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Liver Transplantation at Mayo—Initial Deliberations
SYMPOSIUM ON LIVER TRANSPLANTATION—Introduction
Liver Transplantation at Mayo—Initial Deliberations
The people of Mayo hold a quietly stated but firm belief that the Mayo model of health care has some unique characteristics that serve patients well. One of our long-standing goals, therefore, is to maintain the level of medical care and expertise that our patients have come to know and expect. To achieve this goal, we must con tinually examine our practice, retaining what is best about it and perfecting areas that need improvement. As part of our process of self-examination, Mayo decided in July 1983 to establish a liver trans plantation program. This decision was not made hastily or lightly. Years of consideration and consensus building preceded the approval by the Mayo Board of Governors, and many factors were weighed by the individuals and departments that would be affected by such a program. The process of examination began in 1981 with a group of seven Mayo hepatologists who met regularly to discuss the options available for their patients with end-stage chronic liver disease. Af ter a year of formal and informal discussions, they concluded that liver transplantation might be a promising therapeutic option for their pa tients, and further evaluation was recommended. Led by Drs. Russell H. Wiesner, E. Rolland Dickson, and Nicholas F. LaRusso, the team formu lated a proposal (unpublished data, Mar. 9, 1983) for a liver transplantation program to be con sidered by the Clinical Practice Committee and ultimately the Board of Governors at Mayo. The proposal promoted development of the program based on the following factors: 1. Improved survival after liver transplanta tion because of the use of cyclosporine A Mayo Clin Proc 64:82-83,1989
2. The unacceptably long waiting period at some transplantation centers, which resulted in the death of some patients before liver transplan tation could be performed 3. The cost-effectiveness of liver transplanta tion compared with conventional supportive ther apy for end-stage chronic liver disease 4. The increasing willingness of third-party carriers to assume a major share of the cost for liver transplantation 5. The apparent availability of donor livers nationally (with the assumption that Mayo would develop an active procurement program incor porating the use of air transportation) 6. The strong likelihood that a liver transplanta tion program would be successful at Mayo, because of the available expertise in surgery, hepatology, and numerous support areas 7. The large number of patients with non alcoholic liver disease who undergo yearly evalu ations at Mayo, many of whom would be candi dates for liver transplantation 8. Increased inquiries from well-informed Mayo patients concerning hepatic transplantation as a therapeutic option 9. The prominent position of Mayo as a major tertiary referral center for complex hepatobiliary diseases Mayo had many tasks to accomplish to imple ment a program for liver transplantation, and the proposal outlined these tasks. One of the most important tasks was to identify a liver trans plantation surgeon who would be willing to as sume the responsibility for such a program as his or her primary clinical and research activity. 82
Mayo Clin Proc, January 1989, Vol 64
Six Mayo hepatologists were willing to make a major commitment to liver transplant recip ients and help in organizing a liver transplant service. The service would need an organ procure ment administrator, selected from the Mayo para medical staff and specially trained for this re sponsibility. A Mayo anesthesiologist for liver transplantation would need to be selected and trained, possibly at another medical center that had thorough experience in transplantation. Other key personnel would include nurse coordinators, a psychiatrist, a nutritionist, an infectious disease consultant, a social worker, a hepatic pathologist, and a research immunologist. Beyond the need for trained personnel, Mayo would have to establish a liver transplantation unit in one of the affiliated hospitals and include in it all the surgical and intensive-care facilities and equipment necessary to sustain severely ill patients both before and after transplantation. Furthermore, a comprehensive program in liver transplantation research would have to be devel oped and supported by Mayo. Research, philo sophically a partner of clinical practice at Mayo, would substantiate progress and add to the body of medical knowledge about liver transplantation. The program also needed ready availability of air transportation, to and from Rochester, to supply donor livers. Demographic data indicated that 40% of the population of the United States resided within a 750-mile radius of Rochester, Minnesota. Because human livers can safely be preserved for 6 to 12 hours after removal, it seemed likely that air access to this population would provide a sufficient number of donor livers to support a liver transplantation program at Mayo. Blood banking had long been established at Mayo and would become a vital service to the liver transplantation program. Although this program would demand substantial quantities of blood, Mayo had in place an autologous blood transfusion capability that could help alleviate many of the potential transfusion problems in volved with a liver transplantation program.
SYMPOSIUM ON LIVER TRANSPLANTATION
83
Mayo thoroughly examined the financial re percussions of such a new program, a difficult task without experience in liver transplantation. Studies by other institutions had concluded that the cost-effectiveness of liver transplantation was possibly superior to that of supporting a dying patient being treated by conventional therapy. 1 In addition, an increasing number of insurance companies were willing to pay the costs of liver transplantation, and private fund-raising efforts for transplantation patients were often success ful. The collection rate for transplantation pa tients was generally good (90% at the University of Pittsburgh). After consideration of all these factors, the conclusion to proceed with liver transplantation seemed obvious. On July 20, 1983, the Mayo Board of Governors approved the establishment of a liver transplantation program. The approval was subject to two conditions: (1) recruitment of a surgeon with a primary commitment to liver transplantation and (2) provision for requirements needed to support a transplantation program. Subsequently, Dr., Ruud A. F. Krom became Mayo's first liver transplantation surgeon, the resources to support the program were provided, and the program began with a successful liver transplantation in March 1985. In this and sub sequent issues of the Proceedings, the Sym posium on Liver Transplantation reviews the results of the first 100 procedures in this program and describes the numerous resources used to achieve the results. We at Mayo are extremely proud of our colleagues who have successfully initiated this program. Robert R. Waller, M.D. Chairman, Mayo Board of Governors REFERENCE 1. O'Donnell TF Jr, Gembarowicz RM, Callow AD, Pauker SG, Kelly J J , Deterling RA: The economic impact of acute variceal bleeding: cost-effectiveness implications for medi cal and surgical therapy. Surgery 88:693-701,1980
Liver Transplantation at Mayo—Initial Deliberations
The people of Mayo hold a quietly stated but firm belief that the Mayo model of health care has some unique characteristics that serve patients well. One of our long-standing goals, therefore, is to maintain the level of medical care and expertise that our patients have come to know and expect. To achieve this goal, we must con tinually examine our practice, retaining what is best about it and perfecting areas that need improvement. As part of our process of self-examination, Mayo decided in July 1983 to establish a liver trans plantation program. This decision was not made hastily or lightly. Years of consideration and consensus building preceded the approval by the Mayo Board of Governors, and many factors were weighed by the individuals and departments that would be affected by such a program. The process of examination began in 1981 with a group of seven Mayo hepatologists who met regularly to discuss the options available for their patients with end-stage chronic liver disease. Af ter a year of formal and informal discussions, they concluded that liver transplantation might be a promising therapeutic option for their pa tients, and further evaluation was recommended. Led by Drs. Russell H. Wiesner, E. Rolland Dickson, and Nicholas F. LaRusso, the team formu lated a proposal (unpublished data, Mar. 9, 1983) for a liver transplantation program to be con sidered by the Clinical Practice Committee and ultimately the Board of Governors at Mayo. The proposal promoted development of the program based on the following factors: 1. Improved survival after liver transplanta tion because of the use of cyclosporine A Mayo Clin Proc 64:82-83,1989
2. The unacceptably long waiting period at some transplantation centers, which resulted in the death of some patients before liver transplan tation could be performed 3. The cost-effectiveness of liver transplanta tion compared with conventional supportive ther apy for end-stage chronic liver disease 4. The increasing willingness of third-party carriers to assume a major share of the cost for liver transplantation 5. The apparent availability of donor livers nationally (with the assumption that Mayo would develop an active procurement program incor porating the use of air transportation) 6. The strong likelihood that a liver transplanta tion program would be successful at Mayo, because of the available expertise in surgery, hepatology, and numerous support areas 7. The large number of patients with non alcoholic liver disease who undergo yearly evalu ations at Mayo, many of whom would be candi dates for liver transplantation 8. Increased inquiries from well-informed Mayo patients concerning hepatic transplantation as a therapeutic option 9. The prominent position of Mayo as a major tertiary referral center for complex hepatobiliary diseases Mayo had many tasks to accomplish to imple ment a program for liver transplantation, and the proposal outlined these tasks. One of the most important tasks was to identify a liver trans plantation surgeon who would be willing to as sume the responsibility for such a program as his or her primary clinical and research activity. 82
Mayo Clin Proc, January 1989, Vol 64
Six Mayo hepatologists were willing to make a major commitment to liver transplant recip ients and help in organizing a liver transplant service. The service would need an organ procure ment administrator, selected from the Mayo para medical staff and specially trained for this re sponsibility. A Mayo anesthesiologist for liver transplantation would need to be selected and trained, possibly at another medical center that had thorough experience in transplantation. Other key personnel would include nurse coordinators, a psychiatrist, a nutritionist, an infectious disease consultant, a social worker, a hepatic pathologist, and a research immunologist. Beyond the need for trained personnel, Mayo would have to establish a liver transplantation unit in one of the affiliated hospitals and include in it all the surgical and intensive-care facilities and equipment necessary to sustain severely ill patients both before and after transplantation. Furthermore, a comprehensive program in liver transplantation research would have to be devel oped and supported by Mayo. Research, philo sophically a partner of clinical practice at Mayo, would substantiate progress and add to the body of medical knowledge about liver transplantation. The program also needed ready availability of air transportation, to and from Rochester, to supply donor livers. Demographic data indicated that 40% of the population of the United States resided within a 750-mile radius of Rochester, Minnesota. Because human livers can safely be preserved for 6 to 12 hours after removal, it seemed likely that air access to this population would provide a sufficient number of donor livers to support a liver transplantation program at Mayo. Blood banking had long been established at Mayo and would become a vital service to the liver transplantation program. Although this program would demand substantial quantities of blood, Mayo had in place an autologous blood transfusion capability that could help alleviate many of the potential transfusion problems in volved with a liver transplantation program.
SYMPOSIUM ON LIVER TRANSPLANTATION
83
Mayo thoroughly examined the financial re percussions of such a new program, a difficult task without experience in liver transplantation. Studies by other institutions had concluded that the cost-effectiveness of liver transplantation was possibly superior to that of supporting a dying patient being treated by conventional therapy. 1 In addition, an increasing number of insurance companies were willing to pay the costs of liver transplantation, and private fund-raising efforts for transplantation patients were often success ful. The collection rate for transplantation pa tients was generally good (90% at the University of Pittsburgh). After consideration of all these factors, the conclusion to proceed with liver transplantation seemed obvious. On July 20, 1983, the Mayo Board of Governors approved the establishment of a liver transplantation program. The approval was subject to two conditions: (1) recruitment of a surgeon with a primary commitment to liver transplantation and (2) provision for requirements needed to support a transplantation program. Subsequently, Dr., Ruud A. F. Krom became Mayo's first liver transplantation surgeon, the resources to support the program were provided, and the program began with a successful liver transplantation in March 1985. In this and sub sequent issues of the Proceedings, the Sym posium on Liver Transplantation reviews the results of the first 100 procedures in this program and describes the numerous resources used to achieve the results. We at Mayo are extremely proud of our colleagues who have successfully initiated this program. Robert R. Waller, M.D. Chairman, Mayo Board of Governors REFERENCE 1. O'Donnell TF Jr, Gembarowicz RM, Callow AD, Pauker SG, Kelly J J , Deterling RA: The economic impact of acute variceal bleeding: cost-effectiveness implications for medi cal and surgical therapy. Surgery 88:693-701,1980