By John G. Carlton
Of the Post-Dispatch

Aug. 22, 1999

Edited by Virginia Baldwin Gilbert

Two months ago, Monica Codman Nicholls was given three months to live.

Early this month, Nicholls and her husband, Andrew, came to St. Louis to try a living donor liver transplant -- something that only a few hospitals had tried.

On Aug. 5, Dr. Jeffrey A. Lowell performed the surgery at Barnes-Jewish Hospital.

The next day, the couple were together again in an observation room. Both were recovering. Both were dazed. Both were alive.

Monica Codman Nicholls woke early the morning of the operation.

She had hoped for a few moments alone with her husband.

But by 6:30 a.m., Andrew Nicholls had already been wheeled downstairs for surgery. Any minute, they would be coming for her.

Outside her room, the sixth floor at Barnes-Jewish Hospital was coming slowly to life. Inside, Monica filled the silence with a nervous monologue.

"I was waiting for a new liver. But they moved the goal post on me," she began.

She is a painfully thin 53-year-old woman, half-submerged in a sea of white hospital sheets. Her jaundice was disguised by her dark complexion. But her illness showed in the yellowish cast of her eyes.

For nearly 20 years, Monica has battled a disease called primary biliary cirrhosis. No one knows what causes it, or why it strikes women almost twice as often as men.

It attacks the liver, causing scar tissue to form inside tiny passageways that carry a crucial digestive fluid called bile. Some people like Monica live for years with the disease. Others die within months.

About a year ago, Monica began rapidly losing weight. Fatigue overwhelmed her once effervescent personality.

She had been warned that this day might come. If it did, Monica had been told, her only hope would be a liver transplant.

A little more than two months ago, she was hospitalized near her home in Champaign, Ill. Doctors took 36-year-old Andrew aside to deliver the news: Without a transplant, Monica would die within three months.

She had already been waiting a year for a liver. The best anyone could tell, it might be another year before she reached the top of the list.

Andrew never told Monica about that conversation. He knew in his heart what he had to do.

And so they came to St. Louis on a brilliant August morning to try something that would once have been considered science fiction.

At their wedding 11 years ago, Andrew gave Monica a ring. Today, he would give her something even more precious: 60 percent of his liver.

If it worked, she would bypass the increasingly uncertain wait for a donated organ and begin life anew. Within a few months, both livers would have regrown to full size. And Monica's disease would be a distant nightmare.

If it failed, they both could die before the sun went down.

Only a handful of hospitals have ever tried the operation doctors would perform on Monica and Andrew, called a living donor liver transplant. It has been done fewer than 100 times in the United States.

But, buoyed by their early success and frustrated by a persistent lack of organs from brain-dead donors, some doctors are predicting that the operation will revolutionize transplant surgery.

Waiting in her bed at Barnes, Monica was talking about her last conversation with Andrew. "He said to me, 'I knew you were after my body when you married me, but I didn't know how deep you were willing to go.'"

All morning, she'd asked every nurse who walked into her room: "When am I going to meet this Dr. Howard?" A little before 7 a.m., she got her wish.

Dr. Todd K. Howard, director of liver and kidney transplant surgery at Barnes-Jewish, is a tired-looking man with a thick mustache.

"I thought you were going to get me a liver," she playfully chided him.

Howard replied, "We don't get many of those."

As they spoke, 13,500 people were awaiting a liver. Last year, about 4,500 transplants were performed; 1,300 people died waiting for a liver that never came.

Monica looked up at the man who, on this day, would change her life forever.

"I'm all yours," she said.

Delicate work in the operating room

Just before 8:50 a.m. in operating room 45, a delicate ballet began to unfold.

With the disco standard "Boogie Wonderland" thumping from a small portable stereo, Dr. Jeffrey A. Lowell made the first incision in Andrew's abdomen.

Working slowly with a pencil-size tool called an electrocautery, he cut his way through muscle and fat until he revealed the organs nestled neatly inside.

There was almost no visible blood in the now-gaping surgical wound, a testament both to Lowell's skill and to the tool he was wielding, which uses electricity to cauterize as it cuts.

Andrew lay unconscious upon the table; his jet-black hair hidden by a disposable surgical cap, his piercing blue eyes taped shut.

Around him were clustered a half-dozen gloved and gowned nurses, technicians and surgeons-in-training. Except for the occasional pirouette to reach an instrument or adjust equipment, they stood in silence as Lowell continued his meticulous dissection.

It has been 10 years since the first living donor liver transplant took place, a mother who gave to her dying child.

Because of their size, children need a much smaller liver than adults. That makes the operation safer for the donor.

It wasn't until 1991 that doctors performed the first living donor tr ansplant on an adult.

By 1997, you could count on the fingers of two hands the number of times it had been tried. You'd only need one to count the times it worked.

That year, a team from Barnes performed what was believed to be the first American operation using a new technique for liver transplants. Instead of transplanting the left lobe of the donor's liver, which comprises about 40 percent of the organ, they used the larger, right portion.

About the same time, federal officials began changing how organs are allocated. No longer would they be offered first to hospitals near where the donor died. Instead, they would go to the sickest potential recipient in a broader geographic region.

The new rules sent a shudder through those on waiting lists at small and medium-size transplant programs like those in St. Louis. People who might otherwise have taken their chances on the list began to seek other options.

Increasingly, living donor transplants have become that other option. Already this year, at least twice as many operations have been performed as were done in all of last year.

One, at the University of Virginia Medical Center, involved a man who donated to a woman he first met days before the surgery.

As that case dramatically illustrates, matching livers for transplant is easier than matching other organs. There is no need for the complicated tissue typing that must be done with a kidney transplant. Liver donors must only share the same blood type as the recipient.

That's not to say the surgery is simple.

Inside the operating room, Lowell worked for hours to carefully tease Andrew's liver apart from a major blood vessel that lies just underneath.

Slowly, he identified each of the small veins and arteries that fed it. Each was marked with surgical thread so it could be tied off.

By early afternoon, he was ready to remove the right lobe for Monica's transplant.

The hand of God

As the date for her operation approached, Monica knew it was time for a talk with Emily.

Monica has two grown sons from previous marriages. But she worried more about Emily, Andrew's 9-year-old niece whom the couple are raising.

Transplant surgery is difficult enough for a little girl to grasp. But suppose something went wrong?

Monica searched for the right words. "Doctors are the hand of God," she finally told the little girl. "But maybe God will decide I can't come back."

Emily listened solemnly. She didn't say a word.

The next day, she approached Monica with good news: "I spoke to God and he said it's going to be OK. You're both going to be fine."

Inside operating room 44 at Barnes, Monica's transplant surgeon wasn't quite so confident.

Slowly, Howard had removed her diseased liver, being careful to preserve enough of its supplying blood vessels to reattach the donated piece from Andrew.

Since early afternoon, the liver had been secured inside two plastic bags in a stainless steel container of ice.

When Howard called for it, a nurse gently lifted the liver and carried it across the room, cradled in her arms like an infant. It would take more than an hour to carefully reattach the organ.

It was evening when the job was done and blood began to flow back into the liver. Just before 7 p.m., Monica was brought from the operating room to intensive care.

That night, Howard found it difficult to sleep.

He was exhausted from being awakened the previous night to arrange another transplant. With just a few hours rest, he'd rushed back to the hospital for Monica's surgery.

Still, he kept replaying the details as he lay in bed. He thought he'd covered everything. But there have been so few operations like this. Was there some complication he hadn't anticipated?

Early the next morning, he got his answer. Tests showed the new liver had already begun to work.

About 4 that afternoon, Monica was wheeled out of intensive care. She would spend the next few days in an observation room where Andrew had been recovering.

When they brought Monica in, Andrew was sitting in a reclining chair, dazed with pain but unwilling to take medicine that might put him to sleep.

She was heavily sedated, lying flat on a hospital bed with railings raised to prevent a fall.

Monica reached past the railing, through the tangle of intravenous tubes. Andrew caught her hand in his.

For just a moment, they were together again -- one liver, two lives, one heart.

On Monday, Monica and Andrew Nicholls were released from Barnes-Jewish Hospital. They are staying at an apartment in St. Louis while doctors monitor their recovery.