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Stanford University School of Medicine

How mentorship shaped a Stanford surgeon’s 30 years of liver transplants

This year, pediatric liver transplant surgeon Carlos Esquivel, MD, PhD, is celebrating the 30th anniversary of his first liver transplant and his long career as a innovator of transplantation for tiny, fragile babies. When I was researching a story to mark the milestone, I wondered what led Esquivel to perform his very first transplant back in 1984.

As my story describes, a high-powered mentor shaped Esquivel's career:

Near the end of his surgical residency at UC Davis, [Esquivel] 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.”

The background to that first surgery, which didn't make it into my story, is quite interesting. When Esquivel arrived in Pittsburgh, Starzl’s team was conducting 300 liver transplants per year, sometimes several in a day. Esquivel was one of 40 fellows vying to learn the procedure. Surgeons operated with crowds of these apprentices peering over their shoulders.

Liver transplant was tricky. Because the liver performs many unique functions, including filtering toxins and secreting essential proteins into the blood, the patients were very ill.

“They’re some of the sickest patients in the hospital,” Esquivel told me. “When the liver doesn’t work, the blood doesn’t clot.” During transplant, patients could lose significant amounts of blood.

Esquivel was fortunate: As he described it, Starzl quickly took a liking to him. Many fellows were in Pittsburgh for a long time without being allowed to operate, but just three months after Esquivel arrived, Starzl said “Carlos, you are going to do your first liver transplant.”

Esquivel’s first-time jitters were mild until he learned that his patient was also a surgeon, a young surgical resident who had contracted acute hepatitis through a needle-stick injury. The man's liver was failing fast. He came to the hospital on a respirator, in a deep coma. Despite Esquivel’s anxiety the procedure went smoothly - so well that, when the patient woke up, he was hungry.

“Even still hooked up to the respirator, he was asking what there was for breakfast,” Esquivel said, adding the comment I quoted above about his amazement at seeing the awakening of someone who had been at death's doorstep. With Starzl's guidance, Esquivel went on to tackle the toughest liver transplants with aplomb, eventually saving the lives of many babies and young children whom other surgeons turned away.

After Esquivel shared his memories, I couldn't stop wondering about Starzl's influence. How did the senior surgeon pick Esquivel out of the crowd? Starzl is now professor emeritus at Pittsburgh, so I e-mailed to ask if he'd talk to me, and received a very gracious reply saying that he would "be glad to discuss my favorite person (Carlos Esquivel) at your convenience."

"He’s just an extremely nice man, but that’s only the beginning," Starzl said, when I reached him on the phone last month. In the profile, I quote him as follows:

“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 [of infants and young children]. “It takes a different level of skill than is required for adults,” Starzl said.

Still, how did Starzl know Dr. Esquivel had what it would take? When I posed this question, Starzl's tone of voice told me that, to him, the answer was obvious:

"Take a look at his fingers," Starzl said. "You can just see [it in] the way he uses his hands, the way he cradles pencils or takes care of objects that are important to him."

Though I'm sure that surgical virtuosity would not be obvious to me, I'm glad it was for Starzl, and I know the families of the more than 600 children Esquivel has transplanted are even more grateful. Happy 30 years, Dr. Esquivel!

Previously: Record number of organ transplants saves five lives in a day

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