Press Conference: Duke Health surgeons perform first abdominal wall transplant in NC

Press Conference: Duke Health surgeons perform first abdominal wall transplant in NC


I want to thank you all for coming today.
I’m very honored to have been selected to represent the Duke transplant
programs today and really want to share an inspirational and emotional story
with you. Definitely a story of courage in the face of adversity, generosity in a
time of grief, and surgical innovation and expertise. I’d like to start first
with explaining a little bit about courage. Mr. Nauta who’s the recipient of
the intestine and abdominal wall transplant that we’re here to discuss
started his journey with us about four years ago and I won’t tell his whole
story. I’ll let him share what he would like, but when he came to us he was
desperately ill. His doctors at the outside hospital before referring him
had discussed hospice with him, and one of them had heard about Duke’s innovative
surgical programs and and suggested that maybe we could try to help save his life,
and thankfully they contacted us and we worked with him over many months to
perform many surgeries that eventually led to some stabilization and and he was
able to receive his nutrition through an IV catheter. Although we were not able to
restore his ability to eat at that time, we began to talk about what his
long-term options might be and we felt that intestinal transplant may be the
rest the best way to go, and in fact went ahead and went through an evaluation for
intestinal transplant, but we also knew that the amount of scarring he had had
at the time was too much for us to be able to provide coverage for the
intestine, and so we talked with Dr. Erdmann who I had worked with on a number of other complex patients to try to figure out what options we might have if
we did proceed with an intestine transplant. And at that time Dr. Cendales was here and had performed the first hand
transplant and developed the vascularized compassion composite tissue
allograft program, and so we began to talk about whether abdominal wall
transplant could be an option. Dr. Erdmann actually had started down this path
about 15 years ago when Scott Levin was here, and and he and Dr. Levin had begun
to think about abdominal wall transplantation and begun the
preparation with Dr. Ravindra’s help Detlev and Dr. Ravindra really did a
lot of work in preparation, and I’ll let them speak to some of the work that they
did, but without them this would not have been possible so definitely wanted to
thank them. I also wanted to thank Dr. Ravindra, as well as my other surgical
colleagues, specifically for all of the help that they gave in caring for Mr.
Nauta. Also want to mention Dr. Segovia Julie hire Julie Hudson and I want to
tell you a short story of the night that we actually called Mr. Nauta in for
transplant obviously it takes a multitude of people to to care for
patients through organ donation and transplantation but Michelle Hendricks
was our transplant coordinator that was on that night and some of you may recall
back in the middle of October we had some pretty bad storms and the power was
out and Michelle was on call I couldn’t get on to her laptop to perform the need
that just needed work to call in the patient in pardon me so she actually
went in search of electricity to a local establishment. I believe she said it was
Dougherty’s in Cary, and they provided her a table and an electrical connection
to allow her to do the things that she needed to do in order to call in Mr.
Nauta. So definitely an interesting evening. I
also want to thank our anesthesia colleagues. Our OR staff, Beth Hollister who is instrumental in helping us and setting
up the clinical research side, and I’d like to thank all of you for being here
to celebrate this event. Most of all, I think it’s remarkable that our donor
family has been here to share this with us today. If it weren’t for their
generosity in the time of grief, none of this would be possible. So thank you very
much.>>Good morning thank you for joining us my name is Detlev Erdmann, a German
name. I’m a professor of plastic surgery here at Duke University and as Dr. Sudan
mentioned I have worked with the abdominal transplant surgeons for quite
some time 15 years to be exact, and yes it is true we had in mind to perform an
abdominal wall transplantation for quite some time. We practiced this procedure in
the fresh tissue lab so we have a lab in which we can actually train ourselves to
perform these procedures we also invited a specialist from Great Britain to
assist us in the preparations who was here last year. And well my, my job my
assignment in this kind of scenario and Mr. Nauta’s procedure was to perform an
abdominal wall transplantation at the same time as Dr. Sudan and her team
performed the small bowel transplantation, so we are talking about
two procedures at the same time, which requires a major infrastructure a team
of 25 or more people working in the operating room and really everything has
to come together. What we also did by — in in our preparation — we found a new and
innovative way to reconnect the blood supply to the abdominal wall by creating
a what is called a vascular loop at the thigh level, so we are staying
completely out of out of the space of the transplant surgeons by performing
our revascularization, meaning restoring the blood supply to the graft, so with
this kind of technique we can actually work at the same time doing both
transplantation procedures without interfering with each other, and that is
the new thing that’s the message that I would like to to give you and we also
strongly believe that this type of this modification of this abdominal wall
transplantation will open the door to many more patients in the same
scenario like Mr. Nauta needing an organ transplant and having
major problems with the abdominal wall so surgeons may not be able to perform
the organ transplant without proper closing of the abdominal wall so, needless to say this is a great achievement. We are very happy that we
were able to to do this. I’m excited about Mr. Nauta’s recovery, the fact that
he is able to eat, the fact that he’s able to leave the hospital soon, as Dr.
Sudan told me earlier, and we are really really looking forward to all the
things that can happen in the future. We open the door to many, many more patients
and this is really something we want to we want to tell everybody. It’s not about
us, it’s about the innovation that we provided that hopefully can help many
more patients in the future. So, so again, thank you for joining us this morning. Thank you for being here, and I’m very excited for for all the for all the
progress with Mr. Nauta’s recovery. Thank you. I’d also like to invite Danielle Niedfeldt from the Carolina Donor Services, which is our local organ procurement organization through UNOS, to say a few
words as well. Thank you, good morning. It’s an honor to be here today. It’s an
honor to collaborate with an innovative team like Duke on this kind of research and innovation. I’d like to talk to you a little bit
about the donor and the donor process. When these gifts happen it takes an
innovative team like Duke, and it also takes a very amazing clinical specialist
and the local organ procurement organization. In this case it was
Carolina Donor Services. I’m very proud to be the CEO of that team, but most
importantly the gifts do not happen without the selflessness of a donor and
the donor’s family, so I’m going to talk to you a little bit about Marcus and
about his amazing family. So, Carolina Donor Services is very proud
to partner with Duke Health and other research institutions to provide these
gifts to save and enhance lives through organ and tissue donation. These gifts
are very special and unique in that the next of kin or the family authorizes
these gifts. They do not exist in the North Carolina donor registry, so it is a
very special circumstance with Marcus’s family. His parents identified that
Marcus was not going to survive his injury and in that moment, when they were
were dealing with such a tragedy, they actually stopped and asked the question
about organ donation. So we were able to start working with them. Marcus was a
great candidate for organ donation. They very generously authorized organ, tissue,
and eye donation, and then very early in our process, as we were doing other
screening we identified that Marcus was a great match for this abdominal wall
transplant, so we had an additional conversation with the parents and asked
them to consider this very special gift and it was very automatic for them. They
just wanted to help as many people as they could. Marcus’s donation was also
extraordinary in that typically, an organ donor, we’re able to transplant
three to four organs, and in Marcus’s case we transplanted eight organs with
six different recipients, so it was truly extraordinary in many ways. He and his
parents are heroes. I know a lot of people in this room feel that way and
there are many other recipients and people in their lives that definitely
feel that way. So with that I would love to introduce Marcus’s mom
Sherry. She’s here with some of her other family members and see if she’d like to
share. Marcus was loving and he was caring and
I know that he would be very pleased with what me and his father have chosen
for him since he can no longer be here with us. And we’re just pleased to be
able to extend his life through the other people and help give their
families the chance to be able to spend more time with their loved ones and so
on.>>I also wanted to give our recipient Mr. Johnathan Nauta an opportunity if he’d
like to say a few words and then we’ll open it up for questions after that.>>Good morning everybody. Dr. Sudan, Ravindra, Dr. Cendales and Dr. Erdmann. I’m just blessed to be here thank a lot above you know for everything and for Ms. Scales and her and her family. It’s truly a blessing to be here.
I’m just overwhelmed, a lot of happiness here with the team that, you know, placed
their healing hands on me. And not only did they change my life, they changed my
family life and other people’s that can possibly in my same situation
in life. So I’m just very thankful and blessed to be here. And for everybody’s
support, I really appreciate everybody thank you.>>All right, well I think that that’s the
end of our prepared remarks. And while I would like to open it up to allow
different folks to ask questions, you may ask them of anyone. I would ask Linda to
please come up to the table, as well, you may have some specific questions about
the VCA component. And if you can come to the table to answer those questions as
well.>>(Off-camera) Mr. Nauta, can you tell us your story?>>Yes, I started having, I guess stomach problems, when I was about six years old I’ll start with my appendix and then as
I got older, I had numerous surgeries for an intestinal blockage, scar tissue built up,
and just had numerous stomach problems and I guess this in 2014 when all this
really happened. — I’m sorry excuse me — Um, this all started down in
Fort Jackson, South Carolina, and ended up in a hospital there. And I ended up
being transferred here to Duke, Dr. Sudan’s team was here waiting on me. They was able to help me out, I guess. Then I had an intestinal blockage,
again. I was a Drill Sergeant leader in the Army, and I just kept
throwing up one morning, and I was just feeling very sick, very ill. Took myself
to the emergency room, and the last thing I remember was going to the operating
room September 24, 2014, and waking up here at Duke, October 5th, so 10 days, a lot, you know, has gone on with my family. I woke up with Dr. Sudan and they explained everything that has happened, and what, what they’re able to do. I guess we tried different, different procedures. I think 21. About 21 surgeries, and I think transplant was
like, the last resort, I think. This is from past, past stomach problems.
My appendix had ruptured when I was six years old. When I was about
11 years old that’s when I had an intestinal blockage
and I was actually here at Duke when, uh, when that happened. They started, I was
in a Womack Army Hospital when I had the intestinal blockage. They cut, I
guess, the piece that was blocked and put me back together. But I’m still
having complications. They transferred me here, to Duke, and um
received my care and they took care of me. I was here for about four — four or
five months — and then it happened again in 2010 at Fort Jackson, South
Carolina. Scar tissue had built up on that part that I had the intestinal
blockage. From what I know he — doctor — forget his name. I forgot his name. I’m sorry. He went in cleared that scar tissue out and I was good to go and then
this popped up again in 2014. Fayetteville favor was my hometown so that’s where I spent most of my life. My dad was in the military. He retired there in Fort Bragg. Um — what else.>>How did you keep going day
to day, having like these a series of medical problems and surgeries?>>Well, I was eating, eating normal, but
when I start feeling like, when I know something’s really wrong, I just
feel like dehydrated, couldn’t keep down anything, I was always throwing up like
every 30 minutes. I was trying to be hardcore, I guess. I didn’t want to go to the hospital. I’m thinking. because I felt a little better after I
threw up, but it just, I couldn’t keep anything down.
So I check myself in the hospital.>>Can you tell me a little bit
more about Marcus and his life and you said it was an injury that caused him to
pass away, and you knew this how this was was going to happen and and why you
wanted to donate so many organs and I guess what were those? And if you know
that that’s already gone to six other people? >>Marcus was a very loving and
caring person, so when it came down to make the choice to donate his organs, me
as his mother, I felt like you know it would be something that he would have
wanted done. We donated his heart, his liver, his pancreas, his kidneys, his
abdominal wall, his intestines, and his lungs, which all went to recipients right
away. When we were approached about the abdominal wall, I felt that you know if this
person who was receiving my son’s intestines needed his wall to keep them
protected, and to help, I had no problem doing it. >> I have a question for maybe one of the doctors. Can you explain exactly what an abdominal — I can’t
pronounce — can you explain what that is for like the
people who are not in the medical community, what all did it involve, what
all does it do? >>Sure, yeah, when you if you look down at your stomach that’s your,
that’s your abdominal wall. So it consists of skin, but it consists of
muscles. It’s the entire thickness of your tummy, so to speak, and under
the tummy are your organs, right, so the abdominal wall protects your organs and
is essential to anything we do in transplant surgery or Dr. Sudan’s team
is doing. So once we place an organ in the abdominal cavity, we also have to be able to close the abdominal wall —
muscles and skin — and you saw the pictures there. Mr. Nauta’s abdominal wall was just not sufficient to be closed over a small bowel
transplant. And the abdominal wall also contains the blood vessels to the
muscles, to the skin. So, we cannot just take an abdominal wall and place it on a
recipient. We have to restore blood flow, similar to a kidney or to a small bowel,
or to any other organ, we cannot just take that organ and place it somewhere. We have to restore blood supply. So an abdominal wall is basically an organ, but
it’s not an organ — it’s skin, muscle, fascia and all the components of the
tummy with its maintained blood supply. Does that make sense?>>Yes, it does. So this is the wall that you that was transplanted?>>Skin, muscle, everything including the
belly button, and that was very important for Mr. Nauta.>>Mr. Nauta, as I was
telling people the story that I’m doing today, I guess there’s a certain gross
factor with this how. How do you stomach — I guess, no pun intended — but how did you
stomach the transplant or just the news that you’re getting another person’s
abdomen wall. >>It’s a blessing you know like I said this was one of the options
that Dr. Sudan and her team, you know, came forward to me with. It’s, uh, it’s just mind-blowing to me, you know. I would have never thought this was
possible. I was truly blessed, you know. The doctors that you see up here, you know, I know Duke is all about Duke basketball, you know, but this
is — I’d rather be on this starting team right here any day, you know. Dr. Sudan and she’s gonna be Zion Williamson of the team. Dr. Erdmann be the R.J. Barrett. I’ll start the point guard, you know
do that since I’m a small one. And, you know, Dr. Cendales and Dr. Ravindra
you know, will be the ones throwing up the highlights for everybody. I’m just
blessed to be under their care, you know. This is what, I believe
this is the team that represents Duke, you know, as a whole. This is just
mind-blowing, this is amazing to me. I mean, it still hasn’t really sunk in with me yet. I just know that you know, now I’m part of another
family, the Scales family. I’m just truly blessed, and I hope to to take Marcus’s gifts, and just be, you know, be part of
that innovative, and research to help other lives, and to help you know anybody
else that’s in my situation. So if I can, you know, throw a advertisement
out, you know, this is, this is the place to be. You know, if anybody’s in my situation or somewhat my situation, you know, come
come to Duke, this is the team that you’d rather be with. >>But did anything
make you squeamish about it, just the fact this is …>>No, not really, I’m just glad
to have a belly button that, you know, I never had — I haven’t had … since the second surgery so … I was in sixth grade at the time. Sixth grade when I had the first intestinal blockage. So I haven’t had a belly button since then. So, looking down on it
I’m — it’s just a blessing. You know, I get to pick at something when I’m bored. But is this truly a blessing to be here, and, I can’t, I can’t thank the team. I
can’t thank Mrs. Scales and her family that much. But just a big
THANK YOU, and just God bless everybody here. >>Can you tell us about this — what was going on that 14 hours, and what the risk was involved and so the the donations
were both the intestines and the abdominal wall right does that make it
easier having that may would even be possible to have that from two separate
donors and not not very easily it may be possible but not easy so his intestinal
transplant took quite a long time to perform because of all of the prior
surgeries he had and the extensive scar tissue it actually took quite a while
before we were able to remove the very small amount of remaining small bowel
that he had and identify the vessels to hook the new graft to. So, a lot of
that time was done in preparation for the transplant and while we were working
in the abdominal cavity getting his aorta and vena cava prepared, the blood
vessels, prepared, Dr. Erdmann started working in the groins to prepare the
blood vessels where we could put the abdominal wall graft and then we brought
the organs from, Dr. Ravindra brought the organs from the donor
hospital and prepared them on the back table, and then he helped me sew the
intestine in, and Dr. Erdmann and his plastic surgery team sewed the
abdominal wall in, and it was really quite remarkable. It was incredible to
see his abdominal wall from the beginning to the end. You know, you can
see pictures here. I don’t know if it quite does a justice. But he really had
lived through quite a lot of of pain and suffering, not to mention not being able
to eat, and about a year ago he had a very significant complication from an
infection from his IV nutrition, and Johnathan
nearly died at that time, and we knew at that point there was some urgency with
which we needed to move to save his life, and this was remarkable when this all
came together. >>Yeah again, so if you say like oh this took 14 hours, it’s not only
the transplant process itself, it’s also the preparation for the actual
transplant. So we are not sitting there waiting for Dr. Ravindra to come in
and then we get started. We actually get started at the time when we get the call
from the outside that there is a gift available and, that is very important. So it’s the entire procedure, and I want to make this very clear again, so I was
leading the effort on the abdominal wall transplant, but I would never never be
able to do this by myself. So, I have very very valuable partners, trainees who
helped me during this process and it’s really, it is 14 hours of of work, but
everybody has to take a break in between. So it’s a constant team effort, and
again, not only by myself, I was the leader in this kind of part of the
procedure, but I had plenty of excellent, excellent help. >>Yeah I wanted to give a
little update, brief description of you know. One, the focus was obviously on [Mr.] Nauta getting this organ transplant, but a lot of events happened at the donor hospital
which CDS, you know Danielle, Ms. Niedfeldt, was mentioning, and it truly takes a
village for transplant to happen. Transplant is truly team work, and [Mr.] Nauta summed it up in a basketball analogy, but it’s really this one
specialty in medicine, but really involves teamwork, is transplantation. So
at the donor hospital, we had five different teams flying in — or I wouldn’t
say flying in — but coming from different hospitals some of them driving, some of
them flying, from different and all of them played in the same sandbox, so to
speak. And everybody was trying to get the organs for their own very sick
recipients, and all of this was possible because of Marcus and his mother and
mother’s willingness to donate and the liver was actually split into two — two
parts so that it could be used in two different individuals, one of which was
used at our center. The abdominal the bowel and the pancreas had to be
separated. That itself was a separate exercise. normally we take the pancreas
with the bowel as one to get extra length of vessels, but in this case we
were able to isolate and separate the two of them so that they could be used
in two different individuals and Marcus, we had to make sure that we got
adequate blood vessels and this all took nearly about five to six hours of work
at the donor hospital, which was going on simultaneously with Dr. Sudan and Dr.
Erdmann already starting here, so there was a close cooperation and I would
really like to thank the team at CDS. There are at least five of the
coordinators who were present at that occasion who made it all possible. There
was constant communication and two of my our own team members Dr. Shah, and Stuart Henry, were part of our procurement team who are present at that donor hospital
to bring it back. And once we brought it back, the rest of the events went as Dr.
Sudan described.>>And maybe it’s important for you to also
know that an organ transplant or an abdominal wall cannot sit somewhere for
many, many hours. So there’s, there’s a time limit until that graft
would potentially not do so well, so that’s why we are under tremendous
pressure in terms of timing. And if we then have to do two transplantations in
one patient at the same time, there could potentially, you know, be an interference
in terms of time and space, and we were, I think, elegantly getting around
this by being able to do both the revascularizations, meaning restoring
the blood flow to the organ and the abdominal wall at the same time, and I
don’t think that has been ever described in the way that we did it. >>Is that why
there’s only been about 20 of these in the past 20 years?>>That’s that’s probably
one of the reasons and Dr. Sudan mentioned earlier you really have to
have a a team of specialists, not only specialists in plastic surgery, but also
a specialist in a small bowel transplant, also a special in specialist in you
know, getting the gift from the outside. It’s nursing — specialized nursing care,
specialized intensive care, specialized anesthesiologist. People like
Danielle, who lead the effort of getting the gifts from the family. So
it’s really, it takes so much infrastructure and effort. That’s
probably one of the reason that only 20 have been done over the 20 years, and
also we need to have a good indication. We need to have a patient who is in this
in this kind of scenario, like Mr. Nauta, but what we are believing in that
there are probably plenty of patients at outside institutions who don’t even know
about what we can do and their physicians might not even
be able to get this information. This is why we’re sitting here today. Not
because of us, but to get the message out to other patients and really to
emphasize the donor family and Mr. Nauta>>How is this funded? >>Oh that’s a very good question. We do have a finance team that works with us and secured insurance
coverage for the combined transplant. We do that routinely with any solid organ
transplant, as our finance team will work with the patients and then look at their
insurance and find out what will be covered, and they did their work
beforehand. Part of the big team that is needed for transplantation. >>Do you still
have to pay for — did the insurance cover everything, and recovery and everything
else that you’re dealing with after this?>>Yes ma’am, I’m under TRICARE for life
for the Army. You know, also I’ll have the Medicare
Part A and B I guess, that’s uh taking care of it. But I believe there’s still some
out of pocket costs, and there’s — I enrolled in Help Hope Live organization, a
charity, to also help.>>All right, if there are no other
questions I think we can go ahead and wrap up, but thank you all very much for
coming and listening to the stories of Mr. Nauta and Marcus, and I really
appreciate your being here.

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