Dr. Lobritto: [upbeat music] The medical director of a large transplant program in the south, the largest in the country, uh, had a baby that was on their transplant list for six weeks or so.
Erin Welsh: Dr. Steven Lobritto is the pediatric medical director for liver transplant at NewYork-Presbyterian and Columbia.
Dr. Lobritto: This baby was born early July, and, uh, birth weight was less than two kilos.
Erin Welsh: The patient was now two months old and in extremely fragile health. Most critically, she needed a new liver.
Dr. Lobritto: In multi-organ system failure, um, was on a ventilator, was on dialysis to control the hyperammonemia or, or encephalopathy, had a cardiac arrest. The baby was resuscitated for, like, 45 minutes, had bleeds into the brain, had, had seizures, had infections that were being treated, and on-and-off infections, lines in and out.
Erin Welsh: At two months old, this baby was only 11 pounds. Because of her age and size, she needed a partial, rather than a whole liver transplant.
Dr. Lobritto: There are centers, uh, even large centers, that only do whole livers, and trying to find a full organ for a five-kilo kid is, is not gonna be easy no matter what region you are in the country. So, it sort of begs itself for a partial liver. But even a partial liver, an adult partial liver, would be [laughs] a big liver for a baby this small.
Erin Welsh: The transplant center where the patient and her family originally sought treatment was not able to perform this type of complex partial liver transplant on a patient this small and this sick.
Dr. Lobritto: This patient had deteriorated to the point that without transplant, the baby wouldn't survive.
Erin Welsh: That's when the center reached out.
Dr. Lobritto: To see if we would be able to take on transplantation at our center, especially with our expertise in partial organs and living donation. Our death on the waiting list is almost nonexistent, where in the country it's probably upwards of 6% of the patients who are waiting for livers die waiting for livers. We consider ourselves the court of last resort. If we can't do it, nobody's gonna go someplace else and have it done.
Erin Welsh: [upbeat music] I'm Erin Welsh, and this is Advances in Care.
Today, Dr. Steven Lobritto tells the story of a high-risk pediatric liver transplant that required cross-state collaboration, unique surgical expertise, and multidisciplinary coordination to save the life of a critically ill, two-month-old baby.
Dr. Lobritto: We do offer unusually innovative surgeries here.
Erin Welsh: Dr. Lobritto has been involved in building the liver transplant center at NewYork-Presbyterian and Columbia since 1998, when he began collaborating with leading transplant surgeon Dr. Jean Emond.
Dr. Lobritto: He was involved in the first living donation from a parent, uh, in this country. He came to a faculty meeting asking for hepatology support. I started working with his team and really fell in love with transplant. [gentle music] A lot of programs in the country, the hepatologist, the medical people took care of somebody pre-, and then the surgeons would take over after the surgery, and we did not do that from the very beginning. So it's not just bringing in a famous surgeon who's quite good. It's having a good anesthesia team that can keep the patients going. It's having radiology be premier, having pathology premier, you know, having, um, the intensive care unit trained to take care of these patients both pre- and post-transplant. And I think that's why we were successful, because we knew the elements that needed to be there, and we were able to put it together with the support of the hospital.
Erin Welsh: Almost 30 years later, the liver transplant center has performed more than 3,500 transplants for children and adults. This transitional cross-disciplinary approach has laid the groundwork for Dr. Lobritto and his team to become leaders in the most cutting-edge liver transplantation techniques.
Dr. Lobritto: There's a lot of other transplant centers in the city. A lot of the other centers might take some of the easier cases, and what's left for Columbia is, is certainly some of the hardest cases.
Erin Welsh: Dr. Lobritto and his team routinely execute surgeries other centers can't take on. For one, they're experts in living donor surgery, which significantly increases access to organs for patients who are awaiting transplant. And critically, they're skilled in partial liver transplant techniques.
Dr. Lobritto: In the case of acute liver failure, we actually remove half of their liver and only transplant half a liver. That's called an auxiliary partial liver transplant. You need to have a partial liver expertise in doing that. Um, we allow the native liver the time it needs to recover, and if it does recover, we then can slowly withdraw the immunosuppression so that the patient gets their transplant, survives the acute failure, but then doesn't require meds lifelong. That's, uh, certainly not a standard of care in, in most places. A lot of surgeons in this country don't do partial livers at all. A lot of it has to do with the surgical expertise. There is a learning curve to these operation, and certainly partial liver transplants is one of Dr. Emond's expertise, and now the entire team embraces that.
Erin Welsh: The ability to perform a partial liver transplant is especially crucial in cases involving small children, where it's unlikely that a whole organ will become available that matches their exact size and age. Because of this, children under a year of age have the highest death rate on the transplant waitlist.
Dr. Lobritto: The ideal liver would be age match, size match, blood type match, local, and those just don't come up for a, for a five-kilo baby [laughs] you know, very often. The smallest child we've ever transplanted, I believe, was about 1.8 kilos, which is, you know, relatively, uh, unusual, and, and it's, I think the smallest one ever reported.
Erin Welsh: So, when Dr. Lobritto received a call about this very sick, very small child in need of a liver transplant, he was confident NewYork-Presbyterian and Columbia could take on the case.
Dr. Lobritto: [gentle music] They were going to withdraw care. You know, they, they couldn't offer transplantation, and knowing their limitations. They weren't getting any offers, and by the time they thought they might get an offer, they felt that the baby was too sick to transplant. Based on our history, I don't consider anybody untransplantable. [laughs] I have high expectations of what we can do. There was a lot of things going on that made even the idea of transferring a baby this sick quite hazardous. We first had to come up with a way to get the baby here safely that wouldn't jeopardize or wouldn't cause, you know, an incident on the way here. The baby had had a cardiac arrest in early August, and had some subdural hematomas in the brain, and, uh, had a seizure in that setting. At this point, things had settled. But we have a baby on a ventilator, you know, and the, and the ventilators we use in the hospital are not the ventilators that can travel in a plane or, uh, travel anyway. So we had to put the baby on a travel ventilator, which has different dynamics than the standard ventilator that people use, to demonstrate that they could ventilate the baby effectively, you know, for the eight hours or so we, we assumed it would take to get here, get transferred from the hospital to the s- airport, airport to the hospital, that kind of thing. The other thing we had to make sure is that the baby would tolerate being off dialysis. So the baby was on continuous dialysis. The baby had very high ammonia levels, you know. High ammonia levels take a very short time to basically destroy your brain. So we trialed the baby off the CRT circuit. We aimed for about an 8 to 12-hour period to see if the baby would tolerate that. So we had demonstrated that with the right, you know, team and the right setup and a medical transport, that this baby would be able to survive the transport.
Erin Welsh: Once Dr. Lobritto and the patient's care team coordinated logistics to ensure the baby could survive transport, they got on a plane.
Dr. Lobritto: We have them, um, take a commercial flight. They clean out the, the last six r- you know, rows of seats, and they have a medical team there. There's literally an ICU attending, there's a nurse that accompanies them, people that can intubate the baby if necessary. There's people that can resuscitate the baby. You know, it's a full ICU on wheels, if you will. Everything that needed to be done that was being done in a hospital had to be done in midair.
Erin Welsh: When they arrived at NewYork-Presbyterian and Columbia, Dr. Lobritto's multidisciplinary team stabilized her for surgery. However, they still needed to wait for an acceptable organ.
Dr. Lobritto: You know, in the time that you're waiting, any day you don't make progress, I don't care if it's a little bit more feeds, one less infection, one less medication, is a wasted day, you know? So we try to make some effort to make a positive move every day. We knew that her lungs would require, uh, long-term weaning, so we involved our ENT colleagues, knowing that the patient would need a tracheostomy post-transplant in order to permit the slow wean that was gonna be necessary and rehab these lungs in a premature baby that was insulted for weeks, you know. We made sure that any infection that was, that was present was cleared up, and we optimized nutrition and the hemodynamics of the baby. So all of that was done, you know, within a short period of time. Ducks were in a row, and about 11 days later, we, we got an organ, we got an offer.
Erin Welsh: The patient's parents consented to the operation, a partial liver transplant from a deceased donor, and the transplant team gathered to assess their approach and the potential risks ahead of surgery.
Dr. Lobritto: What our center does is we have a huddle. We have a huddle among, uh, the anesthesiologist, the ICU, the hepatologist, and the surgeons, and discuss the logistics of the transplant, you know, uh, the timing of the transplant, what we're gonna do in the operating room. I think the biggest risk as baby is that even though this liver was partial, it was, it was large for this child. So the cardinal sin in transplant is close the abdomen too tight. You know, when you squeeze the liver, uh, you squeeze the blood vessels, and thrombosis after transplant is disastrous. And if the artery goes out, the liver sometimes needs to be replaced urgently within a few days, or the patient will die.
Erin Welsh: Because of the small size of the patient, surgery would be particularly complex. Close coordination in the operating room was key.
Dr. Lobritto: The select team that's been trained, that know the instruments, that understand the surgeon's preference, they are craftsmen, and there's styles of the surgery that's not universal. So these OR techs know what the surgeon's gonna ask for before he even asks for it. Takes a lot of coordination. It takes a lot of resources, but the hospital is committed to this and the outcomes are, are great. So the transplant [laughs] actually went quite smoothly. I think it was the, the preparation that was the most important part of that. The baby was left open, you know, meaning that we had put an interposition skin graft made of GORE-TEX that allows the abdomen to, to be closed, so you're not seeing internal organs, but there's enough room in there that the liver is not smothered. The mother was relieved, you know, “My baby survived.” You know, survival is goal one, right? But it's not. Survival's not good enough, right? Getting the transplant done is the beginning of the journey. It doesn't end with the transplant, you know. The care is lifelong.
Erin Welsh: After her surgery, Dr. Lobritto and his team monitored the patient closely. Their next challenge would be to make sure she remained healthy enough for the long trip back home. But they noticed an issue.
Dr. Lobritto: This baby actually had a complication in that the bile duct was narrow. So even though the surgeons sew it in a way that permits it to grow over time, there's some edema at the, at the site and, and sometimes even some scar tissue that can form. Our partners in the radiology field were able to put a catheter through the skin that went into this liver and bridged that area and let us serially dilate it over time.
Dr. Lobritto: Every day we have to make progress. The ventilator settings are less, so the baby's breathing better. You see us pulling out lines, pulling out catheters, removing the dialysis.
Erin Welsh: After a high-risk transplant and five months of intensive care in New York, this baby, who had arrived at NewYork-Presbyterian and Columbia critically ill and almost out of options, was stable enough to be sent home with her family.
Dr. Lobritto: She went back in February, and, uh, she's now, uh, discharged.
Erin Welsh: Dr. Lobritto credits the success of this complex transplant to the expert collaboration between all members of his cross-disciplinary team.
Dr. Lobritto: You know, transplant's a high-risk sport, right? It's the whole team. You know? It's the abilities of the ICU to keep this baby stable to get her to transplant. It's our nutrition team that, that helped buff this baby so that she would heal post-transplant. You know, the anesthesia team and what we're able to do, and if there's a complication, that we'll be able to deal with it, that we have the interventional radiology capabilities to intervene without doing repeat surgeries. It's our surgeons' ability to do very small children and to do partial livers, so we knew we would get an organ for this baby. All of that goes into, into the success of this program. We're never satisfied. We're constantly trying to, you know, push the envelope and innovate.
Erin Welsh: Dr. Lobritto's dedication to innovating in the field of transplant extends to his work as co-chair of the STARSL Network, a consortium of 26 hospitals that share protocols, best practices, and learnings to elevate pediatric organ transplantation. For example, he advocates for partial liver transplant, the procedure that saved the two-month-old baby, to be universally taught as a requirement of surgical training, and for innovative organ procurement techniques like living donation to be more widely adopted.
Dr. Lobritto: There's a learning curve in doing this technique, which is gonna be, you know, earth-shattering and game-changing in the future. It shouldn't be that if I live in the middle of the country that I cannot go to a center that does partial livers. We have to offer that in a better way. You know, living donor, there's almost a endless supply of, and it's a superior graft. So most of our transplants done this past year were living donor. We've done the most living donor in the country this, this past year, and the majority of our transplants, I think it was 60/70%, were done with living donation.
Erin Welsh: With the increased access to organs that these cutting-edge surgeries offer, more children will have the chance to grow up, lead normal, active lives, and flourish.
Dr. Lobritto: If you came to my clinic, you couldn't tell which patient had a transplant and which one didn't, and that's exactly the goal. They should live a normal life, and I tell you, if you come to my clinic, they're tearing up the office the same way as, as any other child would do. [laughs]
Erin Welsh: That chance at a normal life is exactly what Dr. Lobritto and his team were able to offer that two-month-old baby. It may seem extraordinary, but for Dr. Lobritto, it's central to the mission of his work.
Dr. Lobritto: It's who we are. It's not like, oh, we did it for this child. This is what we do. [upbeat music]
Erin Welsh: Thanks so much to Dr. Steven Lobritto for his insight into the cutting-edge mindset required to push forward innovative techniques in pediatric liver transplantation, and for his passionate advocacy to go above and beyond for children in need of liver transplant.
Erin Welsh: I'm Erin Welsh. Advances in Care is a production of NewYork-Presbyterian Hospital. As a reminder, the views shared on this podcast solely reflect the expertise and experience of our guests. To listen to more episodes of Advances in Care, be sure to follow and subscribe on Apple Podcasts, Spotify, or wherever you get your podcasts. And to learn more about the latest medical innovations from the pioneering physicians at NewYork-Presbyterian, go to nyp.org/advances. [upbeat music]
