Cristina and Angel DeJesus each have one kidney today.
That's because on Tuesday, both of Angel DeJesus' diseased and enlarged kidneys were removed in a robotic operation, and he now has one given by his wife in a dual transplant operation at Yale New Haven Hospital.
While DeJesus, 40, ended up having a traditional incision because his kidneys were so large, the couple has much to be thankful for.
Cristina DeJesus, 36, had her kidney removed by laparoscopic surgery in an adjoining operating room, and both were doing well Wednesday morning, according to a hospital spokesman.
"Most of us feel pretty full at Thanksgiving," said Dr. David Mulligan, director of the Yale New Haven Transplant Center. "He's going to feel like he can eat another turkey."
That's because Baez has polycystic kidney disease, a genetic disorder that filled his kidneys with cysts, enlarging them so they pressed against his other organs. Each weighed about 20 pounds after many cysts were emptied of fluid and was more than 18 inches long, according to his surgeon, Dr. Danielle Haakinson, compared to about 1 pound for a normal kidney.
A parent with the gene for polycystic kidney disease has a 50% chance of passing it on to his or her children, Mulligan said, and two of the DeJesuses' four children have the disease. Large cysts form on the kidney, some filled with a cup to two cups of fluid, Haakinson said.
"He's really been struggling to eat well and have a good appetite because his bowels have been compressed … for so many years," Mulligan said. His torso, meanwhile, was distended. "He came in and he looked nine months pregnant," Mulligan said.
"When we match a kidney, the biggest thing we do is the blood type," Haakinson said. Both Cristina and Angel DeJesus have the same blood type, enabling the transplant between spouses. Cristina DeJesus' surgery was overseen by Dr. Sanjay Kulkarni.
But there may not be a match "if a patient has had blood transfusions or is a mother who had babies or they've had any kind of sensitizing event where they've been exposed to any blood products," Haakinson said.
DeJesus will have to wait for the turkey, though. "His bowels will be a little sleepy," Mulligan said. DeJesus will be restricted to "clear liquids when he wakes up," he said.
The twin surgeries were expected to last eight hours in total. Cristina DeJesus was expected to be released Thursday.
Angel DeJesus will be released in three to five days, Haakinson said, largely because his kidneys were so large. "So we were able to do it from an incision that went from his breastbone to just below his belly button, and then we are able to do his kidney transplant through that same incision."
The robotic surgery, which involves several small incisions so the da Vinci robotic instruments can be inserted, was not practical given Angel Baez's condition, she said.
During the robotic portion, the first thing that needed to be done was to close the lower vena cava, the large vein that brings blood to the heart, and the main artery that supplies the kidney with blood, using a special stapler. Then the blood vessels were severed. The ureter also needed to be cut.
Next, surgeons removed the connective tissue from the kidney to the liver, diaphragm, back muscles and intestines. When DeJesus' new kidney was implanted, it would be free of those connections.
While the surgeons did empty many of DeJesus' cysts in an attempt to avoid an incision, Haakinson said the fluid was suctioned out. That's because they contain cytokines, part of the immune system.
"They can cause an inflammation response," Mulligan said. The result can be fever and dilated blood vessels. "It's kind of like the flu in many ways. … We try not to open any other than what's necessary to avoid those side effects."
They also had to push organs such as the adrenal glands out of the way.
"It's a tough day," Haakinson said during the operation. "We knew it was going to be a tough case. His kidneys are on the extreme of large, and he's a 6½-foot man, so he's got big kidneys."
The da Vinci robot is "a tremendous instrument," she said. "It's been in use since 1990. The very first kidney transplant was performed in 2008 at the University of Illinois, Chicago."
Yale New Haven flew its doctors and nurses there to train, as well as to the Henry Ford Hospital in Detroit. "They've been very helpful to us," Haakinson said. "Our technique is a hybrid of those two techniques."
The first robotic kidney transplant in New England was performed at Yale New Haven in October 2019, Haakinson said. "The pandemic put a kink in things for a while," she said. "Transplant was kind of shut down."
Haakinson said she has done 20 robotic kidney transplants, three of them on patients with polycystic kidney disease. Yale New Haven is the only hospital in New England that performs the operation. The next nearest is in Maryland.
Hartford Hospital, the state's other transplant center, is training a doctor to be able to begin the procedure next year, according to a spokeswoman for Hartford HealthCare.
"It's a more rare condition to take care of," Haakinson said. "At Yale, we have special nephrology expertise and stuff. So historically, a lot of the patients with this disorder have gravitated to Yale because it's a genetic condition. … We've transplanted three generations of family members already."
One reason to use the robot is because people with polycystic kidney disease can form hernias easily, so it's best not to weaken the muscles of the torso. Other reasons are patients with HIV, to protect the surgical team, or for someone who is morbidly obese.
"We try to be thoughtful and selective about who really is going to benefit from this," Haakinson said.
She said the hospital also uses a holistic approach to pain, with a nerve block before the surgery and avoiding narcotic painkillers. She said both of the Baezes likely will need just Tylenol to control their pain.
'A perfect time'
While Angel DeJesus wants to return to work as quickly as possible, he will have to wait eight to 12 weeks because the drugs to suppress his immune system will also slow healing, Haakinson said.
"So a normal person with normal tissues, your scars are going to be about the strongest they're going to be in six weeks," she said. "But someone with immunosuppression, it's not going to be as strong as it's going to be for about three months."
Doctors waited to schedule the surgery until DeJesus' kidneys began to fail. "He was barely running on fumes with his kidney function," Haakinson said. He had been on dialysis for a week.
"It was a perfect time," according to Cristina DeJesus. "It was shocking that I was a match, that I was able to do this," she said Wednesday. "I was shocked but I was very happy. It was a long process," which began in February.
"I had some challenges. … I had to meet a goal of weight because of some family history that I have where they were concerned about," she said. "So they wanted me at a certain weight. I was just glad I was able to do it before he got worse."
The family, which includes four children, ages 6 to 14, had Thanksgiving last week, Cristina DeJesus said. She said her two youngest have their father's disease. "I'm hoping they're as fortunate as we were when their time comes," she said. The family lives in Hamden.
Cristina DeJesus' laparoscopic surgery "is the standard of care" for kidney transplants, Kulkarni said. "What we do is what's called total laparoscopy," as opposed to hand-assisted laparoscopy, he said.
"The preponderance of living kidney donors are women," as many as 65%, he said. "This is very common, wife giving to husband. … There is more kidney disease in the male population.
"It's the same every year," he said. "People who come forward to be kidney donors, year after year, it's more women."
For more information about becoming a living organ donor, go to the Center for Living Organ Donors web page or call 866-925-3897 (866-YALE-TXP).
Ed Stannard can be reached at email@example.com.