— Vol. 8 Transplant Surgery: Tomoaki Kato, MD – Japanese Medical Society of America

Our latest JMSA Interview Series is with Dr. Tomoaki Kato. Dr. Kato is the Chief of the Division of Abdominal Organ Transplantation at New York-Presbyterian Hospital/Columbia University Medical Center, New York, NY. He specializes in liver, multivisceral, pediatric and intestinal transplantation, as well as ex-vivo tumor resection. His research interests include transplant immunology. Please click "Read More" for the article.

Undergraduate: Tokyo University
Medical School: Osaka University Medical School
General Surgery Internship: Osaka University Hospital, Osaka, Japan
Residency: Itami City Hospital, Hyogo, Japan
Transplant Fellowship: University of Miami, Miami/Jackson Memorial Hospital, Miami, FL

Can you tell me a little bit about your childhood? What made you want to become a doctor?

It was my childhood dream to become a physician. My father wasn’t a doctor but he came from a family of doctors and wanted one of his children to go to medical school. However during high school, I became fascinated by DNA and the genetic code so I decided to become a molecular biologist instead. I studied in the Department of Pharmacy at the University of Tokyo, which had the best molecular biologists. This program included courses in biochemistry, genetics and molecular biology.

While conducting experiments and mouse studies, however, I began to think that I wanted to become a doctor and not a scientist, and that I wanted to work with humans and not bacteria and animals. This thought grew in my mind. One day, when I was traveling on a Japanese bullet train (Shinkansen), somebody called for a doctor. I realized at that moment that I wanted to stand up and say that I was a doctor. So I decided to take the medical school entrance examination and apply. In Japan, students go directly to medical school from high school. However, there was a program at Osaka University Medical School that allows post-baccalaureate students to transfer into the third year of medical school. So that is what I did.

I see that your path to medical school was very different from that of many other Japanese doctors.

In a way, my path to medical school was similar to that of many students in the United States as I completed four years of undergraduate studies before medical school. A lot of Japanese students decide to go to medical school because of rankings or because of their parents, and not necessarily because they want to become a doctor. On the other hand, I studied something else and then decided to go to medical school.

So how did you decide you wanted to become a surgeon?

The reason I wanted to become a doctor was because I wanted to help people in emergencies such as on the Shinkansen. So I didn’t consider subspecialties such as ophthalmology and dermatology and only considered bigger specialties such as surgery, medicine and pediatrics. I didn’t have a strong interest in surgery at first, but I liked it in medical school. With surgery, you can see inside and understand the disease process. Back then, imaging technology wasn’t very developed, and medicine was a lot less clear. Maybe it is different now, but I think there is still some uncertainty in medicine, and sometimes patients die without your doing anything. In surgery that is rare.

I saw that you did your residency in Osaka and then moved to Miami. What made you decide you wanted to come to the States?

I wanted to receive advance training. If you are in academic medicine in Japan, you do four years of research after you finish your residency. I didn’t think four years of research was great at that time because I was gaining more experience in surgery and I didn’t want to stop. I liked research but I didn’t like the way the program was set up. If I was doing research, I wanted to study something I was interested in, not something I was assigned to. Now, I regret that I do not have a lot of experience in bench research. But at that time, I wanted to continue my surgical training.

So I asked my professors what I should do and I came up with the idea of doing something outside of Japan that would expand my clinical skills. I had passed the foreign medical graduate examination so I could use that as a reason to go to the U.S. I became interested in vascular surgery and transplant surgery because those were two fields that weren’t as developed in Japan. So I went to the professor of vascular surgery and asked him to write a letter of recommendation, and he said for me to come back in a month. Then I asked the transplant surgeon, and he said he would do it right away (laugh). I didn’t know too much about transplant surgery, but I wanted a justifiable reason to skip the lab time to learn more in the U.S., at least for two years and then return to Japan.

Did you notice any differences between the two medical systems or experience any surprises when you moved?

Medicine doesn’t differ between the two countries, but the language was difficult to get used to. English was really hard for me. I attended a regular Japanese school and the English language education wasn’t very good.

Your English is good now…

But that was after fifteen years. The hardest time for me was during the first three to six months. During those first few months in Miami, people thought I didn’t know anything because I couldn’t speak English very well. I wasn’t getting many opportunities in the operating room because of the language barriers.

I remember one night, the night that significantly changed my life. We were in the middle of a really tough transplant. The attending was screaming and the second year resident who was assisting him wasn’t doing well. I was just holding the liver. So I told the second year resident that I was going to help him. I changed places with him and the rest of the surgery went really well.

So that was the turning point of my fellowship life. Other surgeons realized that although I couldn’t speak English well, I was very well trained. And after that surgery, people were much nicer, much more patient and listened to me a lot more. My communication skills started to improve considerably and I was given better opportunities in the operating room. The rest of the transplant fellowship went really well.

Did you ever think about going back to Japan?

I was supposed to go back after two years. However, it was such an exciting time for me because I was doing liver transplants on my own. If I went back to Japan I would have little opportunity to do liver transplants. So I wanted to stay for at least a few more years.

At the same time, I also wondered if Miami was an appropriate place for me and I wanted to go somewhere else for an extended fellowship. I was looking into other hospitals. But then Miami wanted me to stay and offered me a position as an attending. They created the position specifically for me. In retrospect it wasn’t a very good position because of the cheap salary (laugh), around half or two thirds of what I was supposed to get as an attending (laugh) but I was happy because I earned more than I did before and I gained a lot of experience.

Around this time, I got an offer from Japan to create a liver transplant surgery program. This was a great opportunity for a young surgeon so I decided to work part time in Miami and full time in the Japan. So I went back and forth between the two countries for two to three years. It was a great experience because I learned a lot and was able to perform procedures on my own. After that, I started to perform multivisceral transplants and bowel transplants in Miami, so there wasn’t any reason for me to go back to Japan.

What are some of your experiences that led you to do ex-vivo surgery?

The beginnings of ex-vivo surgery came from my experiences with multivisceral transplants. I was doing multivisceral transplants for children with diseases in the entire abdominal cavity like necrotizing enterocolitis. Miami was a pioneer in the approach and there were no textbooks about this type of surgery.

One day a patient came to me with a tumor on her aorta, with all blood vessels going through it. I thought that the solution would be to take all the organs out of the abdominal cavity, remove the tumor, and put the healthy organs back in. My mentor in Miami had started ex-vivo bowel surgery and another had done ex-vivo kidney surgery. So the idea of ex-vivo surgery was an extension of our experiences with multivisceral transplants.

During medical school and residency, you learn a lot of standard care and it is easy to forget to think on your own. But doing multivisceral transplants was like being in uncharted waters. We had to create standard of care on our own. This process helped me to think differently and not be afraid of doing something new. I also made it a policy to not start with no as an answer. I realized that you may find a new solution if you look carefully and think about other possibilities to consider. The ex-vivo surgery came about as a result of the same thinking process. You start to think, if you do this and that, maybe something can be done.

You performed ex-vivo surgery on Heather McNamara where you took six organs out of the abdominal cavity, removed the tumor and put healthy organs back in. With Heather’s case, the fear was that the tumor had already spread to the liver. How did you feel not knowing what might happen until after you’ve opened the abdominal cavity?

Planning is very important. You also have to know that the unexpected could happen. It is like being in an ocean without a chart. I think the trip to the moon was similar. People knew that they could get to the moon based on their calculations, but they also knew that something unexpected could happen. So we did a lot of research to examine the patient and come up with a safety net. One safety net for Heather was to have her father as a living liver donor. Even if we had to destroy the liver to remove the tumor, we could use her father’s liver to bridge her to something else. That was something we prepared for but we didn’t need to do. Our preparation was good enough so I was pretty confident that I could do it, and with more of these cases, I started to get a better idea of what might happen.

How many ex-vivo patients have you had?

At Columbia University alone I’ve performed around twenty ex-vivo surgeries, but half of them did not involve multiple organs. So I’ve performed around twelve complex cases, which comes to around four or five surgeries per year.

How are Heather and all your other ex-vivo patients doing?

They are doing really well. So this is something really exciting…

You must get a lot of patients who want to see you.

I’m now known as the doctor who can perform surgeries on ‘inoperable tumors’ (laugh). Ex-vivo surgery is actually becoming well known and I’ve been getting lots of inquiries. But there are many cases that I can’t do because the cancer has already spread or the patient is debilitated. The question is where to draw the line between something I can and can’t do. However I don’t want to start with no as my philosophy so I consider all the patients. This has led me to think outside the box. I recently did a case where the retroperitoneal tumor had metastasized to the liver. This lady had multiple metastatic lesions all over the liver and we had to make her liver like swiss cheese. I also removed a huge abdominal mass weighing around 50lbs from a gentleman. It has been pretty interesting.

Before we finish today, I wanted to ask you about your volunteer activities. Yumi Ando (JMSA junior member) mentioned that you are involved in hepatitis B awareness. Can you tell me about that?

I want to do more rather than less, and lots of things interest me. Outside of transplant and ex-vivo surgery, I am involved in hepatitis B awareness in the Asian community. There were two cases that got me into this. The first case involved a beautiful Korean lady, a fighter I think, who felt strong abdominal pain after one of her matches. The hepatocellular carcinoma had ruptured into her abdomen, and I operated on her and took the tumor out but it was too late. She knew she had hepatitis B but she didn’t know she could get cancer. Another case was a Chinese immigrant, around twenty six or twenty seven years old who also had a huge tumor in his abdomen. I took the tumor out, but the tumor metastasized to the eye, and he suffered a lot and it was very painful for me to watch. He didn’t know he had hepatitis B. Both of these individuals could have been saved with appropriate knowledge about hepatitis B. Hepatitis B is a big problem in NYC with its relatively large Asian population.

I talked to other surgeons involved in hepatitis B awareness and I worked with medical students including Yumi. We went to high schools and taught them about hepatitis B. The idea was to teach students and have them tell their parents about the importance of screening and prevention. Yumi did a lot of work creating skits and other interactive sessions. It was very creative and I love doing this.

Another thing I am doing is going to Venezuela to do liver transplants for children. Ten times a year I fly out on a Friday, perform surgery on Saturday, and then come back on Sunday. I got involved in 2004 when a mother in Venezuela wanted to bring her sick child to Miami but she had no money and couldn’t fundraise. So I came up with the idea that I will go to Venezuela, find a hospital, and do the transplant. I didn’t know anything about Venezuela at that time. I didn’t even know where the country was (laugh). But the idea was that the surgery had to be done locally as the local government was willing to cover the expense. So I found Venezuelan doctors who were interested, and I set up the program. Unfortunately, the child died before the transplant. But there were other children who needed the surgery.

So there were no transplant programs in Venezuela?

No. I performed the first living liver donor transplant ever in Venezuela. Now I do everything with the locals and I train them. After these many years, the surgeons in Venezuela can do half of the surgery by themselves. They are close to being independent now. So we are starting to look for other countries to target, possibly the Dominican Republic and El Salvador. We have received lots of interest from those countries. I work mainly with the pediatric patients there and I really like this development.

Your work is amazing. I learned so much from your inspirational stories. Thank you very much for speaking with me today!