Professor Paolo Muiesan (1961–2022) Surgical Master, Educator, Mentor, and Gentleman

Paolo Muiesan left a huge void when he passed away in March of 2022. Professor Muiesan has contributed in so many ways: he has been a brilliant surgeon, master academician, loved colleague, mentor, and friend to many, leaving a wonderful family that he loved so much. We have asked some of those who have spent time with Paolo to comment and acknowledge the many facets that he presented. Transplantation: Paolo has been recognized by the leaders in the field for his surgical expertise: What made him a master surgeon?Professor Mohamed Rela: Having worked for over 3 decades in organ transplantation and hepato-pancreato-biliary surgery (HPB) surgery, his pioneering efforts in the fields of split-liver transplantation (LT), donation after circulatory death (DCD), machine perfusion, and many other advances and contributions have hugely benefited mankind. Thousands of patients are alive today because of Paolo. It is indeed motivating to delve deeper into the qualities that made a young man conquer one of the most difficult fields in medicine. Paolo lost his father, a cardiologist soon after a liver transplant in London. Within months of this incident, he decided to specialize in the very field of medicine that failed him. The most spectacular thing about this was his brave decision to train in the very same institution where he lost his father. Those were the early days of LT in which outcomes were not as good as today, but he had the vision to recognize the potential of this field. Paolo was one of the hardest-working surgeons I have ever known. A patient and skillful surgeon, Paolo would not leave the patient’s side until he was convinced that the best possible treatment had been provided. Paolo was not only an expert surgeon, but he was also a brilliant academician. He published widely and organized various conferences to further the art of LT and held offices in many professional societies including European Society for Organ Transplantation (ESOT), The European Liver and Intestine Transplant Association, and International Liver Transplantation Society (ILTS). At Queen Elizabeth Hospital in Birmingham, he showcased his abilities by expanding the living donor liver program and through developing new perfusion technologies. In recognition of his contributions, he was awarded a Personal Chair by the University of Birmingham. Paolo was a charming, friendly, and humorous surgeon, ensuring that everyone inside and outside the operating room was at ease. A quality that held him in good stead even during the toughest of transplant operations; an inbuilt stressbuster whose good nature permeated across the operating room. Paolo had all the qualities of a complete surgeon, virtues that the younger generation could learn and emulate. Transplantation: Paolo spent a significant time at King’s College. What surgical legacy did he leave? Nigel Heaton: Paolo joined the Liver Unit at King’s as a young fellow in December 1992 introduced by the late K.C. Tan as the new recruit who was going to find out about LT. A cheeky smile, always a funny quip or retort, and a characteristic glance raising an eyebrow in a questioning manner. Very much the Italian man from Brescia, proud of his origins, his family and friends. I learned key aspects of Italian society that if breached attracted a withering look—always wear long dark socks up to the knees, never ever wear white socks (anathema)‚ and be sartorially well dressed—whether casual or smart, and food and wine found nowhere else in the world and certainly never in England! His time at Kings marked a golden period in LT that helped further develop the international profile of the unit. Through hard work and immense dedication, he developed into a very fine surgeon and colleague. Patients knew that he had their interests at heart and would do his very best for them and they loved him; colleagues could depend on his skill and ability in tight situations. The opportunity to start the DCD liver program at Kings proved to be a defining moment in his career and led to international recognition of his burgeoning expertise. Developing the DCD program by going out on multiple retrievals and standardizing the surgical technique was critical to achieving excellent outcomes with a low incidence of cholangiopathy. Paolo was fastidious in maintaining a database of cases and publishing extensively. He started the international DCD transplant symposium‚ which did much to establish DCD LT worldwide. Paolo had a love of life, family‚ and friends that inspired huge loyalty; his sense of humor could defuse the most difficult of situations and certainly irritated K.C. Tan! As a fellow and as a consultant colleague it was never dull, always laughter and a lot of hard work‚ which was to the benefit of our patients and the transplant program. Paolo died with unfulfilled ambitions, but never knowing failure or decline. Transplantation: Paolo then moved on to the University of Birmingham. What were his surgical and academic contributions? John Isaac: Paolo moved from Kings to Birmingham in 2008 continuing adult and pediatric liver transplants. He had already established himself as a leader in the field of DCD liver transplant and brought his experience to rapidly develop the Birmingham DCD program. The clinical and research program quickly grew into one of international standing contributing valuable knowledge to the field. Paolo started the live donor liver transplant program across both, the Queen Elizabeth Hospital and the pediatrics program at Birmingham Children’s hospital. He took on complex transplant cases and expanded the split-liver program, training a new generation of surgeons in these areas. He was soon fully involved and integral to the machine perfusion program. An accomplished HPB surgeon, he found in Birmingham a team receptive to the skills he brought, introducing complex techniques such as ex situ surgery for liver tumors, associating liver partition and portal vein ligation for staged hepatectomy procedures, and complex tumor resections with vascular reconstructions, especially in hilar cholangiocarcinoma. Paolo was an invaluable resource to whom colleagues came when complex case surgery was needed, and he was always happy to help. Paolo was a larger-than-life character. When he was in the room everyone knew it. He brought his charm and humor along with his skill and knowledge and inspired confidence in everyone. His outstanding contributions to the service and academic output over 11 years at Birmingham were recognized by the award of a professorship from the University of Birmingham. His legacy will live on in the many surgeons he trained and colleagues who admired and learned from him. Transplantation: Toward the end of his career, Paolo moved to Florence and then to Milano: How impactful was Paolo’s work at those institutions and how did his work impact organ transplantation and procurement in Italy? Luciano De Carlis: Paolo was born in Italy and graduated with excellence from the University of Brescia in 1985; he then continued to specialize in general surgery at the University of Brescia and vascular surgery at the University of Milan. During his brilliant career in the UK, Paolo has always maintained close relationships with the Italian transplant community and participated as an invited speaker in numerous congresses, events, and courses. I first met Paolo during the 11th ESOT Congress in Venice in 2003. It was during a dinner in the Piazza San Marco when he enthusiastically told me about the initial experience he had with controlled DCD liver transplants at King’s College. It was precisely this conversation that initiated the start of our first Italian DCD liver transplant program using normothermic regional perfusion and subsequent machine perfusion and overcoming the still-in-existence, 20 min no-touch period.1,2 Paolo moved to the Careggi Hospital in Florence in 2018, following a regional project promoted by Alessandro Nanni Costa (then-director of the Italian National Transplant Center) to increase the activity of DCD, pediatric, and living donor LT. This project did, unfortunately not continue with Nanni Costa’s retirement and Paolo, as a full professor at the University of Florence, directed the HPB Surgery Unit of the Careggi Hospital while initiating a reference surgical center for the entire Tuscany region in parallel to maintaining a continuous transplant collaboration with the University of Birmingham. In November 2021, Paolo was appointed as a full professor of surgery at the University of Milano and asked to direct the Liver Transplant Center at Policlinico Hospital. The Policlinico Hospital has a remarkable tradition in having advanced many areas of surgery, including transplantation: in 1952, Vittorio Staudacher performed here the first experimental liver transplant.3 He also pioneered together with Raffaele Cortesini in Rome, clinical LT. Paolo had thus reached an exceptional milestone with the prospect of returning to Italy in one of the most prestigious centers. Those years formed a deep friendship and mutual esteem, I appreciated his professionalism and surgical competence and enjoyed common surgeries on challenging patients. As a testimony of our friendship, we co-organized the “8th International Meeting on Transplantation from DCD” in Milan together with Costantino Fondevilla with great success and appreciation by the national European and International liver transplant community. Transplantation: Paolo had a stellar academic track record. His particular interest was in novel perfusion methods and the utilization of marginal and DCD livers. What have been lasting contributions? Andrea Schlegel: Paolo Muiesan believed the best possible surgical treatment was a human right. With his skills as brilliant liver transplant and hepatobiliary surgeon and his many accomplishments, he could have settled in a pleasant villa, working at an easy pace in a private hospital, enjoying skiing and other sports he loved. Instead, he seemed to live in operating theatres, removing life-threatening cancers, and transplanting livers of all sizes and shapes. Between patients, relatives, colleagues, and friends he would stand outside in his scrubs, a plucked-looking man with style and with the ever-remaining goal to stand up for those in need. And countless patients owe their lives to his restless and hard work throughout day and night. But wherever he worked, in the United Kingdom, in Italy, in Pakistan, or lately even in Kenia, he fought for the basic human right to live, providing the best surgical care. His surgical successes have been countless, among them the first selective use of split DCD livers for both adults and pediatric recipients, always combined with the best possible surgical technique. Since the early nineties, one of his main interests was the protection of the biliary tree, which started for him with a highly optimized surgical procurement technique. His interest and experience in this field were also one reason why Paolo was one of the early adopters of normothermic regional perfusion and ex situ machine perfusion in the UK and Europe. With his humanity and unique ability to build bridges, he was the motor of various collaborative projects and the tight connection among experts and transplant centers worldwide. Many colleagues within his exceptional network became close friends not only to him but also among themselves. Notably, it was not only Paolo’s surgical expertise that was unique, with >320 articles and book chapters Paolo’s academic contributions added enormously to the field. Transplantation: Paolo was an excellent teacher. What was his mentoring secret? Annemarie Weissenbacher: Professor Paolo Muiesan was outstanding and exceptional, with a considerable impact on more than just one generation of transplant surgeons and professionals. Personally, I had the honor and the privilege to collaborate with him in my role on the Education Committee of the ESOT at a very early stage in my career that was me as a youngster, the young professionals’ representative and Paolo, the highly accomplished world-renowned transplant surgeon and Union Europeenne des Medecins Specialistes representative. We made a great team and the difference in the hierarchy did not matter to Paolo. He cared for the next generation, deeply, encouraged us to speak up, asked us to bring our ideas to the table, questioning current standards, and getting actively involved in transplant societies. Paolo did not just inspire and motivate us to follow our passion for transplantation, he also listened carefully, paid attention, and showed sincere empathy for our real-world problems. Paolo was an exceptionally gifted teacher. A talent that I did experience myself during courses and personal communications, for which I am more than grateful. He could explain the steps of a very advanced and challenging surgery in such a natural and uncomplicated way that it was easy to follow. He could easily make us understand how to achieve the best possible outcome for the patient. It would not do Paolo justice, to say that there was a single secret behind his teaching and mentoring talent, he was all involved with a very unique approach and always driven with heartfelt passion. When he stimulated discussions, it was important for him to consider a wide variety of ideas, especially encouraging those that were different from his own; he challenged us to think out of the box of traditional teachings. Embracing the perspectives of all parties was essential for him in his quest to transform and innovate the field of transplantation. Transplantation: Paolo was what we like to call today a triple or even better a quadruple threat: Being an outstanding clinician, an influential researcher, an impactful educator, and most active in several societies. What were major academic achievements and contributions to professional societies? Marina Berenguer: At all institutions in Europe where Paolo worked, he made major contributions, particularly in the fields of donation after circulatory death, reperfusion injury, and machine perfusion. Early results of his DCD liver transplants at King’s College have published in Annals of Surgery in 2005.3 Sixty livers were retrieved from nonheart-beating donors, and of these 33 were considered suitable for transplantation. Of the 32 transplanted grafts, all except 1 had good early function. The results from this first experience opened the door for further research and adoption of this practice in all liver transplant units in the UK. Paolo went on with the first systematic review on the practice of extracorporeal machine oxygenation.4 The normothermic regional perfusion technique was published as a multicenter experience from Cambridge, Birmingham and Edinburgh.5 Over the years he continued his research with major findings from these studies including (1) the increased incidence of acute kidney injury in DCD liver recipients as compared with donation after brain death liver recipients,6 (2) the increase in the donor pool by extensive use of DCD for LT with outcomes compared by propensity score to those of donation after brain death LT,7 and (3) the understanding of challenges, limitations, and solutions offered by the different techniques to recondition donor livers of DCD liver grafts out of standard criteria.8 In one of his most recent contributions, he collaborated with the DCD Collaborator Group to define global benchmarks for DCD liver transplantation. The best possible outcomes after LT of grafts donated after circulatory death were defined using the concept of benchmarking. These were based on 2219 LTs following controlled DCD donation in 17 centers worldwide. Donor and recipient combinations with higher risk had significantly worse outcomes. However, the use of novel organ perfusion technology helped high-risk patients achieve similar outcomes as the benchmark cohort. Overall, >50 articles established the policies and pushed the limits to enhance the successful use of DCD donors. Importantly, he was instrumental in disseminating the knowledge related to this new source of organs. He visited many countries including Japan, India, Canada, and Singapore to export the DCD model. He organized and chaired 8 International Meetings on Transplantation from DCD (2002–2018) and was a member of the expert group issuing the British Transplantation Society/NHS Blood and Transplant guidelines for transplantation from DCDs. Further, he was also part of the panel of experts that formulated the European recommendations on aspects donation and transplantation from controlled and DCD, including best and promoted by The organized a in in Italy, to review the current clinical practice on Paolo Muiesan was a significant to the success of this His working group performed a critical of the to a of the of early and in the of DCD Paolo participated in the of with an on the machine perfusion the of this technique with traditional Paolo was instrumental in the critical to have in to up a machine perfusion program including and of the different techniques Transplantation: Paolo’s skills and out and left a What made him I had the privilege to work with Paolo Muiesan in ESOT and the of Transplant His style was unique, with aspects he to his took his or over them to make a With his charm and unique he convinced many having to his His style was that of an Italian always and He loved to in various during as he was not very good at He to be at the same time but because of that about a or was in theatres, just a or only just made or had to leave was with Paolo. He did not like and we very through some of the we I find of humor in his with a or or During the initial of the we other a lot similar With Italy of he was me and many that we this we in an by the of Transplant Surgery he the When asked what this he time This was his way of With the ever that is going to be out at some teaching us all how to difficult situations. I am for his friendship and his contributions to our He with had an for talent, hugely young transplant and was to the limits in transplantation. We were in that Transplantation: As if all his and contributions were not Paolo is particularly for his unique His and are only some of his unique What the Paolo, like many of a part of his to the most on medicine. But he also knew how to be a great who loved his and his family more than else within the limits by this What of his private was at to the concept of Paolo enjoyed the he knew how could he never lost himself in he was moved by the of the on the and he enjoyed a of wine in of the in the Paolo was a very and with a particular and a friend to have at the side of as a and but all for his charm and good His was always of in of those who knew how to live the Italian He loved sports and in particular skiing and Paolo to he to but never a He loved good food and good but he went for Paolo was the of in the sense of the his he have the of a in the of a about a he I were to today, I would be happy with the I have led and the We are so to for having the of so many, for having and for having been a wonderful colleague, for unique and most for the wonderful time and friendship that we had with We the contributions of the following for this in Transplantation Mohamed of Education Nigel and Professor of King’s John Isaac: HPB and Liver Transplant Queen Elizabeth Birmingham Liver for Liver Luciano De of the of of the and Transplantation Professor of University of of Andrea Transplant and University Hospital Policlinico Center for Italy, Annemarie Transplant and University of Marina in and for College and Transplant College Hospital UK, Transplant and of and Transplant University Hospital