Clinical Program

In 1984, Duke University Medical Center performed the first liver transplant in the Southeast. Program landmarks include approval as a medicare facility in 1994, the first center world-wide offering an ex-vivo transgenic pig liver perfusion system for fulminant hepatic failure, initiation of the living-related program for children in 1997, and live donor right hepatectomy for adult recipients in 1999.

The OR team consists of five transplant surgeons and five anesthesiologists, of which three have fellowship training in liver transplant anesthesia. Under the direction of the medical faculty, nursing staff have developed a focused subspecialty group, which participates in every liver transplant case providing a resource person to assist in surgical instrumentation and patient care. Dr. Robertson has served as Chief of Liver Transplant Anesthesia at Duke since 1994. Her experience in transplantation includes two years of fellowship training in liver transplant anesthesia with Dr. Thomas Starzl at the University of Pittsburgh and Dr. William Wall at the University of Western Ontario, and 15 years as an active participant on the liver transplant team. Her research interests in management of the deceased donor have expanded to include living-related donation and donation after cardiac death (DCD).

In 2002, a new model for assessing the medical urgency of liver transplant candidates (MELD: Model for End-Stage Liver Disease) was introduced by the United Network for Organ Sharing. This has resulted in a 6% reduction in the size of the liver waiting list, while the number of liver transplants nationally increased from 5,060 in 2002 to 5,534 in 2003. There was also a decrease in the overall waiting list death rate over the past 10 years, from 225 deaths per 1,000 patient years at risk in 1994 to 124 in 2003. As part of the HHS’ Gift of Life Donation Initiative, the Health Resources and Services Administration launched an “Organ Donation Breakthrough Collaborative” in 2003 with a goal to raise the overall donor consent rate to 75%. As a member of the ASA Transplant Committee, and representative to the Consensus Conference on Donation after Cardiac Death, Dr. Robertson continues her involvement in advocating best practices in organ donor care in the hopes that the availability and quality of donor organs will be enhanced.

Nationwide there are currently 121 programs sharing a pool of 5,600 cadaveric donors per year, with 17,700 patients listed as waiting recipients. Despite an increase in the number of transplants and survival rates, the demand for transplantation continues to grow. Within our region, the NCNC-OP 1 Carolina Donor Services recovers between 100-120 deceased donor livers each year which are shared by Duke University Medical Center, Carolinas Medical Center, and UNC Hospitals. The national one-year patient survival rate for liver transplants is 86-87%. To date, Duke has performed 529 liver transplants, 12 of which used a living donor.

Anesthesia faculty members provide 24-hour clinical coverage for 35 to 50 cases per year, from a waiting list exceeding 200 patients. With surgical preservation of the inferior vena cava, use of antifibrinolytic therapy, lowering cardiac filling pressures (low CVP anesthesia), and the infusion of octreotide for portal hypertension, blood product replacement therapy has been significantly reduced. Moments of excellence in patient care have included no transfusion, fast tracking with extubation in the OR, patient survival and hospital discharge following a massive intraoperative pulmonary embolism, use of nitric oxide and flolan to treat pulmonary hypertension and discharge of a patient from hospital on postoperative day 2.

Research Program

Our research interests include pharmacokinetic/pharmacodynamic drug studies of muscle relaxants, defining optimum perioperative care of the living liver donor, determining the clinical efficacy of octreotide, and assessment of the perioperative outcome of resuscitation therapy with 6% hetastarch in lactated Ringer’s solution.

Future endeavors will be focused on studies involving ischemia-reperfusion injury, increasing the overall donor consent rate, advocating and implementing an active DCD program, creating a template for a national teaching curriculum in liver transplantation and liver surgery and establishing best practice guidelines for the perioperative care for the liver transplant patient.

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Kerri M. Wahl, MD, FRCP(C)

Chief, Division of Transplant Services
Associate Clinical Professor of Anesthesiology

Faculty

Wilhem Lombard, MD (OHN)
Timothy Miller, MB ChB FRCA
Eugene Moretti, MD
Tony Roche, MD
David Wright, MB, Ch