Dr. Chen Chao-long and his surgical team at Chang Gung Memorial Hospital, Linkou, Taipei County begin a precisely timed operation to save Lin A-yen's life. But their attention is not now focused on Miss Lin. They act to remove the liver of an automobile-accident victim suffering irreversible brain injury.
Time: 0:30 a.m., March 23,1984
The removal of A-yen's failing liver begins, to be followed immediately with the implant of the donor's liver.
Time 7:40 a.m., March 23, 1984
As soon as the vascular clamps are released, the newly implanted liver in A-yen's body turns rosy, throbbing with life.
Time: 3:30 p.m., March 23, 1984
As the surgeon finishes the last stitch, A-yen flutters her eyes.
Following a 20-plus-hour marathon operation, 18-year-old Lin A-yen, a former factory worker from Changhwa, central Taiwan, had become the first liver transplant recipient in Asia.
Lin A-yen had suffered for years from Wilson's disease—a recessive metabolic disorder characterized by excessive accumulations of copper in the liver, central nervous system, kidneys, eyes, and other organs. Though the disorder is genetic in nature, the signs—significant pathological changes, or clinical manifestations-do not appear before the age of five, and the latter may be delayed until age-50. Recent data suggests that Wilson's disease may affect 1 in every 30,000 people worldwide, with a genetic carrier frequency of about 1 in 90.
When A-yen was hospitalized more than one month ago, she was in the critical stages. She had already entered the last phase of decompensated liver cirrhosis with repeated esophageal variceal bleeding. The latest (March 17) bleeding put A-yen into coma. On March 20, she was transferred to intensive care. "A-yen's life was slipping away. She was now teetering on the edge of death. If she hadn't received a healthy liver in time, she would have died in a very short time," declared Dr. Chen Chao-long.
The liver donor, 31, whose name was withheld at the request of his family, was on his way with a friend to visit a furniture manufacturer in Hsinchu when their car was struck by a bus near Chupei, a Hsinchu suburb. The friend died within minutes of his arrival at Chang Gung Hospital. The other man was only barely alive; his brain was almost completely destroyed and he was maintained by mechanical means. The doctors told his family that nothing more could be done to save his life, but that they could do another human a great favor by allowing the transplation of the brain-dead man's liver. After painstaking, yet necessarily hurried consideration, the grief-stricken family consented.
Liver transplants have been described in surgical circles as "like the engineering project for going from the earth to the moon." They are technically more complicated than heart or lung transplants. The surgeons require as long as four hours to remove the donor's liver while assuring that the blood vessels and bile duct aren't damaged.
While extracting the diseased liver from the recipient, they must take care to cut and suture thousands of abnormal, hard-to-reach blood vessels that have formed in response to liver disease and that increase the risk of hemorrhage during surgery.
A liver patient also has blood clotting problems. In performing the transplant, the surgeon has to make five key connections- the upper and lower portions of the vena cave, the portal vein, the hepatic artery, and the delicate bile duct. By comparison, a kidney transplant requires only three, much smaller suturing jobs.
A complex organ with many still unknown functions, the liver must work right away after the transplant or the operation fails. "However, with the liver, there's nothing like dialysis to back you up," remarked Dr. Chen. He added that according to reports from abroad, a successful liver transplant "may normalize the biochemical abnormalities in Wilson's disease, and even more dramatically, may reverse the neurologic deterioration."
The liver transplant operation was soon trumpeted by the local mass communications media- "Successful Liver Transplant Is Asia's Medical Pride," "A Great Breakthrough in Organ Transplants." The reports focused on the satisfactory outcome. The sweat and tears that made it all possible were near forgotten.
The Chang Gung Hospital surgical team embarked on intensive prepatory efforts from the time Dr. Chen Chao long returned from America, last October. There he had studied with Dr. Thomas E. Starzl, the prestigious liver transplant specialist who has performed 365 of the 550 liver transplants accomplished to date in the world.
"Beginning last October, all members of the surgical team spent their Saturdays in the surgical laboratory, conducting animal experiments," remarked Dr. Chen. As the team's key figure, Chen felt most responsible. He often slept on a cot in the laboratory observing the animals' conditions after operations.
Dr. Chen's concentration on organ transplants traces back a decade ago when he was studying at Kaohsiung Medical College: As a student, he reveled in this contemporary medical drama. Later, as a surgical resident at Chang Gung, he availed himself of the opportunity to proceed with animal experiments.
Still later, Dr. Lin Tien-yu, a pacesetter in Republic of China liver surgery, asked Dr. Chen to do liver illustrations for a textbook, a duty which forced him to research related materials and dissections. The resulting accumulation of background prepared him to meet requirements for the work with Dr. Starzl, which Dr. Chen began after completing a one-year senior residency at the University of Toronto, one of the world's major diabetes research centers, in 1982.
From January to September 1983, Dr. Chen worked with Dr. Starzl at the University of Pittsburgh School of Medicine, as a fellow in liver transplant. He assisted the university team in 72 liver transplants. In some 20 cases, he boarded hospital jets to help retrieve the livers of distant donors. "One time, we even went as far as Arizona," Dr. Chen recalled. The retrieved livers were chilled in a salt solution and placed in a cooler, and were to be used in the 12-hour period after removal. "Faced with such a race against death, I am always under great pressure," Dr. Chen confessed.
Assisting Dr. Starzl was no easy job. Slight mistakes resulted in vehement reprimands. During that period, no matter how tired he was after a day's routine, Dr. Chen made himself tie 200 surgical knots in order to assure the nimbleness of his fingers. His dexterous knot-tying skills later helped him to win assignment as Dr. Starzl's first assistant, giving him the opportunity to more closely observe Starzl's surgical virtuosity.
Dr. Chen Chao-long briefs the surgical team
Dr. Starzl later wrote of Chen: "I feel certain that Dr. Chen Chao-long will be one of the great leaders of surgery in the Orient in the years to come."
Dr. Chen is a slight man, modest and accessible-the "anti-image" of an authoritative surgical team leader. He, himself, likens his part to a role in the performing arts: "Without the sweat and tears offstage, there would never be an outstanding performance onstage."
Dr. Chen's liver transplant team is the world's youngest. Its eldest member, 33, is Dr. Chen himself. Its core members largely consist of pediatric surgeons who had received general surgery training.
Dr. Chen especially makes special mention of the contributions of anesthetist Dr. Tan Pei-chung, who assisted in the operation.
Talking about the challenge encountered during the liver transplant, Dr. Tan noted: "Basically, Lin A-yen's situation was quite different from that of the usual surgery patient. A chemical factory itself, the liver controls the metabolism of the anesthetic. And since her liver was almost completely useless, it was very difficult to predict the effective time of anesthesia. Foreign medical reports failed to provide us with enough information, and we had exhausted our domestic experience. Groping on our own, we collected information from 27 physiological indicators- blood pressure, peak-and valley tracings of the electro-cardiogram and the blood chemistry, etc.-as adjustment information for our anesthesia appliance."
Tan continued, "Water control plays an important role in liver transplantation. Too much water results in edema of the lungs, and a scarcity causes the blood pressure to go down, threatening the patient's vital organs."
As with any attempt to transplant major organs, the biggest obstacle was the body's natural immune reaction that is, the production of antibodies against the antigens in foreign tissues that lead to rejection of the graft. If donor and recipient have the same antigens, as do identical twins, there are no rejections.
Immunologist Dr. Huang Chiu-ching, one of the team members, talked about preventive measures to overcome the immune response: "Before surgery, the tissue antigens of the donor and recipient are matched in much the same way that blood is typed. A further match, in lymphocytes, increases the chances of a successful transplant."
Dr. Huang also pointed out the recent development of cyclosporine, a fungus-based drug approved by the U.S. Food and Drug Administration last September. It helps prevent the body's immune system from rejecting the transplant without also reducing the patient's ability to fight off dangerous infections. It has proved to be the most effective immunity-suppressing drug, promising fewer and less serious side effects.
A notably sweet-voiced lady in her 30s, Dr. Huang earned an M.B. at National Taiwan University, then added to it, seven years of kidney and tissue research at the Universities of Rochester and Alabama in the U.S. She and her husband, kidney expert Dr. Lai Ming-kuen, worked to perfect kidney transplant techniques-Taiwan's earliest organ transplant accomplishment.
Dr. Lee Chung-jen, now director of Taoyuan Provincial Hospital, performed the island's first kidney transplant in 1968 at National Taiwan University Hospital. To date, more than 300 patients have benefitted from this surgical achievement at the four Taiwan kidney transplant centers: Chang Gung Memorial Hospital, National Taiwan University Hospital, Veterans General Hospital, and Taoyuan Provincial Hospital.
Dr. Lai, only 38, but even more youthful in appearance, spoke of the cur rent situation on organ availability: "Chang Gung surpasses other hospitals in organ availability. Though traditional 'complete corpus' concepts cherished by the Chinese are greatly limiting, public views toward organ transplants have been changing, resulting in improved outlooks."
As this article was being written, Taiwan's first bone marrow transplant was made known to the public. The medical community is working hard here to assure that there will be much more to come.