The History of Liver Transplantation in Western Australia by Emeritus Prof Tony House
Prior to 1994, W.A. patients with acute or fulminant liver failure had no option but to be airlifted to the Eastern states for a liver transplant. This often became too risky for very sick patients. With the help and foresight of many involved and with government funding the State Liver Transplant Unit was set up at Sir Charles Gairdner Hospital. Below is a firsthand account from Professor Tony House who gives an in depth look into this incredible journey. Professor House was the first Liver Transplant Surgeon at Sir Charles Gairdner Hospital along with Professor William Reed, the then Medical Director. They were at the helm when the unit began in 1994. Today the transplant Service continues to run successfully under the aegis of Winthrop Professor Gary Jeffrey as Medical Director and Associate Professor Luc Delriviere as the Surgical Director.
The Western Australia Liver Transplantation Service has been in operation at Sir Charles Gairdner Hospital in Perth since 1994. It has been a brief but eventful journey since the inception of this department. A great deal of dedication, inspiration and hard work has gone into it, and today the transplantation service in WA is at par with the best in the world.
Currently kidneys, livers, heart and lungs are transplanted in Western Australia. The transplant endeavour has been the product of research and clinical output from the academic departments of Medicine and Surgery, University of Western Australia. These departments have been supported by the department of immunology, tissue typing, initially under Bill Cross and later, Professor Roger Dawkins. Immense support has also been received from The Department of Cardiology and Cardio-Thoracic surgery at Royal Perth Hospital(RPH), the Department of Renal Medicine, Princess Margaret Hospital(PMH) and the associated departments of Intensive Care, Radiology, Biochemistry and Bacteriology at each of the major hospitals, RPH, Sir Charles Gairdner Hospital(SCGH) and PMH have also played a key role. In each, the support of theatre, ward and dialysis nurses have made a significant contribution to patient outcomes. Donor coordinators have facilitated the provision of donor organs.
Prior to the first successful kidney transplant in 1966 Professor Gwynne Brockis assisted by a lecturer Mr Gerhardt Ibach performed over 100 kidney transplants on dogs. These helped establish the technique of handling the renal vessels and ureter but were associated with few successful outcomes. As a consequence the Coroner was approached and consented to kidney transplantation in humans awaiting autopsy in the mortuary of R.P.H. This provided considerable technical training for the surgical transplant team led by Professor Brockis and Mr Golinger. In those days there was little opportunity for training other than on the job.
Professor House (1969-1971) was appointed as a Research Fellow in the academic Department of Surgery at St Mary’s Hospital, Paddington London He worked in kidney transplantation to develop a thesis for a Master of Surgery degree and simultaneously gained considerable practical experience in donor management and kidney implantation.
Mr Tony Low gained research experience in Leeds in kidney preservation before his return to Perth in the early 1970’s to join the kidney transplant team with two other surgeons Mr Tony van Merwyk and Mr Tony Taylor.
In the 70’s and 80’s dog kidney experiments enabled evaluation of perfusion fluids used in preservation and kidney storage prior to implantation. Professor Kevin Burnand of St Thomas’s Hospital London participated in these experiments while an exchange registrar at R.P.H. Professor House was able to collaborate with Professor Ross Sheils in Sydney while on sabbatical leave in 1978. Professor House also gained experience in Cambridge with Sir Roy Calne and in Pittsburgh with Professor Tom Starzl in 1989 examining the use of University of Wisconisn solution ( also known as Viaspan which is used as a medium for organ preservation during organ transplant) in liver preservation. Further research was also developed in evaluating the impact of immunosuppressive agents on transplant recipient lymphocyte function. In the late 1960’s, Professor Brockis and later in 1970’s Tony House (who was then a lecturer in the Department at RPH), embarked on an experimental model with liver transplantation in pigs. The experiments did not see long-term survivors but did enable the technique of liver handling and venous anastomosis to be perfected. The model used white land race pigs that developed malignant hyperthermia with anaesthesia and initiated learning experience in handling this large animal model. This was reported at the time in the local newspaper by Catherine Martin who quoted Brockis “ the first attempt to anaesthetise a pig; it was a good sized porker, a medical technologist sat astride its back both hands spreading the ear so that I could inject the needle. One light jab and pig and rider went helter skelter the full length of the operating theatre straight into the door knocking them both out cold”.
Subsequently pig transplants were performed in the Experimental laboratories at the QE11 Medical Centre by Senior lecturers Mr Robert Black and Professor House and later in the 1990’s by Mr Roger Bell and Professor House . At that time Roger Bell was preparing work in organ preservation for a Master of Surgery thesis and his studies were furthered in Sydney with Professor Ross Sheil. Dr Neville Gibbs used the pig transplant opportunity to gain experience in liver transplantation anaesthesia. The experimental transplants gave further experience in vascular anastomosis and the use of venovenous bypass.
Professors Reed and Jeffrey each have extensive liver research interests. Professor Reed was initially in the Liver Transplant unit at Kings College, London and in Cambridge while Professor Jeffrey worked in the liver transplantation unit at the Royal Free Hospital, London with Dame Shelia Sherlock between1983-85 and gained early human liver transplantation experience. He later continued liver research at the Massachusetts General in Harvard.
The ongoing success of the Western Australian Transplant program depended on the development of a successful donor service. Initially transplant teams from within individual hospitals sourced organ donation. As transplant programmes extended and brain death was adopted as established practice it became necessary to appoint donor co-ordinators. The first of these were appointed in the mid 1980’s, one to R.P.H, Mr Ken Reed, and a second to S.C.G.H, Mrs Ailsa Allen. These individuals greatly facilitated the donation process and saw the need for recognition and involvement of donor families in the process. They were also instrumental in establishing a regular thanksgiving church service, a commemorative tree planting day and transplant organ donation seminars.
In spite of the energy and activity of these early co-ordinators donor rates were not comparable to the Spanish experience. Consequently, vigorous committee work and submissions to the West Australian government resulted in the formation of a more formal organisation ‘Donate West’, now known as ‘Donate Life’ with independent funding. This organisation was initially under the direction of Dr Millar Forbes, an ICU and Anaesthetic consultant.
The period of organ donation enabled the perfection of organ retrieval in Perth so that liver grafts could confidently be referred to other units throughout Australia and New Zealand in the expectation of good graft function. Clinical Liver Transplantation West Australian physicians and surgeons have long had an interest in liver disease. Professor Richard Joske had a particular interest in liver pathology and saw the need for liver transplantation. Physician members of his Department, Professor WD Reed and later Professor Gary Jeffrey were encouraged to study hepatology and the care of the liver transplanted patients at King’s College Hospital, London and Addenbrookes Hospital, Cambridge under Dr Roger Williams and Professor Sir Roy Calne. Professor Jeffrey also worked at the Royal Free Hospital under Professor Dame Shelia Sherlock and at Massachusetts General Hospital, Harvard. USA.
Prior to liver transplantation being available in Australia a three year old girl was referred from Perth to Professor Tom Starzl in Pittsburgh. She returned home in 1984 alive and well and she remains well today aged 29 years. Professor Sir Roy Calne transplanted a second 18year old West Australian boy in Cambridge in 1986. He required a second transplant before returning and later marrying and having a family. He died in his thirties of biliary sepsis. These and other Act of Grace payments for referral of patients overseas promoted the Federal Minister for Health to establish an Expert Clinical Committee to evaluate the feasibility of liver transplantation in Australia which occurred as a pilot centre at the Royal Prince Alfred Hospital, Sydney in 1986 and Brisbane in 1985. Professor Reed who had established a liver clinic at the SCGH was appointed to this committee.
The committee recommended the establishment of Liver Transplant Assessment panels in each state with medical, surgical and paediatric representation to access potential liver transplantation patients and maintain a registry of these patients. Such a panel was established in Western Australia in 1985 by the Western Australia Commissioner of Health. This committee was to manage the pre and post operative care of liver transplant patients.
The panel was chaired by Professor Reed and had representatives from each of the adult teaching hospitals and PMH; Professor G Jeffrey (SCGH), Dr BA Bramston (RPH), Dr R Hill (PMH), Dr D Adams (FH) and transplant surgeons Professor AK House and Mr R Bell. Subsequently other surgeons Mr Tony Kierath, Mr Dugal Heath and Mr Andrew Mitchell, physician Dr George Garas and anaesthetist Dr Neville Gibbs, Intensivist Dr Brad Power were also involved and supported by nursing, psychiatric and social work staff.
The review panel referred patients interstate for transplantation. By May 1994 one hundred and seventeen adults and nineteen children had been assessed. Thirty-nine had been referred for transplantation, 27 received a transplant with three postoperative deaths and a further one 15 months later in Perth. The remaining transplanted patients went on to lead a good quality of life. However, the patient cohort raised concerns about the trauma of the exercise. They felt disenfranchised from their normal support network of family, social, medical and work colleagues and often incurred a financial burden. Concerns were expressed by numerous other patients, the Western Australian Branch of the Australian Medical Association and other members of the community. The then Minister for Health refused to make a decision about establishing a liver transplant unit in Perth. He had to choose between RPH and SCGH and claimed the expertise in ICU units was not tuned to liver transplantation. This was in spite of there having been two successful liver transplants performed by the Perth team in severely encephalopathic patients considered not suitable for transport to the Eastern states, but fulfilling the criteria for transplantation.
The first of these was in 1992, was a male transplanted at RPH because the ICU at SCGH considered they were not ready to support a liver transplant patient. The donor liver was from a local donor. The surgery was particularly difficult on account of a swollen woody liver with many varices. Bleeding reached 55 units and the procedure lasted twelve hours. Nevertheless the patient recovered quickly in the Intensive Care Unit and the ward and gained normal liver function, but died some months later of carcinoma.
A second female patient with non A non B viral hepatitis and fulminant liver failure was transplanted at SCGH in 1993 with a donor liver from interstate. The operation was short, less than six hours, with minimal blood loss and was followed by a short Intensive Care and ward admission and remains well 17years later.
Both procedures were sanctioned by the Commissioner of Health on the basis of unfavourable previous experience with transporting fulminant patients to the Eastern States. The former experience of managing six fulminant patients was bad. The family of one refused transplantation, the remaining five were activated but three died before a donor organ became available. Two patients were flown to the Eastern States, one transplanted in Brisbane and the other in Sydney but both died of cerebral oedema. Advice from international experts, Professors Roger Williams, Sir Roy Calne and Paul McMaster confirmed the observation of a poor prognosis in airlifting a patient in fulminant liver failure; severe portal hypertension or recent variceal bleeding.
Professors Reed and House in collaboration with all units and staff involved in transplantation drew up a detailed proposal for the establishment of an adult liver transplant unit at the SCGH. This was submitted with input from the Melbourne unit and accepted by the Commissioner and Minister of Health. The unit became operational in May 1994 with Professor House as the surgical director and Professor Reed the Medical Director and was formally called the Western Australian Liver Transplant Service. The first two transplants of the unit following this formal agreement were reported in the West Australian newspaper August 14th 1994. Eighteen months after the commencement of the transplant unit twenty-three transplants had been performed in twenty-two patients. The anticipated transplant rate was 10-15 patients per year. The details of the patients transplanted were summarised with the conclusion that 87% patient and 81% graft survival could be achieved at a mean of 13 months follow up compared with patients transplanted elsewhere before 1994, 86% and 83% survival at one year and it was decided that a unit of this size was viable.
A number of problems were evaluated and corrected. Biliary complications appeared frequent with the finding that many could be avoided by dispensing with the T tube drainage and endoscopic intervention. Hepatic artery problems could be predicted by frequent duplex monitoring and if need be, pre-emptive intervention and hepatic collection evaluated and drained by interventional radiological techniques. Evaluation of rejection using the Banff Schema was also undertaken. In spite of the good results the universal problem of donor shortage hindered the development of a greater number of transplants being carried out. To address this, protocols for split liver grafts were developed and the surgical technique was perfected by Prof House on sabbatical leave and training in Birmingham, UK with Professor McMaster, mastering the technique of liver splitting and transplanting the resultant liver segments between adults. By Dec 1999 eighty four transplants had been performed in 81 patients with a survival rate of 81% at five years. Four of those patients were recipients of split livers .
To manage urgent situations of primary graft non function, rapidly deteriorating liver function post transplant and acute liver failure when no cadaver was available, a further study period with Dr Edgar Cam in Denver, Colorado enabled a related living donor protocol to be developed. All wait listed patients were involved in discussions of living related transplantation at the time of listing and the protocol for this outlined. One such was a patient presenting in fulminant hepatic failure with no apparent cadaver donor available nationally. Her sister volunteered a portion of her liver to enable a living related transplant to occur. The operation was carried out after extensive and urgent workup and was the first of its type in Australia.
In 2001 a further dilemma was faced and solved when a Jehovah witness presented requiring a transplant. Considerable debate regarding the feasibility and ethics of such a transplant was generated in the unit and nationally. The process initiated a change to the unit’s blood management transplant protocol to enable efficient blood use and a successful transplant.
The patient recovered well enough to return to farming. The transplant was an exercise in efficient blood conservation and not religious observance or discrimination for the unit.
In 2001 Professor Reed retired, followed in 2004 by Professor House from the Liver Transplant unit and have been succeeded by Professor Jeffrey as Medical Director and Associate Professor Luc Delriviere as Surgical Director. They are supported by Associate Clinical Professor Gerry MacQuillan, Associate Professor Leon Adams, Associate Clinical Professor George Garas, Transplant surgeon Mr Andrew Mitchell and Clinical Nurse Consultant Barbara Chester.
Chester: Transplant Nurses Journal Vol 9 No 1, April 2000. p 22-26).
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