Dr. Zachary Dietch on a Landmark Liver Retransplant and Evolving Cancer Guidelines

Summary

Becker’s Healthcare Podcast Summary

Episode: Dr. Zachary Dietch on a Landmark Liver Retransplant and Evolving Cancer Guidelines
Host: Mariah Muhammad
Release Date: July 17, 2025

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Introduction

In this episode of the Becker’s Healthcare Podcast, host Mariah Muhammad engages in an insightful conversation with Dr. Zachary Dietch, a transplant surgeon at Northwestern Medicine. The discussion centers around a groundbreaking liver retransplant case involving Andrew Wagner and the evolving guidelines concerning cancer patients' eligibility for organ transplants.

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Dr. Zachary Dietch’s Professional Background

Timestamp: [00:00 – 00:38]

Dr. Dietch introduces himself as a transplant surgeon specializing in liver, kidney, and pancreas transplants at Northwestern Medicine. He is also a key member of the living donor liver transplant team, highlighting his extensive experience in complex transplant procedures.

Quote:
"I perform liver, kidney and pancreas transplants. That's the bulk of my practice. I'm also part of the living donor liver transplant team."
— Dr. Zachary Dietch [00:19]

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Overview of Andrew Wagner’s Liver Retransplant Case

Timestamp: [00:38 – 02:16]

Dr. Dietch delves into the unique case of Andrew Wagner, a patient who required a liver retransplant approximately 20-25 years after his initial transplant for primary sclerosis and cholangitis. Wagner's case was complicated by graft failure and a history of primary lung cancer, which had been successfully resected two years prior without metastasis.

Key Points:

• Wagner had previously undergone multiple transplant evaluations, being declined by five to six centers due to his cancer history.
• Northwestern Medicine accepted his case, providing him with a second chance at a functioning liver transplant.
• This case underscores the complexities and challenges associated with retransplantation in patients with prior cancer diagnoses.

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Surgical Complexities and Team Approach

Timestamp: [02:16 – 06:36]

The discussion shifts to the surgical intricacies involved in Wagner’s retransplant. Dr. Dietch outlines the heightened challenges of redo liver transplants, such as increased scarring and complications from previous surgeries. Additionally, the presence of a prior cancer diagnosis adds another layer of complexity to the decision-making process.

Notable Quotes:

• "Any redo liver transplant is more challenging than the first due to scarring and other complications."
  — Dr. Zachary Dietch [02:40]

• "The degree of scarring and challenges in his hepatectomy were extreme, making the surgery particularly technically challenging."
  — Dr. Zachary Dietch [02:40]

To navigate these challenges, Dr. Dietch emphasizes the importance of a multidisciplinary team approach, leveraging the expertise of anesthesiologists and surgical specialists to ensure a successful outcome.

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Innovative Surgical Techniques: Bypass and "Liver in a Box"

Timestamp: [04:08 – 06:36]

Dr. Dietch explains the blend of traditional and innovative techniques employed during Wagner’s surgery. Historically, veno-bypass has been used in liver transplants to reduce bleeding and simplify the hepatectomy process. Although not routinely used at Northwestern Medicine, bypass was utilized in this case to manage the complex surgical landscape.

Notable Quotes:

• "We elected to put him on bypass to help us in the hepatectomy as we encountered particularly challenging stages."
  — Dr. Zachary Dietch [04:24]

In addition to bypass, the team utilized a "liver in a box" approach, involving a perfusion pump to keep the donor liver functional outside the body. This method allowed for the use of organs from donors typically excluded from retransplants, providing the surgical team with more time to perform the hepatectomy safely.

• "Having a liver on pump really allowed us to do this successfully."
  — Dr. Zachary Dietch [04:24]

These combined techniques were pivotal in overcoming the surgical hurdles presented by Wagner’s case, ultimately leading to a successful transplant outcome.

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Reevaluating Transplant Eligibility for Cancer Patients

Timestamp: [06:36 – 09:06]

A significant portion of the discussion focuses on the paradigm shift in transplant eligibility criteria for patients with a history of cancer. Traditionally, a recent cancer diagnosis has been a stringent barrier to organ transplantation. However, Northwestern Medicine is at the forefront of rethinking these guidelines, particularly for patients like Wagner who demonstrate a successful cancer remission and strong candidacy otherwise.

Key Points:

• The transplant team questions conservative and sometimes arbitrary eligibility rules concerning cancer history.
• In Wagner’s case, his stage one lung cancer was successfully resected with no evidence of disease, making him a viable candidate despite previous declines.
• The broader transplant community is gradually embracing more flexible criteria, especially for cancers with favorable outcomes post-treatment.

Notable Quotes:

• "In some circumstances, it's worth reconsidering traditional guidelines and thinking about whether evidence really supports those guidelines."
  — Dr. Zachary Dietch [06:55]

• "We are rethinking indications for transplant in the setting of cancer, as illustrated by our approach to metastatic colorectal cancer."
  — Dr. Zachary Dietch [09:06]

Dr. Dietch highlights the success of expanding transplant eligibility, noting improved long-term outcomes and survival rates for patients previously deemed ineligible due to cancer history.

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Conclusion and Future Perspectives

Timestamp: [09:06 – 09:20]

Mariah Muhammad wraps up the discussion by acknowledging the depth of information provided by Dr. Dietch, emphasizing the innovative approaches and evolving guidelines that are shaping the future of transplant medicine.

Final Quote:
"This has definitely been a very informative discussion."
— Mariah Muhammad [09:06]

Dr. Dietch reciprocates the appreciation, underscoring the collaborative efforts essential for pioneering advancements in healthcare.

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Takeaways

• Complexity of Redo Transplants: Retransplantation poses significant surgical challenges, especially in patients with extensive scarring and prior complications.

• Innovative Techniques: Combining traditional methods like veno-bypass with innovative approaches such as perfusion pumps can enhance surgical outcomes in high-risk procedures.

• Evolving Eligibility Criteria: There is a growing movement within the transplant community to reassess and broaden eligibility criteria for cancer patients, allowing more individuals to benefit from life-saving transplants.

• Team Collaboration: Successful outcomes in complex transplant cases are heavily reliant on the expertise and coordinated efforts of a multidisciplinary medical team.

This episode sheds light on the intricate balance between surgical innovation and evolving medical guidelines, showcasing how dedicated healthcare professionals are pushing the boundaries to improve patient outcomes.

Transcript

[A]

Welcome everyone to the Beckers Healthcare podcast series. I'm Mariah Muhammad, writer and moderator with Becker's Healthcare. I'm thrilled to have with me today Dr. Zachary Deitsch, transplant surgeon at Northwestern Medicine. Doctor, welcome to the podcast. We're very excited to have you join us today, especially for the first time. But to get us started, would you mind please introducing yourself and telling us a bit about your background?

[B]

Sure. Thanks very much for having me. So my name is Zach Dietsch. I'm a transplant surgeon at Northwestern. I perform liver, kidney and pancreas transplants. That's the bulk of my practice. I'm also part of the living donor liver transplant team.

[A]

Wonderful. Thank you so much for giving us that background. So, Doctor, today we're discussing a patient's surgery, specifically Andrew Wagner and his life saving liver transplant. Could you give us a bit of background on this case?

[B]

Yeah. So Mr. Wagner is certainly an interesting case for a number of reasons. He came to us from Florida, sought out our care. He'd received a liver transplant probably 20, 25 years before we'd seen him for primary sclerosis and cholangitis. And it had a series of complications after his initial transplant, but ultimately had done quite well and returned to a normal life for quite some, quite some time. But he ultimately started to gradually experience graft failure over time and was in need of a redo liver transplant in order to survive. The, you know, interesting twist in his case is he had developed a primary lung cancer in, you know, a couple years before we met him that had been successfully resected and without no evidence of metastases or spread. So he's essentially cured from that operation. But, you know, most centers that had evaluated him for re transplant had declined him because of his cancer diagnosis, having only been a couple years before, you know, his, his decline and need for a retransplant. So he, you know, he, he'd seen, I don't know, probably five or six other centers that had declined to evaluate him and list him for transplant. And he found his way to us just how we met him.

[A]

Got it, got it. So, doctor, Mr. Wagner's case involved not only a retransplant, but a recent cancer history, as you stated, which typically excludes patients from transplant eligibility. And that's why I'm assuming he got, you know, denied several times. From a surgical perspective, what made his transplant particularly complex and how did you, you and your team navigate those challenges?

[B]

Yeah, so, you know, any, any redo liver transplant is more challenging than, than, you know, a patient's first, first liver transplant that has to do with, you know, like any surgery, degree of scarring and so forth. So you redo liver transplant in and of themselves can be challenging to varying degrees. He had had a series of complications after his first transplant that made this a particularly challenging redo liver transplant. And the degree of scarring and the challenges that we encountered in his hepatectomy were I would. I would describe as extreme. So, you know, getting his old liver out and navigating the challenges we encountered was a particularly technically challenging perspective. You know, the cancer diagnosis, I think, didn't increase the technical complexity. That was more a decision that, you know, that we made up front about whether or not to offer him a liver transplant because of his recent cancer history. So to address these challenges, we have got a large team here with a lot of varied expertise. And so this was really a team effort that taxed both our anesthesiologist and then the surgical team. We relied on a number of folks to help in this case and get this done successfully.

[A]

Yeah, yeah, that's absolutely amazing. You mentioned, Andrew. Surgery was a blend of old and new techniques, from traditional bypass to the innovative liver in a box. Can you walk us through how these tools help manage as a high risk and high stakes procedure?

[B]

Yeah, sure, absolutely. So, you know, liver transplant in the, in the grand scheme of things is a relatively young field. And so as surgeons and anesthesiologists initially gained experience doing liver transplants, we tended to rely on techniques putting patients on veno. Veno bypass as a matter of routine for many liver transplants. And that's a technique that persisted for a number of years and still does in some institutions. Putting patients on bypass can reduce bleeding and ultimately make the hepatectomies a little more straightforward. But, you know, it's not a technique that, that is necessary for the vast majority of liver transplants. And it's not one that we, we typically use. You know, Mr. Wagner's case, we elected to put him on bypass to help us in the hepatectomy as we encounter, you know, particularly challenging stages of the hepatectomy to reduce bleeding and so forth. And, and this was a, a helpful adjunct that helped us get through the case at the same time. So that, you know, that was a, that's an old, old technique that we utilized here. But in addition, we also utilized an organ from what we call a DCD donor that was put on a pump, a perfusion pump. So the organ was procured from the donor and then put on a Pump that circulates blood to keep the liver perfused and functioning while it's out of the donor. So this technique allows us to utilize organs from donors that we would not otherwise typically be able to use for a redo liver transplant. And what this does is it gives us more time to complete that vatectomy and do it in a safe manner without having the pressure of having to do it quickly so that we can get the donor organ implanted in a period of time. So, you know, the combination of both using bypass and having a liver on pump really allowed us to do this successfully. And I think without those techniques, we probably would not have had a good outcome.

[A]

Yeah, yeah, absolutely. That makes a lot of sense. And historically, a cancer diagnosis was often seen as a hard stop when it comes to organ transplants, especially. How is Northwestern medicine rethinking that line of thought, especially for patients like Andrew, who had a recent history of cancer but otherwise strong candidate?

[B]

Yeah, it's a tough, you know, we're facing a lot of, you know, we face a lot of tough decisions here. And Mr. Wagner's circumstance, you know, he was ill and declining so rapidly that he certainly didn't have much time to wait. And so, you know, I think a lot of the rules by which we, you know, consider patients eligibility relative to other cancer diagnoses come based on very conservative, you know, and some sometimes arbitrary decisions. And I think, you know, in some circumstances, we, you know, it's worth reconsidering these traditional guidelines and thinking about whether evidence really supports those guidelines. I think, you know, in Andrew's circumstance, he had a small stage one lung cancer that had been successfully resected two years prior. He had no additional risk factors for recurrence and had no evidence of disease at the time we saw him. Certainly, I think, you know, we incur some additional risk by. By taking him on. But at the same time, you know, I think. I think in his circumstance, particularly, the benefits outweigh the. Outweigh the risks here. And so I think it was worth worth reconsidering. And so far, you know, it's turned out to be a good decision. More broadly speaking, you know, I think we are rethinking these things. Transplant community in general is rethinking, you know, indications for transplant, the setting of cancer. And I think this is most clearly illustrated by our approach towards transplants for metastatic colorectal cancer, which historically had been a hard stop and a barrier to liver transplant. But as we've learned with accumulating experience, patients with unresectable liver metastases and favorable tumor biology can be successfully transplanted with excellent long term outcomes and even have the possibility of survival. So this is a paradigm shifting treatment and approach to utilize transplant for oncologic indications?

[A]

Yeah, yeah, absolutely. Thank you so much for giving us that that information, those final thoughts. This has definitely been a very informative discussion. So Doctor, thank you so much again for coming on back to healthcare again, especially for the first time, and I look forward to connecting with you again.

[B]

Likewise. Thanks so much for having me. Appreciate it.