Interested in learning more about single port thoracoscopy, or talking to the inventors of this technique? This March – head to the 1st Asian single port surgery conference in Hong Kong.
It doesn’t look like Cirugia de Torax will be in attendance for this conference, but it’s another opportunity for practicing thoracic surgeons and thoracic surgery fellows to learn more about single port thoracoscopic surgery.
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.)
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.
A look at the literature, including a recent systemic review: exercise is not only safe for lung cancer patients – but improves quality of life, and may (according to Jones) improve post-operative outcomes..
There’s an article ( Jones et. al 2010) on the benefits of pre-operative and post-operative exercise regimens for patients with lung cancer, that was conducted down at Duke. They use a lot of abbreviations in the article, but the gist is that a patient’s post-operative risk can be determined by their peak oxygen consumption (which is measurable), and that this can be modified (improved) prior to surgery with a targeted fitness program. This program notably included weight training in addition to aerobic exercise.
A systematic review was recently published (Feb 2011) looking at a compilation of these types of studies to give an overview of the preponderance of evidence by Granger et. al. This isn’t an open access article so I can’t post the link here – but I can link the abstract which is a short summary of his findings..
So basically Granger looked at the above mentioned study, and fifteen others – and drew limited conclusions.. He limited his conclusions to saying exercise was safe, and helpful in lung cancer patients and improved the ‘health related quality of life’. It’s a bit different from what Jones had to say – but the message is the same; exercise is not only safe for lung cancer patients – but improves quality of life, and may (according to Jones) improve post-operative outcomes..
Nagarajan et al. (2011) reviewed several published papers on the topic of pulmonary rehabilitation in an effort to answer the questions of whether pre-operative pulmonary rehabilitation reduced post-operative complications & overall length of stay. While they were unable to conclusively answer these questions – they did find that pre-operative pulmonary rehabilitation increased exercise capacity, and preserved pulmonary function in patients with COPD. This may not sound important – until you realize that these are critical measures of quality of life. (for example – what if “increased exercise capacity” means a person can now walk to around their home, and perform daily activities of living such as showering and getting dressed without becoming short of breath?)
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.
– 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.
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.”