Lung transplant surgery

Overview

Lung transplantation is a well-accepted therapy option for advanced lung disease. Over 46,000 lung transplants and over 1400 heart/lung transplants have been done in the United States since 1988, accounting for approximately 5% of all organ transplants.

Lung transplant surgery definition

A lung transplant is a surgical procedure that replaces damaged lungs with healthy ones. It is a therapeutic option for patients with severe or advanced chronic lung disorders, such as chronic obstructive pulmonary disease (COPD), cystic fibrosis, and pulmonary fibrosis, that can enhance the quality of life—for example, your capacity to breathe and be active. Potential candidates must go through an examination and grading procedure before obtaining a lung transplant.

Once approved, they are placed on a waiting list for transplant surgery and, hopefully, life after surgery. It's a big procedure with big dangers, and there are several things to think about before and after that you might not think about.

Background

The history of organ transplantation began with multiple failed efforts owing to transplant rejection. In 1963, James Hardy from the University of Mississippi performed the first human lung transplant. The patient, eventually identified as convicted murderer John Richard Russell, lived for 18 days after receiving a single-lung transplant. Multiple lung transplant efforts failed between 1963 and 1978 due to rejection and anastomotic bronchial healing issues.

 Only with the discovery of the heart-lung machine, as well as the introduction of immunosuppressive medications such as ciclosporin, were organs such as the lungs transplantable with a fair prospect of patient recovery.

Dr. Bruce Reitz of Stanford University performed the first successful lung transplant operation in 1981 on a lady suffering from idiopathic pulmonary hypertension.

• 1983: First successful long-term single lung transplant by Joel Cooper (Toronto) 
• 1986: First successful long-term double lung by Joel D. Cooper (Toronto) 
• 1988: First successful long-term double lung transplant for cystic fibrosis by Joel Cooper (Toronto).

Vera Dwyer, an Irishwoman from County Sligo, was diagnosed with an irreversible, chronic, and fibrotic lung illness in 1988. Later that year, in the United Kingdom, she got a single lung transplant. Ms. Dwyer was honored as the world's longest-surviving single lung transplant patient in November 2018 during a ceremony held at the Mater Hospital in Dublin.

Do I need a Lung transplant?

People with 'end stage' lung disorders such as chronic obstructive pulmonary disease (COPD), pulmonary fibrosis, cystic fibrosis (CF), pulmonary arterial hypertension (PAH), sarcoidosis, and other rarer lung diseases may be candidates for lung transplantation. Lung transplantation should be considered only after you and your doctor have exhausted all other treatment options.

However, you should have a lung transplant before you become too unwell to withstand the procedure. As a result, the timing of the examination and operation is critical. To be considered for surgery, you must be examined at a lung transplant clinic. You will meet with a transplant surgeon, transplant pulmonologist (lung specialist), and other experts throughout your examination. They will question about any other medical issues you may be experiencing, such as heart or renal illness.

They will ensure that you have been checked for malignancies specific to your age, such as colon, prostate (in males), breast, and cervical cancer. A complete examination will be performed, which may involve a CT scan of your chest, pulmonary function tests, echocardiography, and maybe a cardiac catheterization.

You may be tested to check whether you have gastroesophageal reflux disease. Finally, they will ensure that you have adequate social support from people who will look after you following your transplant. After the examination, the transplant team will decide if surgery is the best choice for you and whether you should be placed on the lung transplant waiting list.

Indications for Lung transplantation

Lung transplantation is a last-resort therapy option for individuals with end-stage lung illness who have exhausted all other options without improvement. A multitude of problems may necessitate such surgery. The most prevalent causes for lung transplantation in the United States in 2005 were: 

• Chronic obstructive pulmonary disease (COPD), including emphysema (27%)
• Idiopathic pulmonary fibrosis; (16%)
• Cystic fibrosis; (14%)
• Idiopathic (formerly known as "primary") pulmonary hypertension; (12%)
• Alpha 1-antitrypsin deficiency; (5%)
• Other causes, including bronchiectasis and sarcoidosis. (24%)

Contraindications of Lung Transplantation

Absolute contraindications

According to the International Society for Heart and Lung Transplantation, the absolute contraindications are as follows:

• Malignancy in the previous two years, with the exception of non-melanoma localized skin cancer that was adequately treated (a 5-y disease-free interval is prudent)
• Unless coupled organ, transplantation is possible, untreatable advanced malfunction of another major organ system.
• Atherosclerotic disease with suspected or verified end-organ ischemia or dysfunction, as well as coronary artery disease that is not revascularizable
• Acute medical instability, such as sepsis, a heart attack, or liver failure
• Diagnosis of uncorrectable hemorrhage
• Pre-transplant infection with very virulent and/or resistant microorganisms that is poorly managed
• Mycobacterium tuberculosis infection that is active
• Significant chest wall or spinal deformity is likely to result in significant limitation following transplantation.
• Obesity (body mass index 35.0 kg/m2) is a condition in which a person is overweight.
• History of frequent or extended periods of noncompliance with medical care that are thought to enhance the likelihood of noncompliance following transplantation
• Psychiatric problems are characterized by a difficulty to collaborate with the medical/allied health care team and/or adhere to sophisticated medical therapy
• Inadequate or unreliable social support system
• Severely reduced functional status with little prospect for improvement
• Substance addiction or dependency; significant and/or long-term engagement in therapy; repeated blood and urine tests can be performed to certify abstinence from substances of concern;

Relative contraindications

In most circumstances, adults beyond the age of 75 are unlikely to be candidates for lung transplantation. Although age should not be regarded a contraindication to transplantation in and of itself, increasing age is commonly coupled with concomitant diseases that are either absolute or relative contraindications.

Relative contraindications include the following:

• Older age
• Class I obesity (BMI 30.0–34.9 kg/m 2)
• Progressive or severe malnutrition
• Severe, symptomatic osteoporosis
• Prior chest surgery with lung resection
• Infection with highly resistant or pathogenic bacteria, fungus, and some mycobacteria strains (eg, chronic extrapulmonary infection expected to worsen after transplantation)

Types of lung transplant

• Lobe

A lobe transplant is a surgical procedure in which a portion of the donor's living or deceased lung is removed and utilized to replace the recipient's damaged lung. This technique demands the donation of lobes from two distinct persons in order to replace a lung on either side of the recipient. Despite the reduction in lung capacity, donors who have been carefully screened should be able to maintain a normal quality of life. One donor can furnish both lobes in dead lobar transplantation.

• Single-lung

Many people can benefit from a single healthy lung transplant. The donated lung is usually from a donor who has been declared brain-dead.

• Double-lung

Certain individuals may require the replacement of both lungs. This is especially true for persons with cystic fibrosis because bacteria typically colonize the lungs of such patients; if just one lung is transplanted, germs in the original lung might possibly infect the newly donated organ.

• Heart-lung

Some respiratory patients may simultaneously be suffering from serious cardiac illness, necessitating a heart transplant. These individuals can be treated with a procedure that replaces both lungs and the heart with organs from a donor or donors.

In the media, a particularly complex version of this has been dubbed a "domino transplant." This type of transplant, first accomplished in 1987, normally entails the transplanting of a heart and lungs into recipient A, who then has his or her own healthy heart removed and put into recipient B.

What is the surgery like?

The surgery varies depending on the person and the center. Your team will decide whether a single or double lung transplant is best for you and will describe the procedure to you. In sicker and older persons, a single lung transplant may be tolerated better. The procedure itself normally lasts six to eight hours, although patients are routinely in the operating room for considerably longer.

Some patients may require temporary heart-lung bypass and other invasive treatments to get through the operation. An anesthesiologist will keep you sedated for the duration of the procedure. The incision is usually made beneath your breast. You will be awake with chest tubes in your sides and a breathing tube in your mouth. You will be given pain relievers to help you get through the recovery period.

While the specifics of the surgery will vary depending on the kind of transplant, several processes are shared by all of these operations. The transplant surgeon examines the donor lung(s) for evidence of injury or illness before operating on the recipient. If the lung or lungs are accepted, the recipient is given an IV line and several monitoring devices, including pulse oximetry. The patient will be sedated, and a machine will breathe for him or her.

The patient's pre-operative preparation takes around an hour. A single lung transplant takes four to eight hours to complete, whereas a double lung transplant takes six to twelve hours. A history of previous chest surgery may complicate the process and necessitate more time.

Single-lung

In single-lung transplants, the lung with the worse pulmonary function is picked as a substitute If both lungs function similarly, the right lung is typically preferred for removal since it avoids having to maneuver around the heart, as would the left lung.

The procedure of a single-lung transplant begins when the donor lung has been assessed and the decision to accept the donor lung for the patient has been made. In most cases, an incision is made from beneath the shoulder blade around the chest, finishing near the sternum. An alternative procedure includes making an incision beneath the breastbone. The lung is deflated, the blood arteries in the lung are tied off, and the lung is removed at the bronchial tube in the event of a single lung transplant. 

The donor lung is implanted, the blood vessels and bronchial tube are reconnected, and the lung is reinflated. A bronchoscopy will be conducted to ensure that the lung is adequate and to eliminate any lingering blood and mucus in the new lung. The chest incision will be closed if the surgeons are pleased with the lung's function.

Double-lung

A bilateral transplant, often known as a double-lung transplant, can be performed sequentially, en bloc, or simultaneously. En bloc is less common than sequential. This is the same as getting two separate single-lung transplants.

After the donor lungs have been assessed and the decision to transplant has been taken, the transplantation process begins. A clamshell incision is then created from under the patient's armpit, around to the sternum, and back towards the opposite armpit. In a sequential transplant, the recipient's lung with the worst lung function is compressed, the blood arteries are tied up, and the accompanying bronchi are severed.

The new lung is subsequently implanted, and the blood vessels are reconnected. A bronchoscopy is conducted to ensure that the lung is adequate before transplanting the other. When the doctors are happy with the new lung's function, surgery on the second lung will begin. In 10% to 20% of double-lung transplants, the patient is connected to a heart-lung machine, which pumps blood and gives new oxygen to the body.

What do I do while I am waiting? 

The normal wait period ranges from a few weeks to many months. However, you should not remain inactive throughout this period. You should utilize this time to exercise as tolerated in order to prepare your body for surgery.

Your transplant team may advise you to participate in a pulmonary rehabilitation program. In general, the better your physical condition is before to surgery, the simpler and faster your recovery will be. Your team may also request that you relocate closer to the lung transplant center so that they may carefully monitor your development and decrease your travel time to the center when organs become available. It is critical at this time to notify your team if your health changes.

When a suitable organ becomes available, you will be contacted by phone and asked to come into the hospital. Because this call might come at any time, you should have a suitcase packed and be prepared to rush to the hospital. The call may sometimes result in a "dry run," in which the donor organ is discovered to be unsuitable for transplantation following the additional investigation.

Post-operative care 

Immediately following surgery, the patient is hospitalized in an intensive care unit for observation, usually for a few days. A ventilator is used to help the patient breathe. Nutritional demands are normally fulfilled by whole parenteral nourishment, however, a nasogastric tube may suffice in rare circumstances. Chest tubes are inserted to allow excess fluids to be evacuated.

A urinary catheter is utilized because the patient is restricted to bed. IV lines are placed in the neck and arm to monitor and provide drugs. If there are no difficulties, the patient may be moved to a general inpatient unit for continued recuperation within a few days. The normal hospital stay after a lung transplant is one to three weeks, however, problems may necessitate a longer stay.

Following this stage, patients are usually needed to visit a rehabilitation gym for 3 months to restore fitness. The rehabilitation regimen includes light weights, an exercise bike, a treadmill, stretches, and other activities.

Following the procedure, there may be a number of adverse effects. Because key nerve connections to the lungs are severed during the process, transplant patients are unable to feel the need to cough or detect when their new lungs get clogged. To eliminate secretions from the lungs, they must make intentional attempts to take deep breaths and cough. Because the vagus nerve, which typically regulates the heart rate, was severed, their heart rate responds to effort more slowly. They may also notice a change in their voice as a result of nerve injury to the nerves that control the vocal cords.

Exercise may aid to speed up physical recovery in individuals following lung transplantation, reducing impairment from physical inactivity both before and after the transplant. However, there are no specific rules for how exercise should be undertaken in this demographic.

How long is recovery?

If there are no difficulties during the procedure, you may stay in the ICU for 3-5 days. In that situation, you should be released from the hospital within 2-3 weeks. However, if complications arise during the rehabilitation process, the hospital stay might last many months. Much of your hospital stay will be spent ensuring that you receive the correct dosages of immune-suppressing medications to prevent your body from rejecting the lung transplant.

Tacrolimus (or cyclosporine), mycophenolate mofetil (or azathioprine), and prednisone are the most commonly prescribed drugs to suppress your immune system. Rehabilitation is another important aspect of your hospital stay. A physical therapist will begin working with you as soon as medically possible to get you out of bed and walking. This pulmonary rehabilitation may be maintained in an outpatient supervised environment after you are discharged from the hospital. Following your transplant, you will have frequent blood tests, chest x-rays, and spirometry.

A bronchoscopy may also be required from time to time. As long as your new lungs remain healthy, your initial pulmonary function tests will continue to improve over the first year following the transplant. You will also be requested to use a portable micro-spirometer to monitor your pulmonary function on a frequent basis. This may help you spot issues before they become symptoms.

Blood tests will be performed to ensure that your immune system is sufficiently suppressed and that your new drugs are not affecting other organs (such as your kidneys and liver). While a lung transplant is typically a life-saving procedure, patients may have certain complications. Infections and rejection of the transplanted lung are the two significant issues.

You are more susceptible to infections since you are taking drugs that weaken your immune system. Antibiotics will be prescribed as a prophylactic measure for several common illnesses by your team. Unfortunately, not all illnesses are fully avoidable. You should avoid contact with sick persons as much as possible and wash your hands thoroughly and frequently. 

Your team will advise you on which vaccinations to take and how to avoid illness in other ways. Acute rejection, in addition to infection, can develop soon after lung transplantation. When your immune system detects your new lungs as alien and begins to attack them, this is known as acute rejection. Acute rejection necessitates immediate treatment and may necessitate a change in your immune-suppressing medications.

Conclusion

A lung transplant is a successful treatment for an illness that has damaged the majority of the function of the lungs by removing the diseased lung and replacing it with a healthy lung from another person. To ensure that a patient is a good candidate for a lung transplant, each patient must go through a thorough screening process. However, lung transplant procedure is fraught with danger, and complications are prevalent.