After waiting a year for a new liver, 11-year-old Elmer Justice III had to settle for half of one. But as far as his doctors were concerned, half a liver was good enough.
The Johns Hopkins Children's Center is one of about a dozen hospitals across the country that have capitalized on the unique regenerative powers of the liver to get around the shortage of child donors for youngsters in need, such as Elmer.
Here's the problem: Children have smaller livers than adults. So, as the old wisdom went, children need livers from people who are about their size. And there aren't as many child donors as adult donors.
But in the past two years, surgeons at Johns Hopkins and about a dozen other hospitals have found that they can take an adult liver, reduce it to half its original size and transplant it into a child.
The technique is so compelling -- and successful -- that at Hopkins, about one third of the livers transplanted into children the past year have come from adults. It's a trend that ought to continue at least for a few years, said Dr. Paul M. Colombani, director of pediatric surgery.
"By the end of this month, we will have 11 children on the list waiting for livers, many of them infants," he said. "It's unlikely that we'll have appropriate size donors for them in the Baltimore area. And we're getting less calls from the outside."
The survival rate is about the same, according to doctors, whether the young patients get a whole or divided liver: About 80 percent survive two years, and very few who live that long die of liver failure.
At Hopkins, the youngest recipient of a "cut-down" liver was a 9-month-old boy weighing about 15 pounds. "He's fine, and he's almost a year out of surgery," Dr. Colombani said.
Elmer, small for his age because of a congenital liver disorder, is also making a good recovery after his 11-hour operation March 24 in which he received both a new liver and kidney. The Hampden youngster is ex pected to leave the hospital in about two weeks.
"He's feeling pretty good today," said his father, Elmer Justice Jr. "As a matter of fact, his doctor is supposed to be in here today and take all the staples out."
Adult livers for children would not be possible were it not for the peculiar properties of the organ.
The liver performs myriad functions -- breaking down, storing and secreting many different chemicals -- but the cells that do these things are distributed evenly throughout the organ. For this reason, half a liver, or less, does everything a full liver does.
In Elmer's case, surgeons gave him the left lobe and discarded the right. A patient can just as easily receive one lobe as the other, but in Elmer's case, surgeons felt that the left section was a better fit.
Also, the liver is the only organ that will regenerate if divided. As the boy grows, so will his liver until he -- and it -- reach adult size.
"The interesting thing is, if you were to go back in a year and had some reason to look inside this fellow, you'd find the liver is the same size and shape as what we call a normal liver," said Dr. Andrew Klein, director of liver transplants.
It will have filled the space exactly, he said, growing into the irregular recesses created by surrounding organs.
Elmer was born with a liver that was missing an enzyme needed to break down the sugar glycogen into a form that the rest of the body can use to produce energy. His kidneys were failing because glycogen was accumulating to toxic levels.
He could have spent the rest of his life making trips to a dialysis center, but a new kidney and liver seemed far more desirable.
For Elmer's operation, Dr. Klein traveled to the donor's hospital, removed the organs and brought them back to Hopkins. Then Dr. Colombani and Dr. James F. Burdick performed the transplant surgery.
Due to confidentiality rules, the origin of the kidney and liver was not revealed. They could have traveled hundreds or even thousands of miles, because organs in a cooler can survive for 12 to 18 hours. But it is possible that the organs came from a Baltimore donor.
The organs came from a patient -- probably an accident victim -- whose brain had ceased to function but whose heart continued to nourish the body with blood.
Doctors say the method of using reduced-size livers might soon give way to another practice: giving a child part of a liver from a living relative. The technique, pioneered at the University of Chicago in 1989, not only saves children but also frees donated organs for use in adult patients.
The Chicago experience has shown that an adult donor can live with three-quarters of the liver left intact, Dr. Klein said. After surgery, the organ simply grows to normal size.
As for the child, a quarter-size liver does just fine.