Lung Transplant – Thoracic Surgery

Dr. Ross Bremner, and the state of thoracic surgery in Arizona

Talking with Dr. Ross Bremner, Chief of Thoracic Surgery and Chair of Thoracic Disease & Transplant at St. Joseph’s Hospital in Phoenix, Arizona.

St. Joseph’s Hospital

After talking to Dr. Bremner of the phone, I felt compelled to come down to Phoenix and meet him in person. I am glad I did. While St. Joseph’s is a large 607 bed hospital – it’s just one of many large healthcare facilities in the Phoenix area. The same can not be said of their robust thoracic surgery program. They have a surprising range of thoracic surgery subspecialties, and sub-specialty programs including transplant, anti-reflux surgery, minimally invasive surgery, esophageal surgery program and robotic surgery. As you can imagine, I felt a bit like a kid in a candy store – so overwhelmed by the array of services, that my mind was just bursting with questions. (I rounded with the group and got to see the full spectrum of patients – including four recent post-transplant patients.) They also have a pediatric thoracic surgery program and plan to start a pediatric transplant program soon.

The head of the program, Dr. Ross Bremner is one of five thoracic surgeons at the Heart & Lung Institute of St. Joseph’s Hospital in Phoenix, Arizona which is currently the state’s largest thoracic surgery program. A native of Johannesburg, Dr. Bremner maintains international ties to his home country by staying active in the South African Cardiothoracic Surgery Society. He began his thoracic surgery career at University of Southern California (USC) where he met and recruited both Dr. Michael Smith, MD and Sandra Ogawa, ACNP.

As Arizona has grown, so has thoracic surgery. Despite the relatively small population of Arizona overall, both the esophageal surgery program and the lung transplant program maintain volumes that are competitive with the big-name east coast institutions.

With over 45 lung transplants last year – and the University of Arizona currently out of the running, Dr. Bremner* and his team are set to boost those numbers this year. They have already done ten transplants here in the first quarter of 2012, and anticipate doing fifty to sixty this year. (If you remember from our previous posts about lung transplantation – even very large institutions are not doing huge numbers of transplants. In fact, you can check the numbers at the Organ Procurement and Transplant Network if you’re interested*.)

St. Joseph’s also has an esophageal surgery program which maintains the high volumes of esophagectomies needed for optimal outcomes. Dr. Bremner reports that they perform on average 50 – 60 esophagectomies for esophageal cancer ever year in addition to their benign esophageal surgery program. (As we discussed with Dr. Molena, ‘benign’ is a bit of a misnomer for esophageal conditions since achalasia, esophageal strictures and other non-cancerous conditions of the esophagus may have a huge negative impact on the individual’s quality of life.)

The Heart & Lung Institute also offers training courses for surgeons and residents in minimally invasive surgery – in fact, they are teaching a course the weekend of my visit.

As a practicing surgeon in Phoenix, Arizona, Dr. Bremner also sees numerous cases of Coccidoidomycosis** (or Valley Fever) which is endemic to this area of the country. In fact, Maricopa county, which encompasses the city of Phoenix sees more cases annually than the California valley the disease was originally named for.

* At the site, you can create data reports by organ, region, outcome, waiting period, etc.. For example – using this data table – we can see that there were a total 1,516 isolated lung transplants in the United States in 2011 which is actually a decrease from 2010 and 2009.

** Readers can anticipate a future article on this topic

More about Dr. Ross Bremner, MD, PhD

Dr. Bremner is a genial gentleman and a ready conversationalist. Our interview was relaxed, but informative. He welcomed my questions on a variety of topics and was generous with his time. In fact, I had ready access to multiple members of his team, and spent the entire afternoon with the department of thoracic surgery. It was an engaging afternoon, and highlighted one of the reasons I pursue interviews and opportunities to speak to my colleagues within thoracics; it was an opportunity to learn more about the specialty, and the care of thoracic surgery patients.

Dr. Bremner is a board-certified thoracic surgeon. After obtaining his baccalaureate degree and medical school training at Witwatersrand University in South Africa, he continued his education in the United States.

He completed his general surgery residency, PhD research and thoracic surgery residency at the University of Southern California. He was the Director of the Hastings Thoracic Oncology Research Laboratory on the USC campus. At this lab, surgeons along with researchers from multiple disciplines conduct research on the diagnosis and treatment of lung cancer including research in gene therapies prior to coming to Arizona.

He has several YouTube videos talking about his current research projects at St. Joseph’s.

He also has an informational series for patients about Lung Transplant over at EmpowHer.com

Dr. Ross M. Bremner, MD, PhD

Chief of Thoracic Surgery

Chair of the Center for Thoracic Disease & Transplantation

Heart & Lung Institute – St. Joseph’s Hospital and Medical Center

500 W. Thomas Road, Suite 500

Phoenix, Arizona 85013

Tele: (602) 406 4000

Fax: (602) 406 3090

Selected publications (not a full listing)

Jacobs JV, Hodges TN, Bremner RM, Walia R, Huang J, Smith MA. (2011). Hardware preservation after sternal wound infection in a lung transplant recipient. Ann Thorac Surg. 2011 Aug;92(2):718-20. [no free text available].

Felton VM, Inge LJ, Willis BC, Bremner RM, Smith MA. (2011). Immunosuppression-induced bronchial epithelial-mesenchymal transition: a potential contributor to obliterative bronchiolitis. J Thorac Cardiovasc Surg. 2011 Feb;141(2):523-30. [no free text available].

Gotway MB, Conomos PJ, Bremner RM. (2011) Pleural metastatic disease from glioblastoma multiforme. J Thorac Imaging. 2011 May;26(2):W54-8. [no free text available].

Coon KD, Inge LJ, Swetel K, Felton V, Stafford P, Bremner RM. (2010). Genomic characterization of the inflammatory response initiated by surgical intervention and the effect of perioperative cyclooxygenase 2 blockade. J Thorac Cardiovasc Surg. 2010 May;139(5):1253-60, 1260.e1-2. [no free text available].

Wu C, Hao H, Li L, Zhou X, Guo Z, Zhang L, Zhang X, Zhong W, Guo H, Bremner RM, Lin P. (2009). Preliminary investigation of the clinical significance of detecting circulating tumor cells enriched from lung cancer patients. J Thorac Oncol. 2009 Jan;4(1):30-6. [no free full-text available].

Backhus LM, Bremner RM. (2006). Images in clinical medicine. Intrathoracic splenosis after remote trauma. N Engl J Med. 2006 Oct 26;355(17):1811.

Backhus LM, Sievers E, Lin GY, Castanos R, Bart RD, Starnes VA, Bremner RM. (2006). Perioperative cyclooxygenase 2 inhibition to reduce tumor cell adhesion and metastatic potential of circulating tumor cells in non-small cell lung cancer. J Thorac Cardiovasc Surg. 2006 Aug;132(2):297-303. [no free full-text available].

Backhus LM, Sievers EM, Schenkel FA, Barr ML, Cohen RG, Smith MA, Starnes VA, Bremner RM. (2005). Pleural space problems after living lobar transplantation. J Heart Lung Transplant. 2005 Dec;24(12):2086-90. [no free text available].

Backhus LM, Petasis NA, Uddin J, Schönthal AH, Bart RD, Lin Y, Starnes VA, Bremner RM. (2005). Dimethyl celecoxib as a novel non-cyclooxygenase 2 therapy in the treatment of non-small cell lung cancer. J Thorac Cardiovasc Surg. 2005 Nov;130(5):1406-12. [no free full-text available].

Sievers EM, Bart RD, Backhus LM, Lin Y, Starnes M, Castanos R, Starnes VA, Bremner RM. (2005). Evaluation of cyclooxygenase-2 inhibition in an orthotopic murine model of lung cancer for dose-dependent effect. J Thorac Cardiovasc Surg. 2005 Jun;129(6):1242-9. [no free full-text available].

Bowdish ME, Barr ML, Schenkel FA, Woo MS, Bremner RM, Horn MV, Baker CJ, Barbers RG, Wells WJ, Starnes VA. (2004). A decade of living lobar lung transplantation: perioperative complications after 253 donor lobectomies. Am J Transplant. 2004 Aug;4(8):1283-8. [no free full-text available].

Starnes VA, Bowdish ME, Woo MS, Barbers RG, Schenkel FA, Horn MV, Pessotto R, Sievers EM, Baker CJ, Cohen RG, Bremner RM, Wells WJ, Barr ML. (2004). A decade of living lobar lung transplantation: recipient outcomes. J Thorac Cardiovasc Surg. 2004 Jan;127(1):114-22. [no free full-text available].

Haddy SM, Bremner RM, Moore-Jefferies EW, Thangathurai D, Schenkel FA, Barr ML, Starnes VA. (2002). Hyperinflation resulting in hemodynamic collapse following living donor lobar transplantation. Anesthesiology. 2002 Nov;97(5):1315-7.

DiPerna CA, Bowdish ME, Weaver FA, Bremner RM, Jabbour N, Skinner D, Menendez LR, Hood DB, Rowe VL, Katz S, Kohl R. (2002). Concomitant vascular procedures for malignancies with vascular invasion. Arch Surg. 2002 Aug;137(8):901-6; discussion 906-7.

Bremner RM, Hoeft SF, Costantini M, Crookes PF, Bremner CG, DeMeester TR. (1993). Pharyngeal swallowing. The major factor in clearance of esophageal reflux episodes. Ann Surg. 1993 Sep;218(3):364-9; discussion 369-70.

Fundoplication after Lung Transplant

a new article published in the annals of thoracic surgery on using fundoplication to prevent allograft (transplant) rejection in lung patients.

The theme of this article, along with many of the names of the authors should be familiar to readers – during my week with transplant surgeons down at Duke – I met with many of them to discuss gastroesophageal reflux and lung transplant (among other issues in transplant.)

Now Dr. Mathew Hartwig, along with Dr. Shu Lin, Dr. Duane Davis, Dr. Shekur Reddy along with several others in the department of lung surgery have published a study in the Annals of Thoracic Surgery, entitled, “Fundoplication After Lung Transplantation Prevents Allograft Dysfunction” discussing the role of GERD in lung transplant tissue rejection, and how use of early fundoplication procedures prevented graft rejection. In this study, it appears that fundoplication procedures helped preserve post-transplant lung function (in patients with proven GERD on pH probe testing). This certainly suggests that GERD plays a role in lung tissue damage in patients with measurable acid reflux.

I emailed Dr. Hartwig earlier this week for his comments – and I’ll update this post soon.

I met the young, dynamic Dr. Hartwig down at Duke and we briefly discussed his work in this area (before I raced off with Dr. Lin to the operating room.) Dr. Hartwig has been conducting animal studies examining the tissue changes in lung tissue exposed to gastric acids. He has also been heavily involved in several other studies on GERD and lung transplant recipients.

The University of Mississippi: Pioneers in Transplant

Reviewing the history of the first lung transplant and other medical firsts while here in Jackson, Mississippi.

The University of Mississippi Medical Center has been home to some of the greatest innovations in cardiothoracic and transplant surgery, including two of the world’s first organ transplants by Dr. James D. Hardy.

After becoming the first chair of the department of surgery in 1955, Dr. James D. Hardy, was off and running. The University of Mississippi performed the state’s first heart surgery in 1959. More remarkably, just a few years later, Dr. Hardy and his team performed the world’s first lung transplant on June 11, 1963. This was followed by the world’s first heart transplant in January of 1964. While neither of the patients survived long-term (the lung transplant patient died of renal failure 18 days after transplantation, and the heart recipient survived only 90 minutes) these were breakthroughs in the field of surgery. Both of these procedures have changed surgery immeasurably, by lifting the ceiling of our expectations and possibilities. The entire specialty of transplantation was born that hot, humid summer night, here in Jackson, Mississippi*. The cardiac transplant itself opened the door to even further research into xenotransplantation (the initial transplant was a chimpanzee heart to a person). Of course, neither of these surgeries were without considerable controversy at the time – the lung transplant recipient was an incarcerated felon (mirroring some of the current ethical dilemmas faced today by correctional health). The heart transplant sparked an international outcry similar to Baby Fae twenty years later (1984), if only much, much greater in intensity.

Today, the campus itself is large and sprawling, easily located just off I-55 and across the street from the Sonny Montgomery VA facility. St. Dominic’s hospital is visible from the parking lot.

The cardiothoracic surgery program at the University of Mississippi remains alive and well with four cardiothoracic surgeons, performing a range of procedures including a small number of heart transplants. University of Mississippi continues to be the only transplant center in the state – and according to the organ procurement and transplant network performed 9 heart transplants, but did not report any lung transplant or heart lung transplants since 1990.

(I did not have a chance to talk to the surgeons at the University of Mississippi during this brief visit. I hope to return in the future to talk about current programs, and what impact this history has made on medicine and surgery at the University of Mississippi.)

References and Additional Resources:

Dr. James D. Hardy – at the University of Mississippi website.

photo courtesy of the University of Mississippi — Dr. James D. Hardy, transplant pioneer

There is also the James Hardy library on the campus (in the James D. Hardy building) that holds copies of all of his articles, books and even films of the first transplants. (It’s really just one room but it’s crammed full of all sorts of interesting artifacts from the early days of heart / lung surgery.) They keep it locked normally, but are happy to unlock it for any interested visitors. Ms. Neill is one of the people in charge of the artifacts and she tells me that they are working on cataloging and compiling the original films for eventual posting on the internet. There’s even a plaque on the operating room door where the original surgery was performed – along with framed pictures of the surgery, and even one of the patient (lung transplant); awake and looking pretty good on day 3 after surgery.

* The first kidney transplant was in 1954.

In the operating room with Dr. R. Duane Davis

Single lung transplant with Dr. R. Duane Davis, famous cardiothoracic surgeon, and chief of the Lung Tranplant program at Duke. Part of a series.

(Part of a series about the Lung Transplant Program at Duke University, in Durham, North Carolina).

3:40 am.. the surgical team keeps working steadily in the operating room as they wait for Dr. Reddy to arrive.. One diseased lung is being readied for removal to make room for the new organ. The anesthesia team maintains the patient’s oxygenation and blood pressure carefully, a delicate balance, using only one heavily damaged lung. The perfusionist stands by, to assist with CPB* (cardio-pulmonary bypass, also known as the heart-lung machine) if needed. [for this particular case – I was not present to witness this portion of the procedure]

at 03:45 we arrive, Dr. Reddy bringing in a wheeled cooler containing the organ. Quickly, Dr. Davis and another surgeon (one of the graduating thoracic surgery fellows) begins preparing the new lung for implantation.

The clock is ticking, and has been running since the moment the organ was removed, in that OR several states away. This is cold ischemia time – time when the organ is chilled, prior to implantation. The cold lessens the tissue damage, but doesn’t halt it completely. This is why organ procurement is such an orchestrated process, and why Dr. Davis is here, operating at 3 in the morning. Once the lung is removed from the icy solution and placed into the chest to start the implantation, the real clock (a wall mounted clock) is started, to keep track of warm ischemia time.

Warm ischemia time is the period during which the lung is being implanted into the recipient. This is when the most damage occurs to the harvested organ, and surgeons use several methods to limit the amount of warm ischemia that occurs. One of the ways they do this by infusing cold solutions intermittently while attaching the lung to the pulmonary arteries and veins (anastomosis) to re-establish blood flow prior to re-attaching the bronchus (the airway). The operating room clock is used to record the amount of warm ischemia so that the surgeons know when to re-infuse the solution and to keep track of the total ischemic time during the operation.

Once the lung is reattached by re-establishing both the blood supply from the recipient to the donor lung, and by connecting the airway – it’s time to re-inflate the lung. This is the most tense period of the operation – as surgeons wait to see if the new lung will function as intended. If not, the patient will be connected to ECMO (see below for more information on ECMO) to supply the lung with oxygen rich blood to prevent further injury. Often patients require ECMO for a short period of time after implantation.

One of the problems with lung transplantation is reperfusion injury, which begins at this point.

“Re-perfusion injury” itself is a generic term describing the injury that occurs to tissue once blood flow is re-established (whether this occurs during a treatment of a heart attack, stroke, organ transplantation or other disease process). A good way to think about re-perfusion injury is that this process occurs as part of the body’s (misguided) attempts to heal itself. Unfortunately, as the name implies – this sequelae of biochemical events results in more damage to the organ(s) itself. Medications are also used during this process to limit the amount of reperfusion injury.

Once the lung is functioning (breathing) and the patient is able to maintain oxygenation, and other vital signs (blood pressure and heart rate) the incisions are closed, and the patient is taken to the intensive care unit. From there, if everything goes well, the patient will be extubated (breathing tube removed and ventilator turned off) and out of bed and walking by the next day. (In lung transplant, like all lung surgeries, early ambulation is critical.)

* ECMO (extracorporal membraneous oxygenation) by veno-venous access, which is a therapy very similar to cardiopulmonary bypass is also available.

Watching Dr. Davis operating is an experience in itself – among lung transplant surgeons, he is a legend along with Dr. Joel Cooper and Dr. Ken McCurry. Dr. Davis, locally known as “Dr. McDreamy” for his classic good looks; with silver blond hair and piercing blue eyes is affable and kind. He was patient with my multiple questions, which is important; as in lung transplant it seems like every answer you discover just leads to another layer of questions.

We’d met before, on one of his visits to the hospital in Virginia where I worked, but I didn’t know him as well as Dr. Shu Lin, who initially extended the invitation for me to visit the Lung Transplant service when I’d expressed interest.

Now here in the operating room, performing one of his many transplants (he’s done around 750 to 800 lung transplants), Dr. Davis was focused, but confident. He remained in tune to his patient underneath all those drapes, noticing every change in respiration, heart rate or blood pressure before anesthesia could bring it to his attention, even during the more delicate portions of the operation. I’d come into this part of the procedure after a long day myself, starting at 2am the previous day in Virginia, then meeting with Dr. Lin, rounding on patients, witnessing several cardiac operations before flying off with Dr. Reddy. It all culminated in the operating room with Dr. Davis more than 24 hours later – watching him operate, and watching the lung struggle to take its first breaths in its new home. Somehow, all tiredness vanishes at moments like this [though it returns with a vengeance.]

In this case – the lung struggled and needed a very short period of ECMO before recovering in the operating room*. During all of this, Dr. Davis was calm, and in control. After a few tense minutes, the lung recovered and ECMO was discontinued. The remainder of the case proceeded uneventfully, and I stumbled home to get a few hours sleep before my formal interview with Dr. Davis the next day. It was, all told – another successful surgery for Dr. R. Duane Davis, the patient and the Duke Lung Transplant Program.

* This is related to the physiological function of the donor lung, and the patient response – and not due to technical aspects of the surgery.

Additional References: (to be updated)

Dr. Joel Cooper – thoracic surgeon who performed first ‘successful’ single and double lung transplants, known as the “Father of Lung Transplant“. The first actual lung transplant was performed in 1963 by Dr. James D. Hardy at the University of Mississippi in Jackson, MS.

Transplant surgery at Duke: a painful chapter

a dark moment in the history of Duke’s Lung Transplant Program, and the lessons learned.

24 June 2011

As I prepare to spend a week on the lung transplant service at Duke, I am hesitant to rehash the old scandals and painful wounds of Duke’s past. But as a medical writer, and former Duke employee, it would be dishonest to ignore this history.

As many people know, almost 10 years ago there was a terrible medical mistake that resulted in tragedy after a mismatched heart-lung transplant in a teenaged girl, which led to her death. To their credit, in an age of increased medical litigation, and under intense scrutiny, Duke has been honest and open; they admitted their mistake, and have used this tragedy to set procedures in place, which now make Duke University a forerunner in patient safety. There is an excellent article on Medscape.com about this event and the immediate aftermath (but requires subscription). If I get any requests – I will re-post the article here.

In fact, Duke is not the only transplant center to have experienced this sort of medical mistake. Vanderbilt (my alma mater) even published a study based on their experiences.

As someone who knows many of the surgeons involved, I know that as tragic as this episode was, it is only part of the story of these surgeons who perform life-saving operations every single day.

Root cause analysis of a mismatch

Update: 2 July 2011

During my visit down at Duke, this case kept coming back to me. As a former Duke employee, I can imagine how devastating this must have been to Duke employees throughout the facility. One of the things that I always liked about Duke was the culture of patient service and caring. People are proud to work at Duke; janitors, receptionists, cooks, nursing assistants, surgeons, nurses all demonstrate this pride visibly by the wearing of Duke paraphernalia, and personally, through small but important gestures. It’s something that every visitor who ever came to our office in Virginia always remarked on. “When I was down at Duke” they would all say – and then similar stories would emerge “I was lost, and didn’t know what to do, but then a person from radiology was walking by. I asked them for directions and they took me right where I needed to be.”

But it was still hard for me to imagine the immediate aftermath [I started working for Duke in 2007, well after this incident]. But I don’t know how the surgeons felt – and in some ways I was too chicken to ask them. But I also didn’t ask the transplant service about Jesica Santillan because I wasn’t sure what kind of answer they could really give. Of course it was a tragedy, of course, they are sorry. But are there really words for people to express true regret?

Instead, I just looked around, and observed the transplant procedures and looked at the actions Duke has taken in the years since then. In doing so, I can honestly say that Duke has learned from this. Despite HIPAA related anxieties in the medical field* and an era of zealous information hoarding, Duke has enacted steps to ensure this sort of catastrophe never occurs again – by acknowledging that “the need to know” extends beyond the surgeons to include other members of the surgical team. Anyone who has ever been inside an operating room knows that some information is widely shared with operating room personnel, and some isn’t. That is no longer the case at Duke – every member of the team is informed and involved in fact checking, and double checking patient information; from the moment an organ is offered, during organ retrieval / delivery and implantation. All of the surgical nurses know, and the information is double checked when the patient arrives in the operating room. Important patient information is posted in large letters on a whiteboard in the OR. Then anesthesia and the perfusionists confirm this information with the surgeon present during the time out procedures.

This information is relayed several times during phone calls to the procuring surgeon, before leaving Durham, after the flight – arriving at the donor hospital and before leaving to return to Durham. When the procuring surgeon arrives to the Duke, organs in tow – this information is again verified, by a different individual at the operating room front desk before the organs are taken back to the operating room. Then with the organ in the room – the verification process (both the recipient and donor information) is repeated again; circulating and scrub nurses participate – lab personnel participate. Everyone participates.

There’s some redundancy – in fact, it feels a little like cramming for a final exam. (If Joint Commission suddenly appeared at 3am to quiz any of these people – everyone would pass with flying colors.) But it’s also been incorporated into Duke corporate culture and no one seems to give it a second thought. No one complains, no one sighed or shrugged, everyone knows the price they paid in the past – and no one is willing to repeat it.

* Note: None of the new procedures at Duke violate HIPAA or the principles of HIPAA (patient privacy act).

Talking about Transplant with Dr. R. Duane Davis

Interview with Dr. R. Duane Davis, the Chief of Lung Transplant at Duke University

(Part of a series on the lung transplant program at Duke University in Durham, North Carolina)

Dr. R. Duane Davis is the Chief of the Lung Transplant Program at Duke, which is the second largest lung transplant program in the United States (after Cleveland Clinic which performed 154 transplants last year to Duke’s 117*). During my visit, surgeons performed their 70 & 71st transplant this year, and will probably complete around 140 transplants before the year’s end. Much of Duke’s success at becoming a high volume transplant center lays at the feet of Dr. Davis, who took over the program in 1994, after training with the famed Dr. Joel Cooper. However, he credits many of his achievements to his training with several pulmonologists. In fact, he reports that it was his collaborative efforts with pulmonologists that led to his initial observations regarding the frequency of gastric reflux among transplant patients. (Later this was translated into the seminal work on the relationship between reflux / aspiration and graft failure**.) He cites this as one of the more important recent discoveries in the field of lung transplantation.

He estimates that during his career (thus far) he has performed around 750 – 800 lung transplants, making him one of the world’s more prolific lung transplant surgeons.

Dr. Davis is also responsible for several decisions that have distinguished Duke among transplant programs.

One of these decisions was the elimination of upper age restrictions for recipients. Unlike many facilities, Duke does not limit eligibility for transplantation solely based on age. (Many facilities limit transplantation to patients in their mid-sixties or below.) As part of this, he also rejects much of the ageism that is often implicit in transplant. “If we have two patients, otherwise equally matched but one is 18-years-old and the other is 53, then everyone always wants to give the transplant to the 18-year-old,” he explains. “It’s ageism to do that, particularly when research shows that the 18-year-old may not do as well [due to risk of noncompliance with anti-rejection meds. etc] so we need to carefully consider all of the factors before deciding,” he continues. “It makes us all feel good to give it to the 18-year-old, but that’s not always the right decision.”

One of the other decisions is something we talked about in a previous post – the use of organs that other facilities have turned down, sight unseen. He credits this decision with the short waiting periods for Duke patients compared with other patients nationwide.

Dr. Davis explains this policy along with other efforts to expand the donor pool. “There will always be a larger demand than the supply, but by expanding our eligibility criteria we increase our likelihood of finding an organ for our patients. As Dr. Davis explains, using traditional criteria, only about 10,000 donors are available every year, and in this donor pool, only about 17% of donations are lungs. He believes this number should be at least 40%, and that many useful organs that could have been transplanted are discarded. This is why Duke often sends their procuring surgeon on site to examine the lungs personally before deciding to reject organs for transplantation, if the lungs are otherwise a good match; (by size, blood type, etc.). In an attempt to meet demand and extend the lives of patients that might not otherwise receive transplants due to the shortage of donors, Duke surgeons recently implemented a program to accept donors from cardiac death patients (where the heart has stopped beating.) In traditional donor criteria, the patient’s heart is still beating at the time of organ retrieval. However, this criteria severely restricts the amount of donors available. As part of his efforts towards these ends, he reminds people of the value that organ donation has to help others, and encourages people to become organ donors.

During the interview, he also talks about breakthroughs in transplantation, such as the double transplantation of Laura Margaret, a 16-year-old with an immune deficiency disorder (bubble boy disease) who received a double lung transplant, followed by a bone marrow transplant from the same donor. In particular, he sees this particular case as a gateway to future discoveries in preventing graft (organ) rejection.

Like most Lung transplant surgeons, transplantation is only part of what Dr. Davis does, he is also an accomplished cardiothoracic surgeon, and performs cardiac surgery (such as bypass surgery/ valve replacement and surgery for atrial fibrillation) routinely. He states that he doesn’t have a favorite procedure, but he does have a favorite scenario. “I love the Christmas transplant,” he explains, when a patient receives a transplant on or around the holidays, and I get to come out to the family after the operation, and tell them Merry Christmas.” It really is a wonderful gift for the patient, he finishes.

** Surprisingly, even very large centers such as John Hopkins (24 last year), Massachusetts General (16) and Mayo Clinic (16) perform less lung transplants that we might expect. Even UCLA only performed 50 lung transplants in 2010. (Information from Organ Procurement and Transplant Network). Like many thoracic procedures, (as mentioned during discussions on esophagectomy and other lung surgeries) better surgical outcomes are linked to high-volume centers. Whether this is a result of ‘practice makes perfect’ or is due to the fact that high volume centers like Cleveland Clinic and Duke are usually large academic centers with a wealth of resources is not entirely clear. However, I would advise patients to use caution before seeking organ transplant at a center that does only a few transplants per year (less than 20- 30.) A recent study by Weiss et. al (2009) at John Hopkins places this number at 20, which as Dr. Mathew Hartwig noted during a recent lecture, is coincidentally,the three-year average [number of lung transplants] at that center.

* Future article planned for this topic.

More about Laura Margaret:

Double lung transplant saves teen’s life

Pioneer transplant surgery

Laura Margaret story

at 14,000 feet

the writer is out of her element, and reflective during a recent trip for organ procurement with Dr. “Shaker” Reddy during her week on lung transplant at Duke.

** When discussing or writing about organ donation or transplantation, more stringent privacy rules apply for the protection of all parties. For this reason, when discussing both the donor and the recipient, gender pronouns and other identifying features have been intentionally omitted. Post dates have been randomized to further prevent identification of recipients**

After spending most of the day in surgery with Dr. Lin, it’s time to meet with Dr.Lankala Reddy, the procuring surgeon and head for the airport. Dr. Reddy, or “Shaker” as he’s known, has a clipped British accent, and confesses that he hasn’t be home to the UK since he came to Durham four years ago. He came to Duke as part of his fellowship in Lung Transplant, and after completing his studies, stayed on as a procuring surgeon. He also evaluates new patients for the Lung transplant program.

At the airport, we are met by two pilots and the final member of the procurement team, the preservationist on call, Lee Hinesley. Lee is a lanky young guy with small laugh lines at the corners of his eyes which speak of his pleasant, and laid back manner. “This isn’t Three Rivers,” he says with a wry smile, speaking of one of the popular melodramatic medical soap operas. On the way to our destination, Lee pulls out a thick textbook and begins to read. He’s studying for his certification as a preservationist. He’s completed all of his training some time ago, but the exam is only offered a few times a year he explains.

Like Lee says, our journey is ‘not like on TV.” There is no frantic, controlled chaos or adrenaline surges. Procedures have been streamlined and refined to eliminate most of the extraneous time-consuming variables. Routes are carefully planned, with several check-ins and updates to the surgical team back at Duke, who are awaiting our return. Instead of hectic activity, there is calm and carefully scripted movements, as part of an established routine. As one of the busiest transplant centers in the United States, the amazing, and incredible idea of taking an organ from one person, and placing it in another has become, if not quite routine, almost common. So there is no need to worry; they have it all down to a science.

The plane itself is an executive jet; comfortable but by no means luxurious. Rookie that I am, I am greatly relieved. For some reason, I had pictured the close confines of a LifeFlight helicopter. These flights aren’t called life flights – that term is reserved for the emergency flights that bring in trauma patients, and the critically ill; but in my mind – I’ve renamed our journey. “Procurement” is such a cold, clinical term that erases all of the magic of the surgery.

(Now, readers should notice that I don’t usually talk in such fanciful terms, but to me, transplantation, like cardiac surgery doesn’t lose it’s awe-inspiring ability just because the medical community is ‘getting good at it.’ It’s still an amazing miracle every time, even if it’s done 140** times a year here at Duke.)

After flying across several states, we land at a small airport. Within minutes, the plane for another surgical team (who are taking the heart) is landing. We see them arrive through the window of the local sheriff’s vehicle. He and another EMS person were waiting, to transport the teams to the “host” hospital.

The donor is tragically young, as they often are. Looking at the donor, as we enter the operating room, I am stricken by how difficult this must have been for the family, during such an incredibly painful time. Even as an experienced health care provider, I am taken aback. I know that the donor has died, but (particularly in this case, where there is little visible injury) I feel deeply for the family; machines give the appearance of sleep with rise and fall of the chest though this patient will never wake up again. What a caring, compassionate family they must be – to be giving at a time when they are hurting. I hope this gives them solace in the future.

The staff of the local hospital are friendly, accommodating, if a little confused by all the unfamiliar, masked staff in the room. Even without the official badges prominantly displayed the surgeons are easy to identify by their confident, self-assured manner. I stay out of the way, standing near the anesthesiologist. We banter a bit, and do the ‘six degrees of separation’ until we find several points in common, which awkwardly brings home the situation, as I consider the degrees of separation between donor and recipient.

The procedure itself is pretty standard, but intricate as vessels are gently untangled, ice applied and preservation solutions infused to protect the organs during transit. Then steadily, quickly, efficiently but unhurried, the organs are packed for transport. A quick thank you to the staff and we are off to the airport again.

When we land, we notify the operating room, and at 3:45 am, the surgeon wheels the cooler containing the lung into the operating room, where Dr. R. Duane Davis (and the patient) are waiting.

** current lung transplant procedures for the first six months of 2011, place estimates for year end totals around 140.

Lung Transplant at Duke: part one of a series

a series of articles based on a week with the surgeons of the Lung Transplant service at Duke University in Durham, North Carolina including interviews and highlights from my trip for organ procurement.

Durham, North Carolina (USA)

I recently received an amazing invitation from Dr. Shu S. Lin, MD, PhD at Duke University Medical Center. Dr. Lin** and I previously worked together when I was at the Duke cardiothoracic surgery clinic in southern Virginia. Dr. Lin would often rotate up to our facility to help cover the service so the attending surgeon could have a (much-needed) weekend off, so I got to know Dr. Lin fairly well. Dr. Lin is currently the Director of the cardiothoracic intensive care and step-down units, as well as an associate professor of Surgery (cardiovascular and thoracic) and an associate professor in Immunology and Pathology.

I always enjoyed working with Dr. Lin, who is a very calm, quietly brilliant and confident surgeon. He enjoys time with his patients, (and always makes time for them, spending as long as it takes to answer their questions and address their concerns.) He is an elegant surgeon, a throwback to a previous era in surgery – he doesn’t delegate, he manages the smallest details himself.

Working with Dr. Lin at the smaller hospital in Virginia gave me a very different perspective and experience than is typical of interactions with attending surgeons in large volume academic centers. Since our facility was uncluttered with the detritus of academia, with no residents, no students or fellows it was just the surgeon and the NP, which gave me a better chance to know the person inside the surgeon. This is important, because it’s the first thing that often gets lost in academic medicine. It will be interesting to see him here in his native (academic) environment.

During my week down here, I will be interviewing Dr. Lin at length and spending time in Lung Transplant for an upcoming series of articles here at Cirugia de Torax.

Since lung transplantation is such a huge topic, I am devoting a series of articles to my experience here at Duke. As part of the series, I will be publishing articles about the surgeons, the facility itself and more on the lung transplant procedure.

For now, I have including some information on the basics of lung transplantation.

Since many of you are as unfamiliar with lung transplant as I am – I have provided a couple of links that provide a nice overview of Lung transplantation. (Despite working in thoracic surgery for several years, I have never worked with transplant patients, so it’s a learning experience for me as well.)

Medline: Lung Transplant

Roger Steven’s perspective: a patient created website with information on lung transplantation, as well as his own story. Mr. Stevens had a double-lung tranplant in 1997 (at the University of Maryland).

Patient education guide from the American Society of Transplant – (a little dated but written in a patient friendly fashion. (pdf)

Duke affiliated websites:

Lung Transplant at Duke

Patient resources for Lung Transplant

Lung Transplant friends – a support group for patients at Duke undergoing lung transplantation.

Duke Transplant Services

I will be updating these links periodically.

** In-depth article based on interviews with Dr. Shu S. Lin pending.

Talking to Dr. Shu Lin, MD, PhD of Duke University

In and out of the operating room with Dr. Shu S. Lin, MD, PhD, cardiothoracic surgeon and member of the Duke lung transplant program.

As I noted at the beginning of this series of posts about the Duke Lung Transplant program, I have been fortunate enough to know and work with Dr. Lin during my career as a nurse practitioner. But, in all the time we spent rounding and caring for patients at a small community hospital in Virginia, I never scratched the surface of the multi-faceted, and multi-talented Dr. Shu Lin.

Like many talented surgeons (Dr. Thomas D’Amico, Dr. Rafael Beltran, Dr. Edgard Gutierrez are just a few other examples), Dr. Lin is a humble and down to earth person. He is quick to shrug off any praise or admiration of his talents. When receiving tearful thanks from a grateful family member of one of his patients after completing a multi-hour lung transplant, he gives a shy smile, and says “it’s no problem” before giving further details of the operation and the expected post-operative recovery.

At first glance, you expect this soft-spoken and gentle natured surgeon to be shy and retiring but you quickly learn to appreciate his keen wit and fine-tuned sense of humor.

The walls of his office are papered with just a sampling of the numerous awards and recognition he has garnered since childhood, as a concert master for the symphony orchestra (violin, high school), as an avid tennis player, research awards in both the fields of surgery and immunology. More awards undoubtably lay forgotten in a desk drawer somewhere, replaced by photos of his family.

Seeing all of this makes me reconsider the Shu Lin I thought I knew, and whom I call a friend. I always knew he was a gifted and talented surgeon (I always call him ‘quietly brilliant’ due to his unassuming nature) but now, even I am overwhelmed by it all. Yet, he remains unaffected; the gracious, caring surgeon I always knew. He looked surprised when I told him that his was the toughest interview I’d ever done; especially since I’d just come from interviewing one of his colleagues. But it’s true – I pride myself at trying to maintain an aura of objectivity, and to present information with a degree of clinical professionalism, but with Dr. Lin, it’s hard. Not because he isn’t a great surgeon, and a great clinician; but because he is. I worry that this previous working relationship colors my writing, but at the same time, it is these very qualities of patience, kindness and empathy coupled with surgical skill and clinical knowledge that are so important for patients to know about, and read about.

It’s a little awkward too, I think it’s difficult for Dr. Lin to see me in my new role of interviewer, and it’s the first time I’ve seen him in a year – since I left Virginia to embark as a medical writer in Bogotá, Colombia. But after a few minutes, we settle into our roles as he explains some of the issues in lung transplantation. It helps that he’s a great teacher [to the residents and fellows in cardiothoracic surgery].

“I haven’t updated my profile in a few years, I am no longer researching xenotransplantation” [using organs from other species] he says before we launch into a discussion on the effects of acid reflux on lung tissue and graft survival in patients post-transplant. This is one of the current projects at Duke (with Dr. Davis, and Dr. Mathew Hartwig, whom I hope to interview soon).

We review some of the history of lung transplantation, which is ‘still in its infancy’, and discuss the role of continued research to address the problems in transplant surgery; such as graft rejection. He also talks about the need to better delineate lung disease and effective treatment strategies. “Transplantation is always the final option for treatment, after medical therapies fail so it’s important that we know as much as we can about both the diseases and the effectiveness of current therapies.” This is one of the reasons Dr. Lin feels very strongly about the need for patients to participate in research studies – “the more we know, the more we can do to treat them.” This is also important when we discuss the future of lung transplantation.

Dr. Lin sees several evolving adjuvant treatments as essential for driving the future of lung transplant therapies:

– The development of mechanical devices similar to the newest ambulatory VAD (ventricular assist devices) used in heart failure, to allow patients to use mechanical lungs during daily living. Currently, ambulatory ECMO devices allow patients to walk (with assistance) while receiving therapy, which improves survival and prevents complications related to prolonged hospitalization. Dr. Lin foresees the development of more efficient devices (aka artificial lungs) that would resemble the newest VADs in functionality, and would allow patients to live longer, better quality of life while awaiting lung transplant.

– Better medications: the development of a new, better generation of anti-rejection drugs with less side effects than Tacromilus (FK-506), steroids, cyclosporine.

– Tissue therapies, gene therapies – to prevent rejection of transplanted tissues,and prolong graft function.

Dr. Lin believes that the continuing development of all of these competing and adjuvant therapies will promote future research into lung transplantation, for better quality of life for patients, longevity and better post-transplant outcomes.

Dr. Lin still maintains an active cardiac surgery practice since by its nature, lung transplant surgery is sporadic. As a busy cardiac surgeon, Dr. Lin performs a full range of cardiac surgery procedures; most commonly coronary artery bypass surgery and valve repair/ replacement. So during my visit, after rounding on his transplant patients, and post-cardiac surgery patients, I observe him performing two bypass surgeries (coronary artery bypass grafting or CABG). This is familiar territory for me – but later, I see him in his role of transplant surgeon during a double lung transplant with Dr. Hartwig.

Lung Transplant - Dr. Shu S. Lin — Lung Transplant Surgery with Dr. Shu S. Lin

In the operating room, Dr. Lin is deliberate and methodical in his actions, but surprisingly, appears more relaxed*. He tells jokes (clean ones) and stories while working, and appears more comfortable, and unguarded than I am used to seeing. It’s like he left all of the mundane problems of the world outside the operating room door. He works well, in tandem with Dr. Hartwig, who is the newest member of the thoracic surgery department and remains focused but completely aware of his surroundings. This time, I am able to witness the surgery entirely from the recipient’s angle – from the initial clamshell incision, and preparations for the removal of the first lung – to Dr. Reddy’s arrival and lung delivery, and the placement of both lungs to closure of the incisions.

This time, when the lungs are first inflated together, after completing the final anastomosis – there is no struggle, the lungs work perfectly. There were concerns when the donor network first called – that maybe one of the lungs had sustained injury, but as per department policy***, in these cases, Dr. Reddy investigates on site, and make the determination whether the lungs are useable after inspection (in telephone consultation with Dr. Lin).

The entire surgery takes less time than I expected, and by one am – we are in the waiting room, talking to the family.

*He’s not normally tense or uptight, but tends to be very serious during rounds, as part of his role of professor. [Dr. Lin is a professor of both surgery and immunology.]

*** This is one of the reasons Duke has the shortest waiting list time period of any transplant facility in the US. While many facilities reject offered ‘marginal’ appearing organs based on lab values, and the chest x-ray, the surgeons at Duke will often go to inspect the organs before rejecting them outright. As Dr. Davis explained during a separate interview, “sometimes they only give you information about the right or left lung, not both. Maybe the information they give you suggests the lung isn’t perfect, but not terrible either. In these cases, instead of turning the organs down, we would rather take a closer look – so a potentially useable organ doesn’t get wasted. A lot of times, when we actually examine the organs – at least one lung is actually in good condition [suitable for transplant]”.

By doing this – Duke does run the risk of having more ‘dry runs’ than other facilities, meaning that when they get to the donor, the organs aren’t useable, and the procurement team returns empty-handed, but they also get good, functional organs for their patients – that would have been lost. “We get more organs that other facilities,” Dr. Davis explains, “because UNOS/CDS (organ network/ carolina donor services) often call us after everyone else has turned them down.”

Additional information:

History of Lung Transplantation – paper by George Patterson (pdf)

Just one of many of his of grateful patients tells her story.

More information about Ventricular Assist Devices

Medline

VAD information from the manufacturer – with photos