Last week, the doctor who was once told he was too clumsy and too slow to ever perform a difficult operation, led a surgical team that completed the first uterine transplant in the United States.
Andreas Gerasimos Tzakis has overcome more than just doubt and difficulty in routinely doing what others once considered impossible. The son of a Greek naval engineer, Andreas Tzakis’ work has led to one breakthrough after another, performing thousands of complicated, delicate surgeries — including one (described below) during which he had a heart attack — while successfully pioneering the kind of organ transplants that were once considered science fiction.
Meet the man many call the best transplant surgeon in the world today, in two articles excerpted below — the first, a fascinating up-close look that follows Dr. Tzakis during a pioneering combination liver-intestine transplant, and the second an in-depth interview where Dr. Tzakis talks about his Greek background and career path.
In the operating room with Andreas Tzakis
On a morning back in 1994, writes Jonathon King for the Orlando Sentinel, four surgeons, three anesthesiologists, a scrub nurse and an OR nurse work to the bleeting pace of an electronic heartbeat. Bright overhead lamps flash over a lineup of more than 100 steel surgical tools. Under layers of blue sterile sheets, behind a clear oxygen mask, lay a beautiful and precocious 4-year-old named Natasha. Her life was at the fingertips of Andreas Tzakis. And it was her best hope for the simple reason that on this specialized edge of surgery, Tzakis may be the best there is.
The only voice heard belongs to Tzakis. So too does the room.
Here in the OR, Tzakis is the conductor, the general, the director of all that happens for however many hours it takes. The longest took him 36 straight hours standing, concentrating, working at a delicate fusion of man-made suture and natures most intricate plumbing.
Tzakis’ specialty is replacing vital organs, parts gone bad from disease, injury or abuse. From the victims of fatal accidents or homicide, he can take a healthy organ and with a skill only a few doctors in the world possess, he can extend the life of a luckier human being.
As his reward Tzakis carries his own scars one at his neck and the other at the base of his spine from surgeries to remove herniated disks, a condition that has threatened to steal the strength from his hands.
This surgery would take more than 12 hours. Tzakis and his team would replace the little girl’s shrunken liver, stunted small intestine and a 15-inch portion of her large intestine. They would infuse her system with donor bone marrow a procedure that researchers in Pittsburgh, including Tzakis, had began perfecting only two years earlier, to make it easier for the recipients immune system to accept new organs.
By 8 p.m. the new organs were functioning. The cool preservation liquid had been replaced by Natasha’s blood. The intestine shone in its pink and plum color. The liver was producing bile. Natasha was sown up and taken to recovery.
Tired and typically subdued, Tzakis would later announce to the media that the first combination liver-intestine transplant in the southeastern United States had so far been a success.
Back in the OR, Tzakis calls out, “Four-oh.”
He is handed a needle trailing a length of suture as fine as a spiders filament. He stitches and then deftly ties the thread into perfect surgical square knots, over and over and over.
Tzakis takes the instruments from the scrub nurse without looking, sometimes holding two and three in one hand, showing disdain for those tools that do not perform to their design.
“Another right angle,” he snaps. The clamp on this one is not working correctly.
The most versatile tools in the room of course are Tzakis own fingers; probing, holding, measuring, clamping.
Such was not always the case.
A MAN WHO DOESN’T GIVE UP EASILY…
More than a decade ago, when Tzakis had first developed his passion for liver transplantation, he was nearly rejected.
As a chief resident at the State University of New York at Stony Brook on Long Island, Tzakis had applied for a fellowship to learn transplant surgery under the world’s best — Dr. Thomas Starzl at the University of Pittsburgh.
But Tzakis’ mentor at Stony Brook, transplant specialist Felix Rapaport, told Starzl not to accept the then 34-year-old surgeon.
Rapaport’s opinion was that Andy was too clumsy and too slow to ever perform such a difficult operation as liver transplantation, Starzl wrote in his 1992 memoirs.
Starzl initially rejected the application, but Tzakis refused to give in. He persuaded Starzl to give him the fellowship.
No one ever worked so hard and accomplished so little, Starzl wrote. More than a year later (1984), he met with Tzakis and told him that he could never permit him to attempt a human liver transplantation.
Tzakis was assigned to handling less arduous kidney transplants.
But still he would not give up.
Every place he went, he carried instruments with him, fondling them and flipping them . . . until these pieces of steel called hemostats and scissors were like natural extensions of his hands and fingers, Starzl wrote.
Tzakis retrained himself in procedures, incessantly tied surgical knots to chairs and bedposts to perfect technique, and through pure determination, mastered his weaknesses.
After another year of work, he had convinced Starzl, who later wrote:
One night at 4 a.m., I was awakened by an anesthesiologist who asked me to come to the operating room and order Andy Tzakis to pronounce dead a recipient whose heart had quit beating while the liver was being sewed in.
Against the advice of more senior doctors on the team, wrote Starzl in his memoir, Tzakis refused to give up trying to restart the heart. When Starzl arrived he would not override his protege and watched as the team, under Tzakis’ direction, used their hands to pump the heart and then periodically shock the dormant muscle. Finally, the heart began to beat. The patient lived.
It was the day when Tzakis completed his training, wrote Starzl. He had become one of the best surgeons in the world.
Tzakis, with characteristic modesty, discards the aggrandizing story as puffery. He will only say that he was lucky to meet Starzl, writes King.
“I was in the right place at the right time,” says Tzakis.
Yet, it is undeniable that some people make their own luck.
… AND DOESN’T TAKE THE EASY ROUTE
The son of a Greek shipping engineer, Tzakis was raised in the port city of Piraeus and was graduated from the University of Athens Medical School. After serving three years in the medical corps of the Greek air force, he made a very spontaneous decision to come to the United States.
“It was my plan to do plastic surgery and live a comfortable life,” says Tzakis.
Tzakis would gain worldwide notoriety in the early 90s when he headed a Pittsburgh team that twice transplanted livers from baboons into fatally ill patients and participated in the worlds first pancreatic islet cell transplantation, a major medical breakthrough in treating diabetes.
His passion to move transplant surgery forward also led Tzakis to take on intestine replacement. The intestine had been the last organ except the brain to defy transplantation. Tzakis and his colleagues began to tackle the impossible. The University of Pittsburgh has now done more intestinal transplants than any other hospital in the world. By 1994, wrote King for the Sentinel, there had been fewer than 100 intestine transplants done in the United States and Tzakis had participated in nearly 70 of them.
…AND DOESN’T ACCEPT THE WORD ‘IMPOSSIBLE’
“Andy would never accept the word impossible,” says Dr. John Fung, his colleague. “In the past few years he was always asked to do the technically difficult things. The amazing thing about him is his incredible command of anatomy and his ability to see almost three-dimensionally.”
“He can visualize a procedure in his head, and he can get out of trouble without having to think about it, adds Fung. He may not be the flashiest or most delicate of surgeons, but there will never be a wasted motion. And he will always do whats best for the patient.”
And because of Tzakis’ work in Pittsburgh, intestinal failure is no longer a death sentence.
In June 1994, Tzakis was named director of the University of Miami’s new Division of Liver and Intestinal Transplantation, and moved to Miami. His energy startled the Miami staff, writes King.
He is very regimented, very pro-patient. And he is everywhere, says post-transplant clinic director Doreen Scarpone. No one here can keep up with him.
Transplant coordinator Judith Smith calls him the white tornado.
I’ve never seen him tired. He’s always full of energy. It’s unbelievable, says his secretary, Jenni Benson.
Within weeks he beefed up the staff, began training new doctors and invigorated the procurement process. In his first two months, surgeons would perform more transplants than Jackson Memorial had done in the entire previous year.
An in-depth interview with Dr. Andreas Tzakis
In this fascinating in-depth interview with Dr. Pascal Goldschmidt, Dean of the University of Miami Miller School of Medicine, Andreas Tzakis recalls how his childhood in Greece shaped his career choices and his decision to come to the United States, talks about his very first transplant operation (on a nuclear physicist), and shares the incredible moment when he suffered a heart attack while operating on a patient — and shares his views of what changes he thinks the next 20 years will bring to his field, including the possibilities of growing replacement organs.
ON GROWING UP IN GREECE
Q: We want to hear your story and about your career, and how you went about becoming the person you became – a surgeon with tremendous expertise. Can you tell us first how you grew up?
Tzakis: Yes, we’re a family of three children; I have a brother and a sister. I’m the oldest son. My father was a chief engineer in the Greek Navy, so my mother really ran the house. Those days we used to see my father when he would be in port, which would happen every two or three years, so my mother took care of us. My mother was very close with my father, so he always knew what was happening in the house. He would call us from Japan, “Congratulations, for your new scholarship.” And he would bring a special toy for us when he came home for every occasion. Even while he was away, we never really felt like we were apart – we were a very close family. The focus of the attention of my parents was on us, children, including providing us with instant gratification for every success. So, when I succeeded in the entrance exams to Medical School – I was presented with a brand new car.
Q: A car?
Tzakis: My brother and my sister received the same present when they entered the University. If I would get a scholarship in medical school, I could spend the summer anywhere I wanted – do whatever I wanted. My parents achieved their objectives with all three of us. My sister went to medical school; she is the director of a neonatology unit. My brother is a dentist; he is a professor in the Dental School of Athens.
Q: Your two siblings are still in Greece?
Tzakis: Yes, I am the only one who stayed abroad.
Q: What was the attraction to medicine?
Tzakis: It was not an easy decision.
I was considering becoming an engineer, mechanical or civil engineer, something along those lines. There were a couple of people in our environment who were doctors and whom I admired. They were dignified and had the respect of my family and the community. I thought medicine would be a good choice.
Q: So you stayed in Greece until what age?
Tzakis: Until I was 24.
Q: 24. So you were done with medical school?
Tzakis: I went to medical school and then I did military service, which is mandatory in Greece.
Q: What did you do in the military?
Tzakis: I was a doctor, but I had my eyes on what I was going to do next. I had an early mid-life crisis because at that time, I didn’t think that I would get the training that I wanted in Greece. I had been to Europe several times and I liked Europe.
The problem was that I never really felt at home in other countries until I visited the United States. Most of the books I was reading were American, so during my military service I decided to apply for an internship in the United States. I had never been there before.
So, I took a leave of absence from the military and I did interviews for an internship.
ON TRAINING IN THE U.S.
Q: Where did you go?
Tzakis: In those days there were no computers. So I typed applications to all the reputable US programs and I interviewed in all places where I was accepted. I went to New York, Boston, and Houston. I matched at Mount Sinai in New York.
One thing that impressed me from the very first moment is that I was like one of many. Whether I was Greek, American, or whatever, it didn’t seem to make a difference.
I was getting the same forms, interviews, uniforms, and I was getting paid during my training, which would not have been the case in Greece.
Q: So you felt welcomed, right?
Tzakis: I felt at home, yes.
Q: So how did you like Mount Sinai?
Tzakis: I liked it very much. There were several surgeons who were great role models. They were really unbelievable people to work with and I was in awe of being with them and interacting with them on a daily basis. It was great rotating at the City Hospital, to be on call for trauma. The first gunshot wound that arrived would be the chief resident’s case, the second one would be the senior resident’s, and the third one would be mine to handle.
So I was operating a lot from the very beginning, it was amazing. Also, I could do other procedures that in Greece only the big professors would do.
At the ICU in the Bronx VA, I had the liberty to place a Swan-Ganz catheter every time I needed, by myself.
In Greece we had very good basic and theoretical education, but the practical part was not available. I loved it. Suddenly, I was able to do all these things that I only knew about in theory.
When I first came to the U.S., I was thinking to do plastic surgery and go back to Greece to develop a comfortable practice. After my experience at Mt Sinai, there was no way I was going to do plastic surgery.
Q: So you were not thinking about transplant yet?
Tzakis: No, transplant didn’t come along until very much later.
Q: At what point did you meet your wife?
Tzakis: I met her at the City Hospital at Elmhurst. Pat was a medical student at Mount Sinai and I fell in love with her the very first time I saw her. I remember exactly when I first saw her and then she rotated in our service.
Q: Where – at Mount Sinai?
Tzakis: At Elmhurst… Of course I didn’t show any preference to her, but when she left, I made sure to get her telephone number. After we stopped working together, we met and started dating and that was pretty much it.
Q: When did you get married?
Tzakis: We got married about a year after we met.
Q: Back to your interest in transplant. How did it happen?
Tzakis: I finished my General Surgery training at the State University of Stony Brook, New York… As time went on, I realized I didn’t particularly care to go into private practice, so I started looking for another field to work in and develop an academic career.
At the time, cardiac surgery was very glamorous, but on the other hand, it was not too attractive to me because there were just too many people in cardiac surgery. The thinking was what is left for me to do? On the other hand, I always had an affinity for the right upper quadrant of the abdomen. Everywhere I worked, everyone was really very respectful of the liver… I thought the liver must be a good place for me.
I applied to Memorial and Emory but there were no openings. A third place, but that was really a dream place, was Pittsburgh where the doyen of liver surgery, Dr Thomas Starzl did liver transplants. I did not think I had much of a chance to be accepted but sent a letter anyway. Starzl’s reply: “Well, come in for an interview.”
Q: Which year was this?
Tzakis: That was 1982. I was on a plane the following day to Pittsburgh and met him. There was a lot of competition for the positions but miraculously, I was accepted! Dr. Starzl wrote about my interview and career in Pittsburgh in his book “The Puzzle People.” There are some funny parts. Pat went to the Joslin Clinic in Boston to do a fellowship in diabetes, that was the best place for her, and I went to Pittsburgh.
Q: That’s not perfect.
Tzakis: Well, living in different cities and having these reunions for awhile was not bad. There is a romance to it. Over time, it’s not what you want to do, but it was a busy time for both of us. I started training on July 1st. Pat came to Pittsburgh on July 4th to see what life was like in Pittsburgh, it was the third day of my fellowship.
Five minutes after Pat arrived, Dr. Starzl called me: “Andy, are you busy?” I said, “Of course not.” He then said, “Okay you need to go to Peoria to recover a liver.”
So, Pat found out what Pittsburgh was like by herself.
Q: That worked out very well…
Tzakis: Yes, indeed.
ON DOING HIS FIRST TRANSPLANT…
Q: Back to transplants.
Tzakis: Transplants were not immediately on my radar screen, liver was. I went to Pittsburgh in the summer of 1983. In the summer of 83 there was a consensus meeting at the NIH that declared liver transplantation no longer experimental but a treatment for liver failure. I was in the right place at the right time. Speaking of being lucky… I count on my luck, I have always been very lucky,
Q: The gates opened…
Tzakis: Yes, the flood gates suddenly opened and Dr. Starzl was the only person doing liver transplants. Until 1983, liver transplants were experimental. After 1983, they gradually became a standard of care.
Q: That’s amazing.
Tzakis: Of course once you see the light everything changes, so suddenly transplants came into my focus. It became my home.
Q: Do you remember the first one you did?
Tzakis: It was July 4, 1983, the one that I recovered the liver from Peoria. It was a re-transplant and Dr. Starzl asked us to bring back a vascular graft.
This was one of the first vascular grafts that he used because he knew it would be a difficult re-transplant. The patient was a high- powered physicist. He worked at the Los Alamos Lab in New Mexico. He received a total of three livers… [P]art of the reason he had the transplant was because he started having neurological problems – So, we had somebody with a superb brainpower getting neurological complications from Wilson’s disease… he had a very difficult recovery; however, it was like witnessing a miracle to see the neurological problems gradually disappear. Back then, we had fewer patients and we had an opportunity to really get to know them.
A common theme among pioneers like Starzl and Calne, is that they kept working because despite of the many failures, some patients did spectacularly well. It happened with kidney transplants, it happened with liver transplants; it happened with multivisceral transplants, it is happening with tolerance. There are patients who are able to discontinue all the immunosuppressive medications completely.
Q: With no rejection?
Tzakis: No rejection. They do so well. On Saturday there was the wedding of one of the babies I took care of in Pittsburgh when she was only 2 years old. Dr. Starzl did the transplant, I was in training and took care of her.
Tzakis: She has been completely off immunosuppression for more than 10 years and is now a medical student at FIU.
Tzakis: Zero drugs, completely normal. Hopefully we can do this for everyone.
Q: In 2006, the Miami Transplant Institute was created and that’s a big deal because it brings all of the expertise in transplants together rather than being spread across various departments. How did that go?
Tzakis: I think this is a great advance. Recognizing transplantation as one entity within the medical school allows us to concentrate our resources towards the goals of transplantation; it’s no longer fractionated to small research projects. Major goals like tolerance and tissue regeneration suddenly come to life.
…AND ALMOST DYING WHILE DOING SURGERY
Q: There are stories that you basically resuscitated people who were considered dead by most of your colleagues… Your reputation is that you would die to save your patients and you almost did, one day.
From what I understand, you were doing a transplant and you, all of sudden, you had chest pain while doing the surgery and first you thought it would go away, but it really didn’t and you were having a heart attack. You almost died of that heart attack while doing your surgery. Knowing you, you probably finished the operation before you started to get your EKGs and things.
Tzakis: Well, Mylanta didn’t work. I took a bottle of Mylanta and that didn’t work, I continued having the chest pain. When we got things under control in the operating room, I went and I had myself cared for. Actually, I always thought I would have a heart attack at one point or another. Interestingly, I did not feel fear during that crisis, and I was able to finish what I was doing. The care that I received was so excellent I really didn’t have to stop working. I did not have a feeling of impending death. I had chest pain – it was burning, but it was not the worst pain that I have ever felt.
Q: What was the worst pain you ever felt?
Tzakis: I can tell you the worst pain I ever felt was when I broke my leg.
Tzakis: Yeah, it was instant, it was massive. I realized why people cannot move when they have such excruciating pain (laugh)… I could not move. But when I was having the heart attack, I was able to finish the surgery. I was fortunate that way — I think.
ON THE NEXT 20 YEARS
Q: There are two things you told me you wanted to be able to complete during your career. One is that you are extremely interested in the field of regeneration of tissues to make new liver grafts available to patients from tissue regeneration that is increasingly possible to do in the test tube almost. The other one is to complete your work on immune tolerance. To try to understand what’s actually the secret of immune tolerance. Can you tell us a little bit about your plans along this line?
Tzakis: Well, I think transplantation is going to be completely different ten years from now. And it’s definitely going to be completely different 100 years from now.
What’s going to be different about it? I think we’re going to be transplanting more tissues, different organs, that we don’t transplant now. I think we are going to transplant with fewer side effects, with less medications, with tolerance. I think we are going to be transplanting new tissues; we don’t have enough organs. We have to generate new organs.
So, in the field of tolerance, we have made quite a bit of advances.
At this moment, we can take off about 20% of our liver transplant recipients from all the medications, three years or more after the transplant. Our goal is to double this, or triple this number and do it faster, more dependably and monitor the patients better in a more systematic way. I think this is something we should be able to achieve. We don’t know everything but we know enough to make the next step.
In the field of new tissues, there is no doubt we are going to have artificial organs generated, but there… you know, this is a bird in the bush. We don’t know exactly how we are going to go about it, but the incremental steps have been taken.
A year and a half ago, there was a tracheal transplant from a trachea that was repopulated with stem cells from another individual. I think here we have the fortune to have collaborators who work with stem cells who can help us build either tracheas or more likely vessels and we can build on that. That would probably be a concrete step towards building new tissues. So these are the two main areas or directions. I think it’s clear because that’s where I see the field has to go, it has to evolve.
Q: And so your feeling is it’s going to take ten to twenty years to bring these opportunities to the bedside on a nearly guaranteed fashion.
Tzakis: No, I think it’s going to be sooner.
Tzakis: I think it’s going to be sooner. I think transplantation today is completely different than what it was twenty years ago, when I started working in it. I mean yes, the liver transplant is still a liver transplant. Think of it like a car, you know a car is the same as it was twenty or thirty years ago with four wheels, but yet it’s also very different.
And twenty years from now, a liver transplant might still be called a liver transplant, but it would be a different entity. We will be able to do it in a much simpler way, patients will not need to be as ill, with fewer medications, and maybe we’ll have some components that will be new tissues. For example, we need vascular grafts and when we do… we don’t always have them. We need to create them.
LOOKING BACK TO GREECE
Q: So, I know that you went back to Greece, relatively recently for the summer with your family. When you go back to the place where you grew up as a young boy, what do you think about the life of that young boy, looking back?
Tzakis: Well, I think it was the building block for my life. I think, in reality, my upbringing and my family was the most important determinant of what I am now.
Q: For example, when you were back there in the island, in the Greek Islands, I am sure you thought about your early years. What is the thought that crossed your mind when you were there?
Tzakis: I love the island and the ocean, the water, the mountains. I enjoy being there with the friends and the family the culture that I grew up in. I have fun remembering my childhood, its part of my life but I do not look back.
Q: Do you sometimes think about Ulysses in the Odyssey. How do you like Ulysses, who made a long voyage?
Tzakis: Well, remember what the poet said, “May the trip last long, before you reach Ithaca.” I keep that in mind. You know, the goal is one thing, but the trip is maybe the most important part.
Miami’s Pioneering Transplant Surgeon Dr. Andreas Tzakis Is Giving Patients Like 4-year-old Natasha A Fighting Chance
On this morning in an operating room at Miamis Jackson Memorial Hospital, four surgeons, three anesthesiologists, a scrub nurse and an O.R. nurse work to the bleeting pace of an electronic heartbeat. Bright overhead lamps flash over a lineup of more than 100 steel surgical tools. A wisp of charred flesh from the electronic cauterizer stings the nostrils. The voice belongs to Andy Tzakis. So too does the room. Read more at: orlandosentinel.com