Staffed by experienced physicians, the program takes a team approach to performance, efficiency and, most importantly, keeping patients alive.
Since 1996, surgeons at Westchester Medical Center performed more than 400 liver transplants. In the past three years, expert physicians from across the globe have strengthened the program and built a multidisciplinary transplant team ensuring optimum patient care.
In 2011, Youmin Wu, MD, accepted the position of Chief of Intra-Abdominal Transplant and Hepatobiliary Surgery. The inventor of the cavaplasty procedure, Dr. Wu is responsible for worldwide improved outcomes following liver transplant surgery.
“I came to bring this program to a new level,” says Dr. Wu, who is also Professor of Surgery at New York Medical College. “We are building a world-class liver transplant program at Westchester Medical Center and hope to achieve recognition as a Center of Excellence.”
So far, Dr. Wu is accomplishing his goals. During his first year at Westchester Medical Center, liver transplant patients had a 100 percent survival rate for one year following surgery. Overall, the program’s one-year survival rate has averaged 96 percent, while the three-year survival rate is about 95 percent, Dr. Wu says. Nationally, about 86 percent of patients survive one year after liver transplant surgery.
“Our referral rate at Westchester Medical Center’s liver transplant program increased by 40 percent last year. I appreciate those referring physicians’ support and the trust they place in us. Our goal is to live up to that trust and always give our patients and referral physicians the best service possible.”
— Youmin Wu, MD, Chief of Transplant and Hepatobiliary Surgery at Westchester Medical Center, and Professor of Surgery, New York Medical College
In 2012, Thomas Diflo, MD, FACS, joined Dr. Wu. Dr. Diflo, Surgical Director of Renal Transplantation at Westchester Medical Center and Professor of Surgery at New York Medical College, has researched the prevention of transplant rejection and held numerous teaching appointments.
“When I was contacted about the program, I was excited,” Dr. Diflo says. “Westchester Medical Center puts a great deal of institutional support behind its transplant program, and I felt that I could really help them out.”
Gregory Robert Veillette, MD, and Thomas Diflo, MD, FACS, meet with liver transplant patient prior to his surgery, scheduled for later that day.
In July 2013, Gregory Robert Veillette, MD, transplant and hepatobiliary surgeon and Assistant Professor of Surgery at New York Medical Center, joined the program as its third transplant surgeon. Fresh from a multi-organ transplant fellowship, Dr. Veillette is enthusiastic about his new position.
“Dr. Wu had just started here when I heard about the program,” he says. “He is extremely eminent in the field for the excellent outcomes he achieves. As a young surgeon just coming out of training, I am excited to have such an experienced mentor.”
Together, these three surgeons are building a multidisciplinary team that includes not only transplant physicians, but also hepatologists, nephrologists, nurses, pharmacists, dietitians and a host of other support professionals. Dr. Wu’s philosophy of teamwork, attention to detail and efficiency is creating a successful and increasingly widely-known program.
Why the Team Counts
“We run our service as an integrated medical and surgical kidney and liver transplant program,” Dr. Diflo says. “The paradigm we use is really the multidisciplinary approach to rounds. Every morning the entire team, including surgeons, nephrologists, hepatologists, nurse coordinators and fellows, discusses the care and progress of every patient who is in the hospital for a kidney or liver transplant. Our transplant psychiatrist, infectious disease specialist, pharmacist and nutritionist also participate in the rounds. We take a well-coordinated and comprehensive approach that accounts for every aspect of transplantation, before and after surgery.”
Dr. Diflo prepares the patient for liver transplant while Dr. Veillette prepares the donor liver.
Headed by the five nurse coordinators, each professional in the group has a job to do, from the dietitians who measure patients’ caloric intake after surgery to the nurses who follow up rigorously on myriad details before and after procedures to ensure patients thrive in the long term.
“My first goal is quality,” Dr. Wu explains. “Without that, you waste an organ. You waste people’s lives. Good quality leads to better performance and lower costs for the business.”
To achieve quality, every detail must be accounted for.
“You must have an efficient, organized program that takes every discipline into consideration,” Dr. Wu says. “Transplants do not succeed by surgery alone, but through a combination of medicine, surgery, psychology and other fields.”
Dr. Veillette inspects the donor liver for suitability for transplant.
Prior to transplant, patients are screened to ensure they are good candidates, while conditions such as hepatitis or hepatocellular carcinoma are treated before surgery to ensure a higher chance of surgical success. After transplant, patients are closely monitored to ensure they do not experience recurrence of the cirrhosis, liver tumors or other factors that necessitated their transplant.
“If we detect these conditions early, we can treat them,” Dr. Diflo says. “We are in the process of developing a system to monitor patients with regular medical, psychological and social follow-up to ensure their surgeries continue to be successful.”
Surgeons remove the diseased liver.
Dr. Wu personally reviews all current and past transplant patients weekly with a hepatologist and nurse coordinator. Nurse coordinators function as managers and patient advocates for the transplant program, which is key to keeping up with all the patient details.
“Patients are closest to our nurse coordinators emotionally,” Dr. Diflo says. “These nurses meet with patients before they’re listed for transplant, help them with their medical evaluations for candidacy, follow them before and after surgery, assist with their medications and social service needs, and make sure they keep their appointments. Their position is key to both the short- and long-term success of our patients.”
All Hands on Deck
In the operating room, the centerpiece of Westchester Medical Center’s liver transplant program is a procedure known as cavaplasty. Dr. Wu, who developed the procedure in 1994, was involved in the liver transplant advances that made the technique possible.
“In 1987, I joined Dr. Thomas Starzl, who performed the first successful liver transplant surgery, at the University of Pittsburgh,” Dr. Wu says. “We were working on how to shorten transplant times and reduce the need for blood transfusions. Dr. Starzl developed a procedure known as the piggyback technique, which is still in use today.”
The piggyback technique was designed to limit hypotension and the bleeding common during traditional liver transplantation. By maintaining the retrohepatic vena cava, the procedure overcame some of these shortcomings.
However, the piggyback technique can lead to complications, Dr. Wu says, because there is potential for outflow blockage if the hepatic vein is too small.
“When I left Pittsburgh, I was contemplating how to solve this problem,” he says. “Numerous papers had been written about it. At the University of Iowa in 1994, I came up with a solution: surgeons could use the hepatobiliary vein and the vena cava to form a cavaplasty to the transplant.”
Dr. Veillette prepares the hepatic artery down to the aorta to allow adequate length for arterial anastomosis.
By sparing the vena cava, cavaplasty reduces bleeding and blockage, eliminating many surgical complications. Patients continue to receive blood from their lower extremities during removal of the liver, Dr. Wu explains, rendering them hemodynamically more stable. Cavaplasty makes liver transplant safer for patients who have cardiac issues or other conditions that make them unstable.
“With this technique, not one patient has experienced outflow block,” Dr. Wu says. “We can perform up to 30 percent of surgeries without the need for a blood transfusion. With an experienced team, I have completed the cavaplasty procedure in as little as 17 minutes.”
Dr. Veillette dissects the vena cava and hepatic veins to prepare for the cavaplasty procedure.
In the operating room, as on daily transplant rounds, it’s “all hands on deck” at Westchester Medical Center. The full complement of surgeons is present for every transplant operation, Dr. Wu says, with each contributing to the procedure.
“A good transplant operation team consists of senior, mid-level and junior surgeons,” he says. “We always have a senior surgeon for quality and safety. These surgeons provide in-depth experience. Junior surgeons have talent and strength. It’s like distance runners and sprinters — there are advantages to each.”
Surgeons bring their experience in different settings to the procedure, Dr. Wu adds.
“In the United States, surgeons move from hospital to hospital, bringing their best techniques and mixing them together,” he says. “They respect each other, and, joining their ideas together and learning from one another, they jointly discover and perfect new techniques. That is the beauty of the system.”
“One-Stop Shop” for Hepatocellular Carcinoma Patients
About half of liver transplant patients at Westchester Medical Center have hepatocellular carcinoma, or primary liver cancer. These patients’ medical needs extend beyond the domain of surgery and hepatology, Dr. Veillette says. To accommodate them, Westchester Medical Center has created a “one-stop shop” where patients can make a single appointment to meet with multiple specialists and have the best course of treatment mapped out for them.
“Surgery, medical oncology, interventional radiology and hepatology all participate,” Dr. Veillette says. “With long waits for donor livers in the New York area, patients wait a long time once they are listed for transplant, so we do the best we can to list them early.”
To do that, patients need a rapid disposition of their cases. Some will need liver resection but not transplant; others will need a transplant following interim radiological treatment; still others will not be candidates for any kind of surgery due to the size of their tumor or the fact that their cancer has metastasized beyond the liver.
Tests for hepatocellular carcinoma patients are scheduled almost immediately, and resection surgery generally takes place approximately one week following the patient’s initial appointment.
“This is a well-organized method for getting patients into the system and allocating the most appropriate treatment,” Dr. Diflo says.
A Bright Future
With a fourth transplant surgeon scheduled to join them this year, Dr. Wu expects his team to branch out into living donor transplantation and pediatric organ transplant. They also want to achieve a Center of Excellence designation for Westchester Medical Center.
“I was involved in pediatric liver transplants at the University of California, San Francisco,” Dr. Veillette says. “I’m eager to help Dr. Wu start a pediatric transplant program here.”
Dr. Wu is known for having performed the youngest successful living donor pediatric liver transplant — the patient was 19 days old — and for the 100 percent survival rate he achieved in pediatric transplants during 11 years at the University of Iowa.
“We have performed two pediatric liver transplants at Westchester Medical Center so far,” he says. “With our excellent children’s hospital and pediatric gastroenterology and hepatology services, I think we can develop a sizeable pediatric liver, kidney and small bowel transplant program here.”
With the demand for donor organs high and waiting lists long, living donor liver transplant is becoming an increasingly attractive option. While this program is still awaiting approval at Westchester Medical Center, Dr. Veillette, who has experience in living donation, is excited about bringing this opportunity to patients at Westchester Medical Center and their families.
Youmin Wu, MD, Chief of Transplant and Hepatobiliary Surgery at Westchester Medical Center, and Professor of Surgery, New York Medical College
“With donated organ allocation across the country so uneven, living donor transplant has the potential to save lives,” he says. “It is a high-stakes procedure, requiring rigorous preoperative workups for both the donor and recipient. Two surgical teams are required for the tandem procedures, which can take up to 18 hours. However, with a successful living donor program, patients who would otherwise have died while on the transplant waiting list have a chance at life.”
With all these developments in the offing for Westchester Medical Center’s liver transplant program, Dr. Wu is eager to have their superior work and excellent outcomes recognized with a Center of Excellence designation.
“This will signal to insurers and referring physicians that we perform high-volume, high-quality work,” Dr. Wu says. “My goal is simple: anything that any other transplant program can offer, we can do here.”
For more information, visit www.westchestermedicalcenter.com.