Putting the fire back into Yale's transplant program

When Prometheus stole fire from the gods, Zeus condemned him to have his liver eaten by an eagle every day. The myth, says surgeon Sukru Emre, M.D., shows that the ancient Greeks knew that the liver could regenerate—a property that makes it possible for Emre to take part of a healthy person’s liver and use it to sustain another’s life. The story of regeneration also serves as a metaphor for Emre’s new role as chief of Yale’s Section of Organ Transplantation and Immunology, where his charge is to revive a largely inactive liver transplant program while strengthening Yale’s kidney and pancreatic transplant programs as well. Like the classic tale, this story has a hero: Emre himself, a transplant surgeon of international reputation whom patients and colleagues alike praise for his skillful innovation, work ethic and ability to empathize with patients and their families.

Emre prefers to think of himself as a team builder. “Could this work if a single part were missing?” he asks, pulling up his sleeve to reveal his watch.

Emre was director of the adult and pediatric liver transplant programs at Mount Sinai Medical Center in New York for five years before joining the Yale faculty in July. At Mount Sinai his pediatric team achieved a 98 percent one-year survival rate and a 92 percent five-year survival rate while increasing the patient census of 15 to 17 cases per year to an average yearly volume of 28 to 30 cases. He uses one of his favorite words to explain the success: chemistry. In this case, chemistry means getting everyone—from administrative assistants to nurses to specialists—to support one another and deliver outstanding patient care. Emre stresses that transplant surgery is “a complex matrix, not a discipline,” requiring excellence and cooperation across departments.

And that is why Yale is making a $12.5 million investment in its transplant section that will increase the number of surgeons, nurses and support staff, according to Robert Udelsman, M.D., M.B.A., department chair and the William H. Carmalt Professor of Surgery. Every area touched by transplant medicine, such as intensive care and diagnostic imaging, will improve as the transplant program grows, he said. Yale’s strengths in hepatology, transplant immunology and vascular biology set the stage for collaborations between clinicians and bench researchers to improve the level of practice in this young branch of medicine. Emre’s goal is to increase the current number of liver transplants at Yale from four or five a year to between 80 and 100; double the number of kidney transplants to 150; and bring the number of pancreatic transplants up to 20, a five- to 10-fold increase over present figures.

Obviously those ambitious goals will take years to achieve. Benjamin Shneider, M.D., the former chief of pediatric hepatology at Mount Sinai, says that nothing is beyond this surgeon. “One of the striking things about Sukru is that he won’t accept defeat,” says Shneider. He says he routinely saw Emre conquer “unsolvable clinical problems.” Shneider recognized that preoperative evaluations of children to ensure that their anatomical structures would permit transplant surgery were “irrelevant” because Emre would always find a solution in the operating room.

Paul M. Sethi, M.D., an orthopedic surgeon in private practice in Greenwich, Conn., and a former student of Emre’s, says his mentor implored him not to “accept the standards, the norm. … He taught me to use my brain and my hands at the same time for the patient,” Sethi said.

But there is no true norm in transplant surgery, a relatively new field. The first liver transplant took place only 40 years ago and many immunosuppressant drugs became available only in the 1990s. Transplant surgeons literally make the norms as they go along while dealing with significant barriers to success, including transplant rejection and shortages of organ donors. Emre specializes in the field’s most technically difficult area, pediatrics, in which procedures are necessarily in constant evolution. Transplant possibilities are limited by the patient’s size. He routinely performs transplants on adult patients as well, however. Emre has been particularly successful in addressing the shortage of donors through split-liver transplants, in which sections of a single liver are used to serve two patients, a child and an adult; domino transplants, in which the liver removed from one patient undergoing transplantation may still serve another patient with a shorter anticipated lifespan; and living-donor liver transplantation, in which a section of healthy liver is transplanted from a living donor into a recipient whose liver has been removed.

A complete physician

Emre came to the United States from his native Turkey in 1988 to study transplantation. After his fellowship at Mount Sinai was completed, he made the difficult decision to stay in New York because he felt America would offer his children better educational opportunities. Transplant surgery attracted him because of the depth and breadth of medical knowledge it requires. “That makes you a complete physician,” he says.

A complete physician is also available and sympathetic to patients, a challenge for a surgeon who may be performing an 11-hour operation on any given day. But patients say that Emre—not one of his assistants—responds to phone calls and e-mails within 24 hours.

Extended conversations with Emre convinced Phil and Lisa Brudos to fly their 11-year-old daughter, Marie, from Chicago to New York so that Emre could operate on her. Marie’s case was complex. Born with autosomal recessive polycystic kidney disease and congenital hepatic fibrosis, she needed both kidney and liver transplants and, in the opinion of some surgeons, should also have had her spleen removed. Emre outlined a strategy to avoid removing the spleen. “I sent him pages and pages of questions. I called two or three times a week,” Brudos recalls. “Dr. Emre was unbelievable in his compassion and concern.” Three years after the transplants, Marie is thriving.

Judy Gilman, a nurse from New Jersey, appreciated the time Emre took to “explain everything you could possibly ask” when she had her transplant. “He was wonderful, truly a compassionate, sensitive man.”

Twelve-year-old Christopher Lewis from Killingworth, Conn., is also doing well more than two-and-a-half years after his emergency liver transplant, necessary because of an aneurysm in his liver. Upon the recommendation of Yale physicians who sent Christopher to Emre in New York, his mother Karen Lewis found herself riding in an ambulance to Mount Sinai from Yale-New Haven Hospital as her 10-year-old son was failing rapidly. Emre had to remove Christopher’s liver even before the donor organ arrived. “I’ll take care of him like I would if he were my own,” Emre reassured the terrified mother.

“I could tell he meant it,” recalls Lewis, who became the donor of last resort for her son’s transplant. “He must love his job.”

Emre would agree: “Everything grows with love. You’ve got to love what you do. Otherwise it becomes a burden and you can’t carry it.” Still, there are such moments as the fifth birthday party for his daughter, Gulus, when his beeper went off. Emre apologized to the girl for leaving. “That’s okay,” she said through tears. “You’re going to save lives.”

“That’s all my wife,” Emre says. She instilled a deep appreciation in her children for their father’s work, he explains. Umit Emre, M.D., a pediatric pulmonary specialist, has consistently supported her husband’s demanding career while tending her own specialty and taking more than her share of responsibility at home, he says.

His children are never far from his mind, particularly whenever a pediatric liver donation arrives—a chance of life for one child arising from the death of another. “I go home and I thank God my kids are healthy,” he says. If he missed a few birthday parties, Emre has made it to the debate competitions, the Carnegie Hall recitals and many other milestones in the lives of the three daughters he praises with obvious relish. And perhaps their successes have something to do with the life lesson he often repeats to them: “If you use your brain, your sweat and your heart, there is no way that you are going to be failing.”

It’s a lesson he’ll employ at Yale. “One of the best universities in the world deserves a great transplant program. That’s my nature; I accept a challenge,” he says. “And I don’t give up.” YM