Transplant pioneer celebrates 30 years of saving lives

Surgeon Carlos Esquivel was an early advocate of offering liver transplants to babies. Such operations once were considered too difficult. His work has saved hundreds of lives.

Carlos Esquivel was an early advocate for offering transplants to sick babies and children, who were often overlooked because of the difficulty of such surgeries. 
Toni Gauthier

Three decades ago, in the early days of liver transplantation, babies with liver failure usually died. Transplants were saving the lives of adults and older children, but were not offered to patients younger than 2. For these youngsters, doctors thought, the operation was too risky and difficult. But an ambitious surgeon named Carlos Esquivel changed that.

Now chief of the Division of Transplantation at Lucile Packard Children’s Hospital Stanford, Esquivel, MD, PhD, is lauded worldwide for his skill at performing transplants in very sick babies and children.

In 1984, he was a surgeon-in-training who wanted a challenge. He didn’t know he would become both an advocate for pediatric liver transplants and the leader of an extraordinary transplant team that helps patients progress to healthier, happy lives.

Near the end of his surgical residency at UC-Davis, the Costa Rican native realized that his planned career in vascular surgery would not challenge him enough. He sought a fellowship with the University of Pittsburgh’s Thomas Starzl, MD, PhD, who had performed the first successful human liver transplants a few years before and was refining the difficult, esoteric procedure. Soon, Starzl guided Esquivel through a transplant on a man with acute liver failure who had come to the hospital in a deep coma. The operation went well. Two days later, the patient awoke.

“Once I saw that — somebody who was at death’s doorstep waking up — it was unbelievable,” Esquivel said. “I never looked back.”

An early focus on babies

He focused his attention on the babies who weren’t being offered liver transplants. Many had a congenital defect called biliary atresia, which causes liver failure in infancy or toddlerhood.

Patients with liver failure are some of the sickest in the hospital.

“There are huge difficulties with transplanting these patients,” said Esquivel, who is the Arnold and Barbara Silverman Professor in Pediatric Transplantation at the School of Medicine. When the liver doesn’t work, the blood doesn’t clot, increasing blood loss during surgery. The problem is worse for a small patient who has less blood. Hooking up an infant’s tiny blood vessels to the donated organ is also difficult. And these children are small for their age because liver failure hampers growth. In short, said Esquivel, “Patients with liver failure are some of the sickest in the hospital.”

But without transplants, they invariably died. So Esquivel began trying to transplant them. At first, about 70 percent survived.

“Going from 100 percent mortality to 70 percent survival was a huge improvement,” Esquivel said. He published his results in 1987 and began advocating that infants and small children should be offered the benefits of transplant.

“The whole field was just undergoing a revolution,” said Starzl, now professor emeritus at Pittsburgh. Esquivel’s scientific inquisitiveness and warm, sensitive character made him a good person to advance the field’s transformation, Starzl added. But it was his surgical skills that really set him apart.

'Virtuoso qualities'

“He is instinctively a tremendously good surgeon,” said Starzl. “He has the kind of virtuoso qualities that you can’t teach.” Those skills allowed Esquivel to consistently reconstruct the tiny blood vessels and ducts that feed the liver. “It takes a different level of skill than is required for adults,” Starzl said.

From Pittsburgh, Esquivel moved to San Francisco’s Pacific Presbyterian Medical Center (now California Pacific Medical Center) to build a multidisciplinary team to address the many facets of transplant care.

We have been able to put together an unbelievable team.

In 1995, that team came to Lucile Packard Children’s Hospital Stanford, and built a program now recognized as one of the largest and most experienced in the world. They have performed more than 600 liver transplants, including some in which patients also received another organ, such as a heart, kidney, lung or intestines.

In 2013, the team achieved 100 percent one-year survival for their liver transplant patients, a rate that is higher than expected given the acuity of cases they undertake. Their advances include developing regimens of immunosuppressive drugs with fewer side effects; offering liver transplant for new indications, such as inherited metabolic diseases; and pioneering a clinic where teenage transplant recipients learn to take responsibility for their own care.

“We have been able to put together an unbelievable team,” Esquivel said.

Meanwhile, Esquivel still cares for the tiny, fragile babies who inspired him decades ago. Biliary atresia remains the leading cause of childhood liver failure, and many hospitals still turn down difficult cases.

Giving new life to sick youngsters

One such case involved Zachary Teczon, whose health was deteriorating quickly when the team decided that, at 7 months old, he could wait no longer for a liver transplant. In an operation that made use of all of Esquivel’s years of surgical innovation, Zachary received his new liver on Jan. 28, 2012. After months of watching Zachary get sicker, his mom, Jennifer Delia, will never forget how she felt that day.

“I was scared but happy that he was going to have a new life,” Delia said.

The next day, she was relieved and elated when Esquivel came out of the operating room to tell her that Zachary’s operation was a success.

“He saved my baby,” Delia said. “There’s really nothing I can ever do to thank him enough.”

For Esquivel’s part, he’s grateful to see transplant recipients grow and thrive. He loves getting messages from the families of young people, now in their 20s, like Kelly Olmo of Oakland, who was one of his earliest patients when she received her transplant 25 years ago at age 2. Hearing about the lives of former patients like Kelly — and the joy their families feel from watching them grow — convinces him that the difficulties of being a transplant pioneer are worthwhile.

“It’s very moving,” he said. “It’s really the best possible reward.”



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