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INK Conference

Susan Lim: Transplant cells, not organs

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Pioneering surgeon Susan Lim performed the first liver transplant in Asia. But a moral concern with transplants (where do donor livers come from ...) led her to look further, and to ask: Could we be transplanting cells, not whole organs? At the INK Conference, she talks through her new research, discovering healing cells in some surprising places.

- Surgeon
A surgical pioneer in Singapore, Susan Lim is a researcher and entrepreneur. Full bio

So I was privileged to train in transplantation
00:16
under two great surgical pioneers:
00:20
Thomas Starzl,
00:22
who performed the world's first successful liver transplant
00:24
in 1967,
00:27
and Sir Roy Calne,
00:29
who performed the first liver transplant in the U.K.
00:31
in the following year.
00:34
I returned to Singapore
00:37
and, in 1990,
00:39
performed Asia's first successful
00:41
cadaveric liver transplant procedure,
00:43
but against all odds.
00:46
Now when I look back,
00:49
the transplant was actually the easiest part.
00:51
Next, raising the money to fund the procedure.
00:55
But perhaps the most challenging part
00:59
was to convince the regulators --
01:03
a matter which was debated in the parliament --
01:05
that a young female surgeon
01:09
be allowed the opportunity
01:11
to pioneer for her country.
01:13
But 20 years on,
01:16
my patient, Surinder,
01:18
is Asia's longest surviving
01:20
cadaveric liver transplant to date.
01:22
(Applause)
01:25
And perhaps more important,
01:29
I am the proud godmother
01:32
to her 14 year-old son.
01:34
(Applause)
01:36
But not all patients on the transplant wait list
01:40
are so fortunate.
01:42
The truth is,
01:44
there are just simply not enough donor organs
01:46
to go around.
01:48
As the demand for donor organs
01:50
continues to rise,
01:52
in large part due to the aging population,
01:54
the supply has remained relatively constant.
01:57
In the United States alone,
02:01
100,000 men, women and children
02:03
are on the waiting list for donor organs,
02:07
and more than a dozen die each day
02:10
because of a lack of donor organs.
02:13
The transplant community
02:16
has actively campaigned in organ donation.
02:18
And the gift of life
02:21
has been extended
02:23
from brain-dead donors
02:25
to living, related donors --
02:27
relatives who might donate an organ
02:29
or a part of an organ,
02:32
like a split liver graft,
02:34
to a relative or loved one.
02:36
But as there was still a dire shortage of donor organs,
02:39
the gift of life was then extended
02:42
from living, related donors
02:44
to now living, unrelated donors.
02:46
And this then has given rise
02:49
to unprecedented and unexpected
02:52
moral controversy.
02:55
How can one distinguish
02:58
a donation that is voluntary and altruistic
03:01
from one that is forced or coerced
03:04
from, for example,
03:07
a submissive spouse, an in-law,
03:09
a servant, a slave,
03:12
an employee?
03:14
Where and how can we draw the line?
03:16
In my part of the world,
03:20
too many people live below the poverty line.
03:23
And in some areas,
03:26
the commercial gifting of an organ
03:28
in exchange for monetary reward
03:30
has led to a flourishing trade
03:33
in living, unrelated donors.
03:35
Shortly after I performed the first liver transplant,
03:39
I received my next assignment,
03:42
and that was to go to the prisons
03:44
to harvest organs
03:47
from executed prisoners.
03:49
I was also pregnant at the time.
03:52
Pregnancies are meant
03:55
to be happy and fulfilling moments
03:57
in any woman's life.
04:00
But my joyful period
04:02
was marred by solemn and morbid thoughts --
04:04
thoughts of walking through
04:09
the prison's high-security death row,
04:11
as this was the only route
04:14
to take me to the makeshift operating room.
04:16
And at each time,
04:20
I would feel the chilling stares
04:22
of condemned prisoners' eyes follow me.
04:25
And for two years,
04:29
I struggled with the dilemma
04:31
of waking up at 4:30 am
04:33
on a Friday morning,
04:35
driving to the prison,
04:37
getting down, gloved and scrubbed,
04:39
ready to receive the body
04:41
of an executed prisoner,
04:44
remove the organs
04:46
and then transport these organs
04:48
to the recipient hospital
04:50
and then graft the gift of life
04:52
to a recipient the same afternoon.
04:55
No doubt, I was informed,
04:58
the consent had been obtained.
05:00
But, in my life,
05:06
the one fulfilling skill that I had
05:08
was now invoking feelings of conflict --
05:13
conflict ranging
05:17
from extreme sorrow and doubt at dawn
05:19
to celebratory joy
05:23
at engrafting the gift of life at dusk.
05:25
In my team,
05:29
the lives of one or two of my colleagues
05:31
were tainted by this experience.
05:34
Some of us may have been sublimated,
05:37
but really none of us remained the same.
05:40
I was troubled
05:44
that the retrieval of organs from executed prisoners
05:47
was at least as morally controversial
05:51
as the harvesting of stem cells
05:54
from human embryos.
05:56
And in my mind,
05:59
I realized as a surgical pioneer
06:01
that the purpose of my position of influence
06:04
was surely to speak up
06:07
for those who have no influence.
06:09
It made me wonder
06:12
if there could be a better way --
06:14
a way to circumvent death
06:16
and yet deliver the gift of life
06:19
that might exponentially impact
06:21
millions of patients worldwide.
06:24
Now just about that time,
06:28
the practice of surgery evolved
06:30
from big to small,
06:32
from wide open incisions
06:34
to keyhole procedures,
06:36
tiny incisions.
06:38
And in transplantation, concepts shifted
06:41
from whole organs to cells.
06:44
In 1988, at the University of Minnesota,
06:47
I participated in a small series
06:50
of whole organ pancreas transplants.
06:53
I witnessed the technical difficulty.
06:56
And this inspired in my mind
06:59
a shift from transplanting whole organs
07:01
to perhaps transplanting cells.
07:05
I thought to myself,
07:07
why not take the individual cells
07:09
out of the pancreas --
07:12
the cells that secrete insulin to cure diabetes --
07:14
and transplant these cells? --
07:17
technically a much simpler procedure
07:20
than having to grapple with the complexities
07:22
of transplanting a whole organ.
07:25
And at that time,
07:28
stem cell research
07:30
had gained momentum,
07:32
following the isolation of the world's first
07:34
human embryonic stem cells
07:37
in the 1990s.
07:39
The observation that stem cells, as master cells,
07:42
could give rise
07:45
to a whole variety of different cell types --
07:47
heart cells, liver cells,
07:49
pancreatic islet cells --
07:51
captured the attention of the media
07:53
and the imagination of the public.
07:56
I too was fascinated
07:59
by this new and disruptive cell technology,
08:01
and this inspired a shift in my mindset,
08:04
from transplanting whole organs
08:07
to transplanting cells.
08:09
And I focused my research on stem cells
08:12
as a possible source
08:15
for cell transplants.
08:17
Today we realize
08:20
that there are many different types of stem cells.
08:22
Embryonic stem cells
08:25
have occupied center stage,
08:27
chiefly because of their pluripotency --
08:29
that is their ease in differentiating
08:33
into a variety of different cell types.
08:36
But the moral controversy
08:40
surrounding embryonic stem cells --
08:43
the fact that these cells are derived
08:46
from five-day old human embryos --
08:48
has encouraged research
08:51
into other types of stem cells.
08:53
Now to the ridicule of my colleagues,
08:56
I inspired my lab
09:00
to focus on what I thought
09:02
was the most non-controversial source of stem cells,
09:05
adipose tissue, or fat, yes fat --
09:09
nowadays available in abundant supply --
09:12
you and I, I think, would be very happy to get rid of anyway.
09:16
Fat-derived stem cells
09:21
are adult stem cells.
09:23
And adult stem cells
09:25
are found in you and me --
09:27
in our blood, in our bone marrow,
09:29
in our fat, our skin and other organs.
09:31
And as it turns out,
09:34
fat is one of the best sources
09:36
of adult stem cells.
09:38
But adult stem cells
09:40
are not embryonic stem cells.
09:42
And here is the limitation:
09:45
adult stem cells are mature cells,
09:47
and, like mature human beings,
09:50
these cells are more restricted in their thought
09:53
and more restricted in their behavior
09:56
and are unable to give rise
09:59
to the wide variety of specialized cell types,
10:01
as embryonic stem cells [can].
10:04
But in 2007,
10:06
two remarkable individuals,
10:09
Shinya Yamanaka of Japan
10:12
and Jamie Thomson of the United States,
10:14
made an astounding discovery.
10:17
They discovered
10:20
that adult cells, taken from you and me,
10:22
could be reprogrammed
10:25
back into embryonic-like cells,
10:28
which they termed IPS cells,
10:30
or induced pluripotent stem cells.
10:33
And so guess what,
10:38
scientists around the world and in the labs
10:40
are racing
10:43
to convert aging adult cells --
10:45
aging adult cells from you and me --
10:48
they are racing to reprogram these cells
10:50
back into more useful IPS cells.
10:53
And in our lab,
10:58
we are focused on taking fat
11:00
and reprogramming
11:02
mounds of fat
11:04
into fountains of youthful cells --
11:06
cells that we may use
11:10
to then form other,
11:12
more specialized, cells,
11:14
which one day may be used as cell transplants.
11:16
If this research is successful,
11:20
it may then reduce the need
11:23
to research and sacrifice
11:26
human embryos.
11:28
Indeed, there is a lot of hype, but also hope
11:32
that the promise of stem cells
11:35
will one day provide cures
11:37
for a whole range of conditions.
11:39
Heart disease, stroke, diabetes,
11:41
spinal cord injury, muscular dystrophy,
11:44
retinal eye diseases --
11:46
are any of these conditions
11:49
relevant, personally, to you?
11:51
In May 2006,
11:54
something horrible happened to me.
11:57
I was about to start a robotic operation,
12:00
but stepping out of the elevator
12:02
into the bright and glaring lights of the operating room,
12:04
I realized
12:07
that my left visual field
12:09
was fast collapsing into darkness.
12:11
Earlier that week,
12:14
I had taken a rather hard knock
12:16
during late spring skiing -- yes, I fell.
12:18
And I started to see floaters and stars,
12:21
which I casually dismissed
12:23
as too much high-altitude sun exposure.
12:25
What happened to me
12:28
might have been catastrophic,
12:30
if not for the fact
12:32
that I was in reach of good surgical access.
12:34
And I had my vision restored,
12:36
but not before a prolonged period of convalescence --
12:38
three months --
12:41
in a head down position.
12:43
This experience
12:45
taught me to empathize more with my patients,
12:47
and especially those with retinal diseases.
12:50
37 million people worldwide
12:54
are blind,
12:56
and 127 million more
12:58
suffer from impaired vision.
13:01
Stem cell-derived retinal transplants,
13:04
now in a research phase,
13:07
may one day restore vision,
13:09
or part vision,
13:11
to millions of patients with retinal diseases worldwide.
13:13
Indeed, we live
13:17
in both challenging
13:19
as well as exciting times.
13:21
As the world population ages,
13:25
scientists are racing
13:28
to discover new ways
13:30
to enhance the power of the body
13:32
to heal itself through stem cells.
13:34
It is a fact
13:37
that when our organs or tissues are injured,
13:39
our bone marrow
13:42
releases stem cells
13:44
into our circulation.
13:46
And these stem cells
13:48
then float in the bloodstream
13:50
and hone in to damaged organs
13:52
to release growth factors
13:55
to repair the damaged tissue.
13:57
Stem cells may be used as building blocks
13:59
to repair damaged scaffolds within our body,
14:02
or to provide new liver cells
14:06
to repair damaged liver.
14:08
As we speak, there are 117 or so clinical trials
14:11
researching the use of stem cells
14:14
for liver diseases.
14:17
What lies ahead?
14:19
Heart disease
14:21
is the leading cause of death worldwide.
14:23
1.1 million Americans
14:25
suffer heart attacks yearly.
14:27
4.8 million
14:30
suffer cardiac failure.
14:32
Stem cells may be used
14:34
to deliver growth factors
14:36
to repair damaged heart muscle
14:38
or be differentiated
14:40
into heart muscle cells
14:42
to restore heart function.
14:44
There are 170 clinical trials
14:46
investigating the role of stem cells in heart disease.
14:49
While still in a research phase,
14:53
stem cells may one day herald
14:56
a quantum leap in the field of cardiology.
14:59
Stem cells provide hope for new beginnings --
15:03
small, incremental steps,
15:06
cells rather than organs,
15:09
repair rather than replacement.
15:12
Stem cell therapies
15:15
may one day reduce the need for donor organs.
15:18
Powerful new technologies
15:22
always present enigmas.
15:24
As we speak,
15:26
the world's first human embryonic stem cell trial for spinal cord injury
15:28
is currently underway
15:31
following the USFDA approval.
15:33
And in the U.K.,
15:36
neural stem cells to treat stroke
15:38
are being investigated in a phase one trial.
15:40
The research success that we celebrate today
15:44
has been made possible
15:47
by the curiosity and contribution and commitment
15:49
of individual scientists
15:53
and medical pioneers.
15:55
Each one has his story.
15:57
My story has been about my journey
16:00
from organs to cells --
16:03
a journey through controversy,
16:05
inspired by hope --
16:07
hope that, as we age,
16:09
you and I may one day celebrate longevity
16:12
with an improved quality of life.
16:15
Thank you.
16:17

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About the speaker:

Susan Lim - Surgeon
A surgical pioneer in Singapore, Susan Lim is a researcher and entrepreneur.

Why you should listen

Dr Susan Lim is the current Co-chair of the Global Advisory Council of the International Society for Stem Cell Research (ISSCR). She performed the first successful cadaveric liver transplant for Singapore in 1990, the second woman in the world to have done so at the time.

Her academic recognitions include election as Fellow, Trinity College (2005), University of Melbourne, the Monash University Distinguished Alumnus Award (2006), and an Honorary Degree of Doctor of Medicine by The University of Newcastle, Australia (2007). In 2007, the American Academy of Continuing Medical Education (AACME) 28th award, was named the “Dr Susan Lim Award” for the advancement in Laparoscopic & Minimally Invasive Surgery. Her more recent public lectures include “Robotic Surgery - Engineering from a surgeon’s perspective”, as visiting scholar to UC Berkeley, and a 2016 TEDx Berkeley talk “The Dawn of a New Ecosystem in Organ Replacement.”

For her humanitarian work, she was recognized in the Australian House of Parliament (House of Representatives Official Hansard no. 17, 2005) for treating Australian victims of the second Bali bomb blast. In giving back to society, the family have established the Dr. Susan Lim Endowment for Education and Research, which supports medical and research scholarships at Trinity College, University of Melbourne, the University of Newcastle, Australia, and the International Society for Stem Cell Research (ISSCR).

 

More profile about the speaker
Susan Lim | Speaker | TED.com