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A legacy of leadership in hepatology

Liver research at Yale
Photo by Vshivkova
Liver research at Yale
Liver research at Yale was brought into the modern era with a successful biopsy by Gerald Klatskin, MD, in 1947.

Among the many reasons the VA Connecticut Healthcare System in West Haven is regarded as one of the best in the country is its expertise in treating liver disease. This legacy extends back over decades and is the result of many illustrious physicians and researchers building on the work of their predecessors. These same individuals are recognized for having played a role in developing Yale School of Medicine’s reputation as a leader in the field.

Guadalupe Garcia-Tsao, MD, chief of digestive diseases at the VA Connecticut Healthcare System; professor of medicine (digestive diseases); and director of the Clinical and Translational Core of the Yale Liver Center, highlights one aspect of the VA CT’s success: the superlative doctors and the longstanding reciprocal relationship between the Yale School of Medicine and the VA. Another is the strong history of liver research. “From Gerald Klatskin, MD—a veteran himself—to Harold Conn, MD, and Roberto Groszmann, MD, there has been a legacy of excellence here at the VA,” said Garcia-Tsao.

Klatskin performed the first liver biopsy at Yale in 1947. Conn’s studies resulted in the West Haven Criteria, a globally adopted grading system for hepatic encephalopathy (altered level of consciousness resulting from liver failure). Groszmann focused on cirrhosis and portal hypertension. Each researcher’s work overlapped and assisted with those of the others. Garcia-Tsao led the VA CT Hepatitis C Resource Center, one of four centers nationally funded for over 10 years for the treatment and research of hepatitis C. During this time, VA CT developed an enduring reputation for excellence in liver education, research, and innovations in health care delivery.

James Boyer, MD, Ensign Professor of Medicine (digestive diseases), who founded the Yale Liver Center in 1984 after his mentor Klatskin retired, noted that liver research at YSM and the VA were for many years inextricably intertwined. “For many years, Dr. Klatskin would give a talk every week at the VA. It was where he’d buy the Edgeworth tobacco he’d smoke in his pipe, at the commissary,” said Boyer. “Klatskin’s efforts here and in West Haven laid the groundwork, along with Conn and Groszmann, for the work we do today.”

Boyer remembers Klatskin with great respect, and wrote a compelling tribute to the man who hired him into his laboratory—a speech published by the American Gastroenterological Association in the December 1983 issue of Gastroenterology on the occasion of Klatskin’s receipt of the Julius Friedenwald Medal.

That great legacy is carried on by current faculty appointed primarily or exclusively to the VA. Garcia-Tsao, who spends much of her time tending to patients, has many positive things to say about them as individuals and as a population. “Veterans are incredibly generous as patients and as research subjects,” said Garcia-Tsao. “They are used to service, and when offered opportunities to participate in research, veterans are almost always excited to help.”

Doctors enjoy the sense of purpose derived from caring for veterans and from the benefits of a nationwide health care system focused entirely on caring for this population. “The patients here are extraordinary, and it’s a privilege to work for them,” said Tamar Taddei, MD, associate professor of medicine (digestive diseases).

One patient of Taddei’s, James Cochrane, credits her with saving his life. Discharged from the Navy in 1974 after a three-year stint, he waited until 2010 to seek treatment. “A lot of guys don’t think about the VA when they’re getting out. All they want to do is move on from the service,” he said. It was good that he came when he did; he was diagnosed with end-stage liver disease in 2011. “They told me in March of 2012 that it was over if I didn’t get a transplant, ‘say goodbye.’ ” Cochrane said. “Once I said I was onboard with receiving a transplant and doing everything I needed to to make that happen, including getting 100% sober, Dr. Taddei moved heaven and earth for me.” Cochrane received a transplant at the Mayo Clinic in Jacksonville, Florida, in 2014. Taddei “fought to get me listed for a transplant,” Cochrane said, “I owe her my life.”

Some wish to discontinue government funding for veterans’ health care under the assumption that private health care will better serve this population. Taddei is unreservedly set against privatization initiatives targeting the VA. Apart from the longer waits for “care in the community”—two to three months, as opposed to 14–30 days in the VA—Taddei thinks that providers who spend their careers working with veterans come to know more about efficient health care delivery for this population than private-sector practitioners.

“Take hepatitis C,” Taddei said. “The incidence of this in the general population is 1.4%. But it’s as high as 12–20% among veterans born between 1945–65, especially those who served in Vietnam. The odds are pretty slim of receiving better treatment anywhere else than you can find here.” Recent efforts to cure all veterans with hepatitis C infection have met with success, according to an article posted on Military.com by Patricia Kime on June 4, 2019. Nearly 100,000 of the 126,000 veterans infected with hepatitis C have been cured to date.

Despite the great success in curing hepatitis C, the prevalence of cirrhosis is increasing in the VA, and VA CT is focused on improving care of patients with advanced liver disease. Patients who suffer from cirrhosis are at high risk of developing liver cancer. VA CT is a regional center for liver cancer care, harnessing telehealth technology to manage patients diagnosed with hepatic cancer through a weekly multidisciplinary liver tumor board attended by providers in Connecticut, Massachusetts, Vermont, and Rhode Island.

“West Haven is great,” said Cochrane. “Everyone there has looked out for me from day one, and I still see Dr. Taddei and her team once every three months. It’s a wonderful place. I don’t know where I’d be without it.”