Talking with Dr. Diego Gonzalez Rivas about single port surgery

an Interview with Dr. Diego Gonzalez Rivas – and coverage of ‘Videotoracoscopia y cirugia robotica en torax: Avances y perspectivas’ in Santiago, Chile

Santiago, Chile

I was a little intimidated to actually interview Dr. Diego Gonzalez Rivas after reading his articles and pestering him with emails for the last few years.  But he was just as nice and patient with my questions as he’s always been.

Dr. Diego Gonzalez

Dr. Gonzalez is here in Santiago for the single port thoracic surgery / robotic surgery conference at Clinica Alemana, hosted by Dr. Raimundo Santolaya.

Dr. Santolaya, Dr. Sales dos Santos, Dr.Berrios and Dr. Diego Gonzalez Rivas

Since publishing the last few articles on his single port technique, Dr. Gonzalez has been in high demand from thoracic surgeons wanting to learn more, and to train in single port techniques.  In addition to traveling the world to teach – he continues to offer training at the Minimally Invasive Thoracic Surgery Unit at the Complexo Hospitalario Universitario de A Coruna, in Coruna, Spain.


Dr. Gonzalez reports that single port thoracoscopy doesn’t just provide patients with the least invasive surgery possible, but that single port thoracoscopy is superior to traditional VATS in the vast majority of cases.  Single port thoracoscopy is defined by the creation of one 2cm to 4cm incision – with no rib spreading and utilization of video-assisted thoracoscopy.

“Forward Motion”

He states that using a single port approach gives much better visibility than traditional VATS.  This visibility is equal to that of open surgery – versus the 3 or 4 port approach, which is constrained by the 30 degree movement / rotation of the thoracoscope.  This visibility concept; called ‘Forward Motion,’ along with the ease of using instrumentation through the same port makes single port surgery amendable to most thoracic surgery procedures.

Learning curve? What learning curve?

He reports that members of the “Playstation Generation” as he terms the newest young surgeons, adapt more readily to the use of both traditional and single port thoracoscopy.  In fact,  he reports that the residents (in his program) are able to learn and use this approach with minimal assistance.

With the exception of lung transplantation (requiring the traditional clamshell incision), Dr. Gonzalez reports that he is able to successfully perform a wide range of surgeries from wedge resections and lobectomies to more complicated procedures such as pneumonectomies and sleeve resections.

In today’s lecture he debunks some of the myths regarding the ‘classic contraindications’ to video-assisted thoracoscopy (VATS) such as broncheoplasty, the presence of dense adhesions or the need for complete lymph node dissection.  While he reports that dense adhesions may make the procedure more painstaking and difficult – it is still possible.

Lymph Node Dissection

In cases of lymph node dissection – he reports that lymphadenectomy is actually superior by single port and other VATS methods, with the average surgeon actually harvesting more nodes, more easily.

While he initially believed that right upper lobe resections would be impossible with this method – his recent experiences (included in an upcoming paper on 102 cases) show that any anatomic complexities are readily overcome by an experienced VATS surgeon.  Not only that, but he has been able to successfully remove very large (8cm or greater) lung tumors using this method – by slightly enlarging the port at the time of specimen removal.  He has also successfully removed Pancoast tumors and performed chest wall resections with this procedure, as well as single port thoracoscopy after previous VATS or previous thoracotomy including completion pnuemonectomies and completion sleeve lobectomies.

One of the biggest obstacles for surgeons implementing the single port method is the dreaded complication of catastrophic bleeding.  This often causes inexperienced single port surgeons to hasten to convert to open surgery without attempting to control the bleeding.  Dr. Gonzalez presented several cases today to demonstrate the difference between controlled bleeding that can be managed with the speedy application of surgical staples, clips or sutures versus heavy uncontrolled bleeding, which requires quick recognition and prompt conversion to open thoracotomy.

He reports that in the over 500 cases he has performed by VATS (3 port, dual port and single port), conversion to open thoracotomy remains a very rare occurence.  (He presented data on his outcomes today.)

In his own practice, he reports that prior to 2007 the majority of cases were by traditional thoracotomy.  He began using 3 port VATS more heavily in 2007 – 2009.  After training with Dr. D’Amico at Duke  University in Durham, NC – he moved to dual port thoracoscopy in 2009.  Since 2010, his practice is almost exclusively single port thoracoscopy.

The future of single port thoracoscopy

Dr. Gonzalez believes the future of single port thoracoscopy will be a hybridization of current robotic thoracic surgery (which now uses three and four port techniques) to using less invasive, smaller robotic arms that will allow surgeons to enjoy the micro-precision of robotic technology through a single port.

Not just a ‘single port surgeon’

While he is famous internationally for his innovations in the field of minimally invasive surgery, he is also a transplant surgeon.  In fact, along with his partners, he performed an average of 35 – 40 lung transplants a year.*  This makes the transplant program in Coruna the second largest in Spain, despite the relatively small size of Coruna compared to other cities such as Barcelona or Madrid.

For patients who are interested in Dr. Gonzalez-Rivas and his program, please contact him at Info@videocirugiatoracica.com

I published an article based on this interview over at Examiner.com

* Spain is reported to have one of the highest rates of voluntary organ donation in the world.  According to data provided by the Organ Registry of Spain – there were 230 lung transplants in 2011.

Additional Information

Spanish language interview with Dr. Gonzalez

Dr. Gonzalez’s YouTube channel

Publications/ References – Dr. Gonzalez Rivas

1. Single-port video-assisted thoracoscopic anatomic segmentectomy and right upper lobectomy.  Gonzalez-Rivas D, Fieira E, Mendez L, Garcia J. Eur J Cardiothorac Surg. 2012 Aug 24

2 / Single-incision video-assisted thoracoscopic lobectomy: Initial results. Gonzalez-Rivas D, Paradela M, Fieira E, Velasco C.J Thorac Cardiovasc Surg. 2012;143(3):745-7

3 / Single-incision video-assisted thoracoscopic right pneumonectomy.  Gonzalez Rivas D, De la Torre M, Fernandez R, Garcia J. Surgical Endoscopy. Jan 11. 2012 (Epub ahead of print)

4 / Single-port video-assisted thoracoscopic left upper lobectomy.  Gonzalez-Rivas D, de la Torre M, Fernandez R, Mosquera VX. Interact Cardiovasc Thorac Surg. 2011 Nov;13(5):539-41

5 / Video-assisted thoracic surgery lobectomy: 3-year initial experience with 200 cases.  Gonzalez D, De la Torre M, Paradela M, Fernandez R, Delgado M, Garcia J,Fieira E, Mendez L. Eur J Cardiothorac Surg. 2011 40(1):e21-8.

6 / Single-port Video-Assisted Thoracoscopic Anatomical Resection: Initial Experience.  Diego Gonzalez , Ricardo Fernandez, Mercedes De La Torre, Maria Delgado, Marina Paradela, Lucia Mendez. Innovations.Vol 6.Number 3. May/jun 2011. Page 165.

Books/ Book Chapters

1 / Thoracoscopic lobectomy through a single incision.  Diego Gonzalez-Rivas, Ricardo Fernandez, Mercedes de la Torre, and Antonio E. Martin-Ucar. Multimedia Manual of Cardio-Thoracic Surgery. MMCTS (2012) Vol. 2012 doi:10.1093/mmcts/mms007.  Includes multiple videos demonstrating single port techniques.

2 / Tumores del diafragma.  M. de la Torre Bravos, D. González Rivas, R. Fernández Prado, JM Borro Maté. Tratado de Cirugía Torácica. Editores L. Fernandez Fau, J. Freixinet Gilart. SEPAR Editores médicos SA. Madrid 2010. Vol 2, Sec VIII, Capitulo 87: 1269-78.

3 / Trasplante Pulmonar.  C. Damas, M. De la Torre, W. Hespanhol, J.M. Borro. Atlas de Pneumología. Editores A. Segorbe Luís y R. Sotto-Mayor 2010. Vol 2, Capítulo 54 651-8.

4 / Doble utilidad hemostática y sellante de fuga aérea de tachosil en un caso de cirugía compleja por bronquiectasias.  M. De la Torre, J.M. Borro, D. González, R. Fernández, M. Delgado, M. Paradela. Anuario 2009. Casos clínicos en cirugía. Accesit en la 3ª edición de los Premios Nycomed 2008.

5 / Cirugía Torácica videoasistida avanzada.  D. González Rivas. Videomed 2008. Certamen internacional de cine médico y científico.

6 / Traumatismo Torácico. M. de la Torre, M. Córdoba. En « Manual de Urgencias en Neumología». Editado por Luis M Domínguez Juncal, 1999 165-78.

7 / Neumotórax.  M. Córdoba, M. de la Torre. En « Manual de Urgencias en Neumología». Editado por Luis M Domínguez Juncal, 1999 139-56.

8 / Cirugía del enfisema.  P. Gámez, J.J. Rivas, M . de la Torre. En « Neumología Práctica al Día». Boehringer Ingelheim 1998 77-102.

9 / Neumotórax.  J.J. Rivas, J. Torres, M. de la Torre, E. Toubes. En « Manual de Neumología y Cirugía Torácica». Editores Médicos S.A. 1998 1721-37.

Talking with Dr. Raimundo Santolaya, MD, thoracic and transplant surgeon at the Instituto Nacional del Torax

an interview with thoracic and tranplant surgeon, Dr. Raimundo Santolaya Cohen of Santiago, Chile

Dr. Raimundo Santolaya, Thoracic and Transplant Surgeon

After listening to Dr. Raimundo Santolaya Cohen at the National Conference, where he discussed the diagnosis and management of Pneumothoraces, I immediately contacted him following the lecture to arrange an interview.  I was delighted to be able to spend several hours in the charismatic and elegant Chilean surgeon’s company while we talked about thoracic surgery, and the state of lung transplant in Chile.

Dr. Raimundo Santolaya, is a Valparaiso native who currently practices in Santiago at the Instituto Nacional del Torax and the Clinica Alemana.  He is also a professor and the Chief of the thoracic surgery fellowship program at the Universidad de Chile.

While he reports that while lung transplant programs are fairly small in Chile (in comparison to American institutions) he performs several transplants every year.

In addition to his interest in pulmonary transplant, he is also keenly interested in minimally invasive surgery, including uni-port surgery.  In fact, he is currently arranging for Dr. Diego Gonzalez, the Spanish thoracic surgeon to come to Chile in October to teach uni-port lobectomy.

Like most thoracic surgeons, he performs a wide range of thoracic procedures including lung surgeries, and mediastinal masses.

We also discussed the incidence of Hidatidosis/ hydatidosis, (echinococcus granulosus) which is endemic in Chile.  Hidatidosis is an infection caused by a parasite transmitted by animals (commonly dogs), and is more commonly known as a tapeworm.  Infection with this organism can affect multiple organs, but frequently affects the liver and the lungs, called hepatopulmonary hydatidosis.  Infection is marked by the development of hydatid cysts which are filled with tapeworm larvae.  In the lungs, these cysts can become quite large.

When this occurs, the cysts must be surgically excised in addition to aggressive medical management.

About Dr. Santolaya:

Dr. Raimundo Santolaya completed his thoracic surgery fellowship at the Universidad de Chile before traveling to Madrid, Spain to study lung transplant for an additional year.

Instituto Nacional del Torax

J. M. Infante 717, 4th floor

Santiago, Chile

Telephone (56-2) 340 3462

Clinica Alemana

Manquehue Norte 1410

Centro de Diagnostico, 11th floor

Santiago, Chile

Telephone (56-2) 210 1114

The Clamshell Incision

Talking about the clamshell incision in thoracic, cardiac and vascular surgery. Also, soliciting surgical photographs.

The Clamshell Incision

The clamshell incision, also known as a transverse sternotomy, is one of my favorite surgical incisions utilized in thoracic surgery.  As surgical procedures become more and more minimally invasive with the use of robotics, and thoracoscopy, we sometimes forget the beauty of the clamshell incision for large-scale thoracic surgeries.

As a frequent observer in the operating rooms of a variety of surgeons employing an array of surgical techniques and operative philosophies, I have a greater opportunity than most to consider the distinct advantages and disadvantages of this surgical approach.

The clamshell incision is shaped like a curved ‘W”, and is typically performed in the anatomic skin / rib groove below the breasts.  The surgeon then dissects through the tissue, and intercostal muscles to enter the pleural space bilaterally.   It allows greater access than the traditional sternotomy, and has become more popular for bilateral lung transplantation (Durrleman & Massard, 2006).  This technique has also been used to salvage lungs in donors that would have otherwise gone unused due to previous sternotomies (Zuin, Marulli, Loy & Rea, 2008).

This incision gives the surgeon easy access to the heart and both lungs, and the great vessels and is sometimes used by cardiovascular surgeons for repair of the thoracic aorta and aortic arch. (Doss et al. 2003).

example of surgical exposure with hemi-clamshell incision

Somewhat ironically, one of the things I like best about this very large surgical incision is the cosmetic results after a successful surgery. Due to the location of anatomical skin folds beneath the breasts, particularly in females – the incision is minimized, and more cosmetically pleasing that standard sternotomy incisions.  (There is a nice photo of a healed clamshell incision at this neighboring blog.)

This disadvantages of this incision are obvious; as a large chest incision; longer hospital stays, infection/ poor wound healing, and increased pain but when compared to a similar incision such as a sternotomy, the clamshell may prove superior.

* If you have any medical photographs showing clamshell incisions that you would like featured at cirugia de torax.org, please contact me.

References

Doss M, Woehleke T, Wood JP, Martens S, Greinecker GW, Moritz A.  (2003).  The clamshell approach for the treatment of extensive thoracic aortic disease.  J Thorac Cardiovasc Surg. 2003 Sep;126(3):814-7.

Doss, M., Woehlecke, T., Wood, J. P., Martens, S., Greinecker, G. W. & Moritz, A. (2003).  The clamshell approach for the treatment of extensive thoracic aortic disease.  Journal of Thoracic & Cardiovascular Surgery, 2003 Sept., 123(3); 814 -817.

Durrleman, N. & Massard, G. (2006).  Clamshell and hemi-clamshell incisionsMulti-media manual of cardio-thoracic surgery, 2006, Issue 0810.  Full-text article with discussion of incisions, and intra-operative photos.

Wise, D., Davies, G., Coats, T., Lockey, D., Hyde, J. & Good, A.  (2005).  Emergency thoracotomy: How to do itEmergency Medical Journal, 2005;22:22-24. Full-text article with photos showing planned incision and exposure created by the clamshell incision.

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

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.

Dr. Lin scrubs in preparation for surgery

 

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