Transplant Surgeon: 'I Do Not Believe in a Top-Down Approach'

Pediatric experts from 15 different specialties and departments collaborate to make teen's fourth liver transplant a success.

A fourth liver transplant for a Montana teenager was an exercise in clinical leadership, care coordination, and team-based care, the surgeon who led the care team says.

Standard liver transplant teams involve several care team members, including care coordinators, nursing staff, surgeons, anesthesiologists, blood bank, and hepatologists. In this case, the care team consisted of pediatric experts from 15 different specialties and departments across Children's Hospital Colorado, including cardiac surgeons and a dialysis team.

Seth was 17 when he had his fourth liver transplant more than a year ago. When he was 2 years old, he was diagnosed with a genetic liver disease known as progressive familial intrahepatic cholestasis. At 8, Seth was diagnosed with a type of liver cancer known as hepatocellular carcinoma, which led to his first liver transplant.

Unfortunately, a complication with his liver and a critical illness compromised the first and second liver transplants. After the third liver transplant, Seth and his family were able to return to a normal life, and he lived for about 8 years without serious complications. But in November 2021, his artery clotted and he developed infected bilomas that were not responsive to medical management or interventional radiology treatment.

It is extremely uncommon to conduct four liver transplants in a patient, Michael Wachs, MD, chief of abdominal transplant surgery at Children's Hospital Colorado, told HealthLeaders. "The reason I thought it was reasonable to do was the first three transplants were conducted close together—they were all part of an initial complication and getting Seth through that. Then he had a period of years when he did well. In my mind, I grouped the first three transplants he had as a young child as his first transplant experience, so the fourth transplant was more like doing a second transplant."

The possibility of complications expanded the care team, he says. "In this case, because it was the fourth transplant, we were concerned about the outflow of the liver, which is only a couple of centimeters from the diaphragm and the heart. We had put a stent in during the previous transplant and that was going to have to come out. Then we were going to have to suture the new liver above where the stent used to be. So, we were going to be very close to the heart and we had to coordinate with the cardiac surgeons and the cardiac bypass team—the team that runs the bypass pump."

Dialysis was also a possibility, Wachs says. "It was pretty clear that if it was a tough operation, we were most likely going to have to do dialysis in the operating room, so we had to bring in a dialysis team, which is a group of nurses that runs the dialysis machine and the nephrologists determine how much dialysis the patient needs."

Logistics were also a challenge, he says. "It was not a live donor transplant—it was going to be a deceased donor transplant—we never knew when it was going to happen. … To have all of our people ready at any given time, we had to have more than one person from each team in on the plan. For example, if the main cardiac surgeon was not on call that day and we had the perfect immunologic organ, we wanted to have a backup cardiac surgeon. So, not only were there more groups involved, there was duplication of effort to make sure there was always going to be somebody available."

Collaboration was one of the keys to success in Seth's fourth liver transplant, Wachs says. "There is always collaboration among the groups that are involved in transplants, but we were communicating with the other teams that are not typically involved in a liver transplant. It is not just asking for their help—you need to ask for their opinions. So, I sat down several times with the cardiac surgeons and the radiologists to try to anticipate what we were going to do first, second, and third, and when we might need the heart surgeons. We talked with them about whether we could get the stent out, and what were the options if we had to go around it. We worked through those various steps and drew them out almost like you draw out a playbook in a football game. That was the primary collaboration—everybody talked about how the operation would go if we ran into particular situations."

Team-based care was pivotal, he says. "A good team functions by having leadership where you find good people to surround yourself with, and you let them brainstorm, you ask them questions, and you let them use their expertise to help you do the best that you can. I do not believe in a top-down approach. The old-fashioned surgery approach is the surgeon being the captain of the ship. That's great when the ship is going down—somebody must be in charge. But most of the time, when you want things to go well, the better approach is to have a level playing field of colleagues, where you put together a team of colleagues that work well together and complement each other. Then you plan out what you are going to do. Everybody gets the credit when it goes well. Everybody shares the blame when it does not go well."

Clinical leadership was also crucial, Wachs says. "My approach to clinical leadership is to lead from behind, which involves putting good people together, giving everyone a chance to speak, then once everyone has been heard, putting things together in a way that makes sense. Collaborative leadership is how we conduct transplant operations."