Tomoaki Kato, MD, MBA, FACS, The Marathon Surgeon : Transplantation

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In View: People in Transplantation

Tomoaki Kato, MD, MBA, FACS, The Marathon Surgeon

Kato, Tomoaki MD, MBA1

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doi: 10.1097/TP.0000000000004249
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You received a degree in Biochemistry from the University of Tokyo, attended Osaka Medical School and completed your residency in Japan. What motivated you to relocate to the University of Miami, Jackson Memorial Hospital for a Clinical Transplant Fellowship?

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TK: I always wanted to work globally. Japan is a very nice society and the medical profession is well respected. The scope of practice, however, is narrow and geared toward taking care of a relatively homogeneous population. I wanted to see the world. It could have been in Europe, but the set up for foreign medical graduate in the United States seemed very robust with more opportunities.

Once I made up my mind to move, I decided to focus on 2 surgical subspecialities that were not easy to learn in Japan: transplant and vascular surgery. Organ transplantation in Japan, at the time, was less active as brain death was not accepted in the society. Vascular surgery was not common in Japan because the incidence of atherosclerosis was low.

I first went to a vascular surgery professor, who told me to come back 2 wk later as he was busy preparing for a talk abroad. Then I went to a transplant professor who said he would write a recommendation for me. Thus, it was a straightforward decision to chose transplant.

After choosing the specialty, I began learning what the field entailed. I still remember very well that the first thing I learned was the definition of cold and warm ischemia time. You see, I did not even know what Cold Ischemia Time and Warm Ischemia Time were, nor did I understand the implications but still decided to enter the field of transplantation. I started to write applications to US fellowship programs. I applied to almost 30 centers and got only 2 responses: one from Pittsburgh and the other from Baylor Medical Center. I recall very well having received letters from Drs Thomas Starzl and John Fung with details of their fellowship program. I also received a letter from Dr Malon Levy, and we spoke over the phone.

The year I was applying for fellowship, the International Transplant Congress (The Transplant Society meeting) was held in Kyoto (1994). Although I did not attend the meeting, I was told through a surgeon who attended that Dr Andreas Tzakis who had just moved to Miami where he did a “crazy” volume of liver transplants was in desperate need of fellows. Although the Miami program did not reply to me originally, I wrote to Dr Tzakis directly, and I got accepted without an interview. So, I ended up in Miami.

The next location in your career was New York Presbyterian/Columbia University Center. What were opportunities and challenges linked to that move?

TK: My father was a philosopher. He taught me many things, one of his lessons was based on Confucius’ teachings in which he explains that 10-y intervals (with the first 2 intervals in a lifetime being 15 y) represent distinct stages of a lifetime. This teaching is very famous in Japan, and it remained in my mind from my early life until now. I spent most of my thirties and early forties in Miami and felt that I had to take a step to a different stage of my life.

I was very fortunate in Miami. My mentor Andy Tzakis had been a wonderful support. I was given many opportunities to advance my career including both clinical and research activities. But because I was trained in Miami and stayed there for a long time, there were also a lot of expectations that curtailed my personal progress. Thus, I started to feel that I cannot to do anything new unless I dropped what I was doing.

That is when the opportunity in New York came up. I did not want to move to a place that would not allow me to continue innovative surgeries that I was taught and got experienced in while having been in Miami. I also wanted to be in a place with a research infrastructure and the opportunity for translational research. New York Presbyterian/Columbia University offered me both. Dr Jean Emond was known for his innovative approach, seeking surgical challenges. At the same time, Dr Megan Sykes was on her way to build a robust translational research environment at Columbia.

I stayed in touch with Dr Starzl ever since the beginning of my career, and I consulted him during each career move. I spoke to him about this opportunity, and he advised me to take it.

In parallel to your clinical work, you did a Master of Public Administration (MPA) and a Master of Business Administration at Columbia. What motivated you to get those additional degrees, and how do you use them?

TK: I attended top schools in Japan including the University of Tokyo and Osaka University Medical School, both comparable to the highest ranked academic institutions in the United States. Being on the faculty of an Ivy League Medical Center, I felt that not having experience in higher education in the United States may represent a weakness in advancing into a leadership role. First, I took an executive MPA course at the School of International and Public Affairs, Columbia University, a school that was founded to support the United Nations. What I learned in the MPA program was the basis for public policy making, microeconomics and macroeconomics, and leadership in addition to governmental communication. This was a great program but the environment was not very competitive. As I wanted to do more, I enrolled in the executive Master of Business Administration program at Columbia Business School, which was a lot more competitive. I needed my clinical colleagues’ support to cover me when I attended classes. I studied hard and was able to complete the program with honors. What I learned in business school was great. The leadership classes were mind-blowing experiences. I started to understand the difference between people who know tactics (or naturally have them) and those who do not. I still have a lot to learn in leadership skills, but the business school gave me a solid basis.

You are widely recognized for your innovative work in ex vivo surgeries. One of your surgeries lasted 43 h and went over 3 d. Can you share how you prepare yourself and your team for those herculean efforts?

TK: Well, to be honest, no one prepares for a 43-h surgery. It is impossible! But if you ask me how to prepare for a long surgery, I will say that this is an absolute team effort. When an extensive surgery that includes an ex vivo component is booked, everyone knows what it means. In addition to fellows and residents, attending surgeons are needed at the time when organs go ex vivo. Because of the complexity, the ex vivo portion of the surgery may not start until late. Dr Emond likes to jokingly mention that I should rather start the surgery in the evening that he can join during the usual morning hours. We also often need experts from other specialties including cardiac, vascular, or colorectal surgery join us. Of course, anesthesia is playing a critical role in all of this.

You recently published your experience of ex vivo surgeries of unresectable tumors. What are lessons have you learnt from those procedures?

TK: Patient selection is the most important factor. In the “right” patient, this complex surgical approach is of great benefit.

Another surgical milestone have been ex vivo pancreaticoduodenectomies and liver autotransplantation? What is the potential of that approach?

TK: The idea behind this procedure is an interesting one as the ex vivo portion is not targeting an intrahepatic tumor but is rather aiming for a large pancreas head tumor encasing the hepatoduodenal ligament. Notably, it is not possible to separate and reconstruct the hepatic vasculature with a gigantic tumor in the way. Our approach therefore aims to avoid a prolonged warm hepatic ischemia. I personally believe that many oncological procedures may benefit from this approach. It would be great to see other surgeons taking this approach on as well.

“Transplants do their job and then fade away” was the title of a New York Times article referencing your work on auxiliary liver transplants. What is the potential of this procedure? Speculating on the background of the most recent advancements: Can xenotransplantation play a role here?

TK: We are doing auxiliary partial orthotopic liver transplantation for children (or young adults) with fulminant hepatic failure. It works very well. Almost all patients are off immunosuppression as the native liver regenerates. I think this procedure should be used more widely in the United States. As to the use of xenografts in auxiliary partial orthotopic liver transplantation, this is a very interesting thought. At this time, we are anticipating that a significant immunosuppression will be necessary to preserve the function of the xenotransplant. That could indeed be different if used as an auxiliary transplant, potentially a great indication for the use of xenografts.

Intestinal transplantation is another specialty of yours. What surgical and immunological progress do you envision over the next 10 y?

TK: I have done many pediatric intestinal transplants in the early 2000s. I started to see these patients becoming adults. As you may know, one of them became a pediatric transplant hepatologist. I know many other recipients that went on having stable, productive‚ and happy lives. Long-term outcomes have been encouraging and outcomes have improved recently. At the same time, management of Total Parenteral Nutrition has improved, restricting the indication for intestinal transplants. Nevertheless, with further improvements in management, indications for intestinal transplants may increase again as a quality of life improving measure. Many children are growing up to adults with Total Parenteral Nutrition but have unfortunately not enjoyed a “normal” life including eating.

We started a clinical trial of tolerance induction with outcomes that are already a lot better compared with 10 y ago. Avoiding immunosuppressants long-term would indeed make intestinal transplantation a more viable option. There may also be a role of multivisceral transplants for low-grade disseminated malignancies. I think improved outcomes may provide a very different picture of the use of intestine and multivisceral transplants in the future.

In 2020, you have been a coauthor on a article summarizing the outcome of an infant that developed COVID-19 shortly after a live donor liver transplant. The article does not share that you contracted COVID yourself during the surgery. What is your recollection of the disease and recovery?

TK: It is unclear if I contracted COVID from the donor or if the source of the infection has been entirely different. Well, the experience of going through COVID is indeed a whole other chapter.

I got sick during the early phase of the pandemic in New York when no one knew how to deal with this disease. About a week after the living donor liver transplant, I developed severe back pain and fever. At that time, we were told do not get tested just do not come to work. I followed those instructions and stayed home but did not get better. Then I tested positive and a few days later, I was intubated and a week after intubation I was on Extracoporeal Membrane Oxygenation. Thanks to God and thanks to my colleagues, I survived. The recovery was really tough. I was on a ventilator for 3 wk and unconscious for another week. When I woke up, I could not turn over in bed. I got sick by the end of March and was discharged home by the end of May. But again, thanks to my colleagues, I was able to start doing surgeries again in August, and one of the cases I did in August included ex vivo surgery. In September, I started to take calls for liver transplant and performed >30 liver transplants before the end of the year.

It was scary, when I went back doing surgeries at first, and I was very concerned. Dr Montgomery from New York University shared his experience with me after he recovered from his heart transplant. It was very reassuring to hear from him that the surgical skills come back “naturally.” He was correct.

In November of 2021, you completed your 8th New York City marathon. What an amazing recovery from COVID, and what a fantastic achievement!! What were thoughts going through your head running through the city that suffered so much during the pandemic?

TK: I never could have imagined that I would run a marathon again when I first started my physical therapy. After being discharged from the hospital, I was taking a mile long walk everyday to train my endurance. One day, I tried to jog. But my first experience was not encouraging at all. Only 10 m of jogging were sufficient to bring my heart rate up to the sky. But I kept trying. Finally, by the end of 2020, I was able to run up to 6 miles with a very slow pace. That’s when I was given the option to run the race in 2021 or 2022 because I had a slot in the 2020 marathon that had been canceled. As 2021 was the 50-y anniversary of the NY marathon, I decided to sign up.

The race was fantastic. The energy of the city was so strong. People were cheering enthusiastically at every corner, celebrating the recovery of the city. I cried many times during the race. I was thinking about myself but also about the many colleagues in the hospital who did not only fight for me but for so many patients during the pandemic. You may recall the long lines of cooling trucks storing the deceased in front of hospitals during the pandemic. Our care providers who continued to work during those challenging times were the true heroes.

Challenging to envision that there is any time left between preparing for running marathons and performing marathon surgeries. In case that there is time: What do you enjoy doing in your “free” time?

TK: I enjoy playing the guitar, which I used to do a lot during college. After starting Medical School, I found less time to do that and picked this hobby up again recently. Besides playing the guitar, I like to cook. I also like traveling, particularly to European Cities. For my first travel after the pandemic, I went to Paris and spent a few days. It was great.

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