselves need a donor organ. Not yet in force, the law displeases many, who say medical decisions should be made solely on medical grounds. Dr. Merhav suggests a monetary incentive: People should be allowed to will their organs as they do their house or car, with the health service paying the bill.
“We should recognize that there’s a business side to organ transplantation, and confront it rather than ignore it,” he says. “I’m in favor of the government paying heirs for organs at a set rate, as part of the inheritance.”
He envisions a time when there will be a steady supply of organs for transplant and surgery need not be delayed. With patients thus in better condition and the new surgical techniques in operation, organ-transplant surgery would then no longer be the extreme option that it is today.