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Issue #10: June 29th, 2023

Updated: Sep 25, 2024

O what can ail thee, knight-at-arms,

Alone and palely loitering?

The sedge has wither’d from the lake,

And no birds sing.


O what can ail thee, knight-at-arms,

So haggard and so woe-begone?

The squirrel’s granary is full,

And the harvest’s done.


I see a lily on thy brow,

With anguish moist and fever dew,

And on thy cheeks a fading rose

Fast withereth too.


— John Keats, 1820, "La Belle Dame Sans Merci"




For years, lobectomy has been the standard surgical treatment for patients with early-stage non-small cell lung cancer (NSCLC), but what if a less invasive technique could offer better outcomes? Recent advances in earlier detection of smaller tumors has shown renewed interest in sublobar resection in contrast to lobectomy. In this multicenter, randomized phase III clinical trial, researchers compared sublobar resection (wedge resection or segmentectomy) with lobectomy in patients with Stage IA NSCLC that was 2 cm or smaller in size. The primary endpoint was disease-free survival, defined as the time between randomization and disease recurrence or death from any cause. Other endpoints included overall survival, regional recurrence, and postoperative expiratory flow rates. Sublobar resection was found to be noninferior to lobectomy in terms of disease-free survival, with the hazard ratio for disease recurrence or death being 1.01 (90% confidence interval, 0.83 to 1.24). The 5-year disease-free survival rates were 63.6% for sublobar resection and 64.1% for lobectomy with regional recurrence occurring in 1.8% of the patients after sublobar resection and 2.6% of the patients after lobectomy. Overall survival rates were similar between the two treatment groups. The study demonstrated that sublobar resection is a viable alternative to lobectomy for patients with stage IA NSCLC. These findings suggest that a less invasive surgical approach may be appropriate for selected patients, potentially leading to reduced morbidity and improved quality of life. However, it should be noted that individual patient factors and preferences should be considered when making treatment decisions. Further research is needed to validate these results and determine the optimal surgical approach for different patient populations.


Gastric cancer is the fifth most common malignant neoplasm and, presently, two surgical options exist for patients with potentially curable gastric cancer. Nevertheless, it is unclear whether laparoscopic or open distal gastrectomy produces comparable outcomes. The Chinese Laparoscopic Gastrointestinal Surgical Study (CLASS-01) trial is the first completed multicenter, randomized clinical trial to compare long-term outcomes of laparoscopic distal gastrectomy (LDG) with open distal gastrectomy (ODG) for locally advanced gastric cancer (LAGC). CLASS-01 participants were randomly assigned in a 1:1 ratio after matching for tumor stage, patient age, and histologic features to groups that underwent LDG (n = 528) or ODG (n = 528). No significant differences were found in three-year disease-free survival among patients undergoing LDG (76.5%) vs. those undergoing ODG (77.8%). The CLASS-01 trial outcomes have since been revised with five-year follow-up outcomes (the standard endpoint for any cancer trial). The Kaplan-Meier method was employed to evaluate the difference in overall survival between the groups five years following the procedures. The determined rates of five-year overall survival were 72.6% in the LDG group and 76.3% in the ODG group (log-rank P = .19; hazard ratio, 1.17; 95% CI, 0.93-1.48; P = .19). The results demonstrate no significant difference in the five-year overall survival rate of patients with LAGC treated with LDG with vs. ODG. These conclusions deliver further evidence for the safety and efficacy of LDG for treating locally advanced gastric cancer.


With over half a million of adenotonsillectomies performed annually in children 15 years and younger, the need for effective postoperative pain management is apparent. The procedure often presents with post-adenotonsillectomy pain on awakening (POA) that can be worse than initial preoperative pain score. The current methods for pain control in pediatric patients, such as narcotics and non-steroidal anti-inflammatory drugs, present an increased risk of respiratory depression and bleeding. Even the use of anesthesia can lead to emergence delirium (ED), for which there are no preventive measures or treatments available. While previous studies have found evidence of reduction in post-operative pain with auditory stimulation in adult patients, there has not been a randomized trial investigating intraoperative auditory stimulation in the pediatric population. In this single-center, double-blinded randomized clinical trial , researchers aimed to assess the effects of intraoperative auditory stimulation on reduction of POA and ED after pediatric adenotonsillectomy. A total of 115 children were randomized and 104 analyzed in 1 of the 4 groups: auditory stimulation with (classical harmony) music (n=26); auditory stimulation with noise (noise with heartbeat and a regular rhythm) (n=25); ambient noise insulation with earplugs (n=25); control group with no intervention (n=28). The auditory stimulation was individualized to optimize sound level and prevent hearing damage or ineffectual hearing levels. The POA was measured as pain greater than 4, and a Pediatric Anesthesia Emergence Delirium (PAED) score of 10 or more indicated the presence of clinically significant ED. The results showed that when compared to the control group, music had a large effect on POA (effect size (η2) = 0.63; 98% CI, 0.43 to 0.84; P < .001), and a medium effect on ED (η2 = 0.47; 98% CI, 0.21 to 0.75; P = .001). Noise had a medium effect size on POA (η2 = 0.47; 98% CI, 0.22 to 0.73; P = .003) and a large effect size on ED (η2 =0.63; 98% CI, 0.44 to 0.85; P < .001). The earplugs group showed a small effect size on POA (η2 = 0.05; 98% CI, −0.24 to 0.2;) and on ED ((η2= 0.17; 98% CI, −0.1 to 0.4). Based on the results, children stimulated music and noise had better outcomes. However, the subjective nature of pain scales, the type of surgery performed, route of administration of anesthesia as well as the duration can have bearing on the level of POA and ED seen in patients. Interestingly, the study does raise the question as to whether music or noise with emotional attachment to the patient can alter or strengthen the results. Future studies can investigate how the nature and properties of the auditory stimulation can influence POA and ED in the pediatric patients.



When we discuss anastomotic leakage (AL), the most severe complication following low anterior resection (LAR), we think of diverting stomas to prevent it, despite its high morbidity in patients. Previous studies have suggested the potential benefits of transanal drainage tubes (TDTs) as an alternative preventive measure. However, inconsistent results and limitations in previous studies drove the necessity to further investigation; Therefore, this prospective, multicenter, randomized clinical trial aimed to evaluate the use of TDT as a safe and effective measure preventing the incidence of AL in patients with rectal cancer undergoing LAR during a period of 30 days; comparing TDT insertion to non-TDT insertion after stapled LAR for rectal cancer. The AL rate was 6.4% (n = 18) in the TDT group and 6.8% (n = 19) in the non-TDT group, showing no significant difference (relative risk, 0.947; 95% CI, 0.508-1.766, P = 0.87). Subgroup analysis based on the presence or absence of a diverting stoma did not reveal a significant difference. Secondary endpoints, including bleeding and iatrogenic perforation, were not observed. However, they identified anal pain as a substantial factor. In conclusion, due to the unremarkable differences between groups, the use of TDT cannot be recommended, at least for this specific case scenario. ven though this study aimed to minimize the sample heterogeneity, eliminate biases, and do a stratified analysis to control confounding, it did not include patients undergoing other types of colorectal surgeries or patients undergoing preprocedural radiotherapy; also revealed findings that TDTs might not reduce the AL rate in patients with or without a diverting stoma and finally, many patients experienced postoperative anal pain, some reporting it as intolerable and unexpected early dislodgement of the TDT was another adverse event reported. Although it is important to note that the number of grade-C AL cases was higher in the non-TDT group, suggesting a potential efficacy of TDTs in reducing severe AL when a diverting stoma is not used, but in order to prove this, further research into larger populations is required.


Subspecialties: Cardiothoracics/Vascular


The standard for lung transplantation requires receiving organs from brain-dead donors. However, due to an extreme organ shortage in Japan patients may wait as long as 800 days before transplantation. Living-Donor Lobar Lung Transplant (LDLLT) initiated for patients who cannot wait for brain-dead donors due to severe respiratory distress. This was complicated in pediatric patients who couldn’t accommodate adult whole lobes due to small thoracic cavity volumes. In this study, investigators search for the possibility of using two separate adult donors’ basal or S6 segments rather than whole lobes in pediatric patients with extremely small chest cavities, a procedure termed Living-Donor Segmental Lung Transplantation (LDSLT).


The retrospective study analyzed 6 critically ill pediatric patients who received LDSLT, 4 of whom required transplantation due to pulmonary complications after allogeneic hematopoietic stem cell transplantation and 2 due to pulmonary fibrosis. A calculated donor functional vital capacity (FVC) of >45% of recipient FVC determined proper functional size matching. 3-dimensional computed tomography was utilized to determine anatomic size matching by comparing donor lung volume to recipient chest cavity volume. The average right graft to cavity volume was 190.5% (range: 122.9%-381.7%) and left graft to cavity volume was 161.1% (range: 95.4%-315.0%). The upper limit was set at 200%, and any size >200% was downsized by segmentectomy on either a back table or within the thoracic region. Three cases received a basal segment and lower lobe while the other three received a basal segment and S6 segment. After vascular anastomoses, all basal segments were rotated 90 degrees. Two of the three cases receiving S6 segments were rotated horizontally 180 degrees to accommodate for the extreme mismatch size.


Of the 9 segmental lung grafts (6 basal and 3 S6 segments) implanted, 7 (6 basal and 1 S6 segment) functioned well after transplant. The two patients with 180-degree rotated S6 segments experienced pulmonary congestion requiring immediate surgical intervention, where one sustained graft removal due to severe primary graft dysfunction (requiring ECMO) and later passed away from sepsis. The other required a re-anastomosis of the superior segmental vein, which improved drainage and resolved the edema. The other segmental graft complication was due to persistent air leakage requiring repeated pleurodesis by minocycline and an autologous blood patch. Overall, two deaths were observed with one patient on postoperative day 14 due to sepsis and the other after 9 years due to leukoencephalopathy. The median observation period was 1.3 years with no chronic lung allograft dysfunction in the remaining 4 patients. The septic patient’s graft volume was 465.7% of the thoracic volume and even after resection on a back table was still 341.6% leading to venous stasis and sepsis. Congestion seen in all 180-degree rotated S6 segments was believed to be due to possible vascular kinking after temporary closure, causing impaired venous drainage. LDSLT is believed to be a potential alternative solution for size mismatch in pediatric patients, but it is not without its limitations. This study had an extremely small sample size and with limited follow-up. Also, validity is difficult to achieve when there is no standard LDLLT control group. The procedure has potential, but more studies including multi-center, larger sample sizes, and with longer follow-up would be powerful in determining mortality and morbidity rates for pediatric patients undergoing LDSLT, especially as chest volume increases as patients mature into adulthood.


Subspecialties: Orthopedics


Calcaneal fractures are common in men of working age, but treatment varies from non-surgical to surgical techniques. Depending on classifications, type I usually only requires conservative treatment, but types II through IV usually undergo a procedure. However, robotics have become a vastly developing field within surgical options of treatment, including ones for calcaneal fractures. This study retrospectively studied 26 patients of age 18-65 years with closed calcaneal fractures of types II or III. These patients received either a robotic surgery with screw fixation (n= 15) or open reduction and internal fixation using a plate (ORIF) (n=13). Chi-square test results revealed that robot-assisted surgeries had significantly shorter waiting times preoperatively (p<0.001) and postoperatively (p=0.003) during their hospital stays. Four patients in the ORIF group experienced postoperative complications due to infections, lengthening overall recovery time. The robotic and ORIF groups did not have any statistically significant comparative data that portrayed superiority when solely comparing 3-month post-surgical data. Both groups had an overall satisfactory reduction of their fractures. This study efficiently revealed the competency of robot assisted surgical treatments for calcaneal fractures, but could be improved by studying larger sample groups while expanding criteria to include type IV fractures as well.


Subspecialties: Orthopedics


Virtual Reality (VR) could make it easier for orthopedic residents to learn tedious pediatric procedures. Implementing VR simulation could improve students’ ability to operate in 3 dimensions and understand obscured intricate anatomical relationships. For example, students who used VR were able to more proficiently learn how to perform delicate procedures such as Slipped Capital Femoral Epiphysis (SCFE) repair. Medical students and orthopedic residents were randomly assigned to a training group that only utilized a surgical technique guide and demonstration video or a group with the same material and VR training. After each group trained, they were all instructed to place a guidewire in a realistic model femur. Subjects in the VR group were 132.6 seconds faster at placing pins, had 70% fewer incidents of the pin going in and out of bone, and 50% less articular surface penetrations. Findings also suggest that VR training can highlight a trainees’ baseline and create tailored learning. However, a limitation of the study is the restriction on pediatric cases. One must be careful not to generalize the results of this study with the entirety of the surgical education process.


Subspecialties: Neurosurgery


Although frailty is defined as a condition of weakness or being delicate, it is a relatively new diagnosis that highlights the difference in an individuals chronological versus physiological age. Consequently, researchers have developed the Adult Spinal Deformity Frailty Index (ASD-FI) to predict the risk of complications in spinal surgery patients. While the impact of frailty on complex surgeries is well known, its effect on simpler procedures, like open transforaminal lumbar interbody fusion (TLIF), is not well studied. This study aimed to understand if frailty could help determine whether patients should undergo minimally invasive surgery TLIF (MIS-TLIF) or open TLIF based on their risk level. Using a retrospective analysis of 115 TLIF surgeries at a single center, 44 MIS-TLIF and 71 open TLIF procedures were compared for revision, discharge location, and frailty score. Univariate analysis and multivariate logistic regression were used to analyze associations and outcomes respectively.


Frailty was found to predict reoperation (p = .0005, 95% CI 2.5-26.1, OR 8.1) and discharge location ( p = .0239, 95% CI 1.2-12.7, OR 3.9). Post hoc analysis revealed frail patients had a revision rate of 51.72% for open TLIF and 16.7% for MIS-TLIF while patients without frailty had revision rates of 7.5% for open TLIF and 7.7% for MIS-TLIF. Ultimately, this study found that patients with frailty have higher rates of revision surgery and discharge to locations other than home for both open TLIF and MIS-TLIF when compared to those without frailty. However, the overall outcomes of MIS-TLIF were found to be better suited for patients with frailty. Although the association between frailty and complications may seem obvious, indications for open TLIF versus MIS-TLIF were not known at the time of data analysis and accurate measures for operative success rates (i.e., appropriate fusion based on postoperative CT) were not assessed, which may have unknown effects on the results of this study.


Subspecialties: Neurosurgery


All modern neurosurgeons are familiar with awake procedures for patients with arteriovascular malformations (AVM) in those same regions. In this multicentric consecutive series of 59 patients, pt underwent resection of cerebral AVMs located in eloquent areas and stratified into two groups: asleep) during operation (n=25) and awake during operation (n=34). Neurologic outcome was assessed preoperatively, at 1-month, and 1-year of follow-up using Karnofsky Performance Scale.

No statistically significant differences were found regarding the risk of postoperative complications, surgical radically, presence of residual lesions, and the need for adjuvant treatments. However, the improvement of functional recovery was faster and more effective during the follow-up of patients operated on in the awake stage compared to those who were asleep. Patients operated on in the awake state allowed for more precise brain mapping and superior neurological monitoring, which facilitates resection by defining safety margins without increasing the risk.


Subspecialties: OB/GYN


Vacuum aspiration, without direct visualization of the uterus, has been the gold standard to remove products of conception for years. However, there is concern for scarring of the uterus which could impact one’s fertility.The investigators in this study were interested in determining whether hysteroscopy, a procedure that allows visualization of the uterus, would lead to less scarring.

In this randomized, single blind clinical study, patients from 15 different centers in France who had experienced incomplete spontaneous abortion were blinded to whether they received a hysteroscopy with surgical resection or vacuum aspiration. By comparing the 282 patients who received a hysteroscopy to the 281 patients who received only vacuum aspiration, there were no statistically significant findings for fewer surgical complications and/or better future fertility than the other. Additionally, the patients in the hysteroscopy group were found to have longer surgery times, duration of stay in the hospital, and increased rate of uterine perforations and reintervention surgeries needed, although this was not statistically significant. The hysteroscopy group also had a higher failure of planned procedure rate (7% compared to the vacuum aspiration group). This aspect of the study was in part due to the inclusion of emergent patients, as well as the difficulty of hysteroscopy as a procedure.

In summation, hysteroscopy allowing for direct visualization seems to not provide any additional benefit compared to vacuum aspiration. In fact, it could contribute to an increase in adverse events. Limitations of this study include short term follow-up, particularly given that recommended time between parity is 1.5-2 years, and significant scarring which may impact future pregnancies was not directly studied in this paper.


Subspecialties: Urology


Is the solution to increasing efficiency and safety of pediatric kidney stone removal a single step? Percutaneous Nephrolithotomy (PCNL) is the gold standard for minimally invasive removal of large kidney stones, and establishing safe access is an essential step of the procedure. The small size and flexibility of the pediatric urinary tract can make establishing tract access particularly challenging leading to more potential complications and adverse outcomes in pediatric patients. To determine the optimal technique for tract dilatation, this randomized controlled study compared the safety, efficacy, and complications of single step track dilatation versus the traditional method of serial tract dilatation in pediatric percutaneous nephrolithotomy (PCNL).


Of the 70 pediatric patients who underwent PCNL in this study, 35 patients were randomized to recieve serial tract dilatation using Alken metal telescopic dilators, and 35 underwent single step dilatation over an Alken guide wire. Preoperatively, there was a significant difference between the groups with regards to demographic characteristics or stone burden. In all procedures, access was successfully obtained and the procedures were performed through a single tract. The rate of stone-free status in both groups was 94.3% at 1 month follow-up. The average access procedure time was 3.4 mins and 1.4 minutes for the serial dilatation and single step dilatation groups respectively (p=0.034). Patients who received single step dilatation had an overall lower incidence of complications within 24 hours of the operation (p=0.081), hemoglobin deficits due to blood loss (p=0.026), and fewer of these patients required blood transfusions (p=0.045) group than those receiving serial dilatation.


This study evaluated rate of complications within the first 24 hours postoperatively and confirmed stone-free status of participants in a one-month follow up. Future studies may benefit from evaluating larger sample sizes and accounting for additional complications and indicators of long-term success after the one-month follow up. Overall, this study provides promising evidence to support the use of single tract dilatation in pediatric PCNL procedures due to decreased procedural time and complications compared to serial dilatation with equal effectiveness in stone removal.



Radiology


Glioblastoma Multiforme: The Butterfly Tumor of the Brain


Case courtesy of Frank Gaillard, Radiopaedia.org, rID: 2589


Glioblastoma Multiforme (GBM) is an aggressive brain tumor associated with a poor prognosis. The above T1 MRI images illustrate GBM forming within both hemispheres of the brain. The central hypointense region is a mixture of necrosis and edema surrounded by hyperintense regions of white matter (the periphery of the tumor). While the images depict a GBM deep within the cerebrum, it is worth noting that GBMs may form anywhere within the brain. Treatment involves surgery, radiotherapy, and chemotherapy. However, for GBMs, the more common mode of treatment is with radiotherapy and chemotherapy rather than surgical resection.



References


  • Article: Radiopaedia (2023, February 19). Glioblastoma, IDH-wildtype. Radiopaedia. https://radiopaedia.org/articles/glioblastoma-idh-wildtype?lang=us

  • Image: Gaillard, F. (2008). Glioblastoma NOS (butterfly morphology). Radiopaedia.

  • https://radiopaedia.org/cases/2589?lang=us

  • Further reading on T1 MRI Imaging: Radiopaedia (2022, September 4). MRI Sequences (Overview). Radiopaedia. https://radiopaedia.org/articles/mri-sequences-overview?lang=us


SURGEON SPOTLIGHT OF THE MONTH


Dr. Thomas Earl Starzl


March 11, 1926 - March 4, 2017


“What was inconceivable yesterday, and barely achievable today, often becomes routine tomorrow.”

Dr. Starzl was a transplant surgeon whose achievements continue to make an impact in the lives of the over 144,000 annual organ transplant recipients worldwide. Known largely as the "Father of Transplantation," Dr. Starzl lived a life driven by curiosity and opportunity. It was said that Dr. Starzl stimulated his research and clinical teams to superhuman effort purely through the novelty of his work. He multiplied the effectiveness of his hands with intellectual passion and audacious leadership.

Thomas E. Starzl was born on March 11, 1926 in Le Mars, Iowa, the second son of first generation Czechoslovakian and Irish immigrants, Roman Frederick Starzl and Anna Laura Starzl.Following his service in the U.S. Navy after high school, Dr. Starzl obtained a bachelor's degree in biology in 1947 from Westminster College. He then went to earn his medical degree and doctorate in neuroscience at Northwestern University, which were both awarded in 1952. In 1950, Dr. Starzl also earned a master's in anatomy from Northwestern. It has been stated that Dr. Starzl was not the average medical student. One of his classmates described their medical class as, "142 medical students and Tom Starzl." Midway through his medical degree, Dr. Starzl took a year off to work with Dr. Horace Magoun on the organization and role of lower brain components. It was around this time that Dr. Starzl discovered the extralemniscal pathway, an alternative brain pathway for transmission of sensory stimuli to the cerebral cortex. This feat goes to show Dr. Starzl's inquisitive nature and pursuit of excellence.

Following graduation from medical school, he attended surgical residencies at Johns Hopkins University in Baltimore (1952–1956), the University of Miami (1956–1958), and Northwestern University (1958–1959). During his time at Johns Hopkins, Dr. Starzl characterized the first model of complete heart block in dogs. This method was devised for an eventual understanding of how to reverse complications encountered during open heart surgery. His brilliance again was at display but in a completely different field than neuroscience. Dr. Starzl clearly was a physician-scientist who sought opportunities to problem-solve for the betterment of patient care.

During his time in surgical residency, Dr. Starzl developed a keen interest in metabolism, leading to his interest in liver transplantation. Despite the relatively straightforward nature of liver transplantation [which consists of removal of the native organ and replacement with the donor graft via three vascular anastomoses and one biliary anastomosis], this would prove to be an incredible venture given the liver's need for double blood supply, highly variable coagulable state in liver disease, and lack of adequate immunosuppression at the time. Dr. Starzl's excellent surgical skills allowed him to dissect the high-pressure venous collaterals resulting from portal hypertension in his first ever attempt at liver transplantation in a 3-year-old child with biliary atresia. In this monumental procedure, Dr. Starzl was able to connect the donor graft to portal inflow instead of avoiding anastomosis to the portal system by connecting the caval system to inflow and outflow of the liver. The nutrient-rich blood provided directly by the portal vein was important for proper functioning of the graft. However, the problem of coagulopathy rapidly became evident, when despite Dr. Starzl’s extreme care and surgical precision, his patient exsanguinated during the operation. Following this dreadful event, Dr. Starzl knew that considerable hemostasis would be needed if liver transplantation were to ever occur and collaborated with Dr. Von Kaulla, a leading expert in the coagulation pathway. Dr. Von Kaulla pioneered use of epsilon amino caproic acid and specific coagulation agents which allowed liver transplantation to be tolerable. The lessons learned during Dr. Starzl's first attempt at liver transplantation, though detrimentally mournful and unfortunate, proved to be a foundation for an achievement that would later bring hope to millions worldwide.

After dealing with the issue of coagulopathy, the next problem that arose was the need for immunosuppression. At the time, organ transplantation was highly experimental in nature, and many other physician-scientists were unsuccessful in their attempts. Without proper immunosuppression, the average post kidney transplant survival period was less than 70 days, which was consistent with Dr. Starzl’s attempts in kidney transplantation.After the first seven unsuccessful liver transplants, five of which were performed by Dr. Starzl in the early 1960's, it was deemed that liver transplantation was highly experimental in nature. The lack of any immunologic regulation made the benefits of transplantation futile. It also made many doubt the overall feasibility of transplantation.

It may have been fate, but Dr. Starzl caught wind of a British transplant surgeon and researcher, Dr. Roy Y. Calne, who was using azathioprine to delay rejection of kidney allografts in dogs. Dr. Starzl obtained a supply of the new drug and began testing its effect in dogs he performed liver and kidney transplantation procedures on. Azathioprine alone only delayed signs of rejection for days or weeks;however, if a regimen of high dose prednisone was added, acute rejection was prevented and long term survival could be achieved. These findings spurred similar exciting results in human kidney allografts performed by Dr. Starzl. He would later present his substantial findings at the momentous 1963 National Research Council, during a time when there was a growing impression that organ transplantation was borderline unethical, should be ceased, and a pitiful attempt of physicians trying to assume the position of God. His presentation generated so much commotion that afterwards the council was described as, "Letting a genie out of a bottle." Many researchers followed him to Denver, where he moved following his first appointment at Northwestern, to learn of the immunosuppression cocktail he used to prevent graft and host immunological reactions allowing for long term survival of kidney allograft recipients in his care.

While Dr. Starzl's achievement with kidney allografts was tremendous, he was determined on completing liver transplantation with long-term survival. Equipped with his new method of immunosuppression, Dr. Starzl performed the first liver transplant in 1967 with long-term survival on a 19-month-old girl named Julie Rodriguez with hepatoblastoma. She lived 400 days but unfortunately passed away due to metastatic recurrence of her tumor. This success proved the concept of immunosuppression was possible with liver transplantation. It laid the groundwork for the numerous future successful transplant surgeries Dr. Starzl would go on to perform. From this point, he would continually refine his strategy for immunosuppression using agents such as cyclosporine and eventually tacrolimus, which is currently the gold standard for immunosuppression in transplant patients. Additionally, Dr. Starzl would contribute evidence that there existed donor-specific tolerance in organ recipients that worked in tandem with graft acceptance to promote successful outcomes. Dr. Starzl would also continue his experimentation by transplanting other organs and completing multivisceral transplantation; for example, completing the world's first heart and liver transplant on Stormie Jones, a 6-year-old female with severe heart disease from homozygous familial hypercholesterolemia on February 14, 1984.

Dr. Starzl is regarded as a pioneer to a field that many critics blatantly considered impossible. The book “1000 Years, 1000 People: Ranking the Men and Women Who Shaped the Millennium,” placed Dr. Starzl 213th on its list of those whose contributions have significantly impacted history. He was awarded many notable accolades, such as being inducted into the prestigious National French Academy of Medicine in 1992. On February 13, 2006, he was presented with the National Medal of Science for biological sciences by President George W. Bush in a White House East Room ceremony for his pioneering work in transplantation.

Dr. Starzl retired from clinical appointments in 1991 and stayed at the University of Pittsburg, where he moved following his short tenure at Denver. He spent his time actively in search of methods to refine transplantation. It was said that Dr. Starzl was a hospitable and welcoming host to guest researchers. He loved intricate discussions of basic immunology and seamlessly avoided clinical nuances for the betterment of patient care. His generous teaching and pedagogy was an expression of the American academic tradition.

Dr. Thomas E. Starzl, the renowned transplant surgeon and researcher, died at the humble age of 91 on March 4th 2017 in Pittsburg, PA. His death brought great mourning to the medical community he worked with throughout his career. Dr. Starzl was survived by his wife of 36 years, Joy; a son, Timothy, and a grandchild, Ravi. He was preceded in death by a daughter, Rebecca, and a son, Thomas.


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