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Day 2: Starzl institute: 'Nobody has a unit like this'

| Monday, March 10, 2008

On a recent clinic day at UPMC Montefiore, dozens of liver and kidney transplant patients clogged the seventh-floor waiting room.

A man with jaundiced skin wrapped his fingers around a Styrofoam coffee cup. A woman, not older than 30, watched a portable DVD player. Yet another man in a wheelchair stared into space.

"Nobody has a unit like this," said Dr. Amadeo Marcos, showing off the 21-room clinic. "Nobody has a clinic entirely devoted to transplantation."

After all, it's the Starzl Transplantation Institute, named after the now semi-retired transplant great who finished his career in these very same hallways.

It took 30 minutes for Marcos, the center's director of transplantation until he resigned last week, to explain why the Starzl institute has performed more liver surgeries -- 4,930 since 1988 -- than any other center in the country.

The institute's infrastructure makes it a city of sorts, and includes the types of services typically shared by an entire hospital: its own blood bank, pharmacy and radiology suite. Asked how many operating rooms are available, Marcos responded: "As many as we need."

That confidence has been a part of Marco's often-charming personality. Wearing a dark brown suit and loafers, with brown hair, Marcos, 46, walked the hallways with an impish grin as he is greeted by virtually everyone who sees him.

"It's so good to see you," said a patient in an elevator.

Marcos, 46, came to Pittsburgh in 2002 with an impressive resume. By the time he left the University of Rochester Medical Center in New York, he had performed 56 liver transplants using live donors, a then-emerging field that Pittsburgh was just starting to delve into.

Marcos also arrived with a reputation of being an aggressive surgeon willing to take risks that few others would. He was convinced that the nation's organ shortage could be addressed by making use of more organs from dead donors.

That means using organs from donors often considered questionable. Although there is no agreement over what constitutes a marginal liver, those organs can come from older donors, or people who've died from cardiac arrest.

At the Starzl institute, as in other transplant centers, those organs go to patients who are less sick.

Marcos disputed scientific data that show those patients are better off waiting for a transplant until they become sicker.

"Organs that are questionable don't do well on higher-MELD patients," he said. "The common knowledge is that we can't use them in sicker patients."

At the Starzl institute, nearly one of every three liver transplants is done on patients with a low-MELD score, a highly debated practice.

"It's pretty much impossible to show patients with low-MELD scores benefit from transplants," said Dr. Jeffrey Punch, a UNOS regional councilor and director of the transplant center at University of Michigan Medical Center. "The burden of proof is on the people transplanting patients with low-MELD to prove they're doing a benefit."

Marcos defended the practice, saying UPMC practices responsible medicine.

"Don't get this impression that we have all these livers and don't turn anything away," he said. "We responsibly look at every offer out there."

Of about 1,300 livers offered to UPMC every year, only about 600 are evaluated through a biopsy, said Bill Morris, executive director of transplant services at UPMC. The other 700 are either passed upon, or rejected as being unfit.

Marcos said his motivation is to save patients and he accepts that some of his colleagues will think otherwise.

"You can't expect all transplant surgeons to have the same philosophy," he said.

It isn't known what role, if any, Marcos' philosophy played in his sudden resignation. UPMC officials will not say why he left, even though a key program overseen by Marcos -- the live-donor liver transplants -- is under review by a panel of experts.

"The program grew while I was there," Marcos said this past week. "I did a great job."

Luis Fábregas can be reached at lfabregas@tribweb.com or 412-320-7998. Andrew Conte can be reached at andrewconte@tribweb.com or 412-320-7835.

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