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30 Years of Lung Transplantation … What’s next?

IT IS EASY AND RELIABLE TO REGISTER AS AN ORGAN DONOR OVER THE INTERNET

The first successful lung transplant was performed in Toronto thirty years ago. The transplant was the culmination of an intense and brilliant research campaign driven by the remarkable determination of Joel Cooper, then a young staff surgeon on the thoracic service headed by Griff Pearson at Toronto General Hospital.

Problems that had been encountered in previous attempts to transplant the lung were systematically addressed across a broad research spectrum. Muscular deconditioning resulting from chronic pulmonary insufficiency was countered by exercising the patients under the supervision of physiotherapists, who monitored oxygen saturation and heart rate while pushing the rest of the transplant candidate’s body to the maximum tolerance. The problem of bronchial dehiscence related to the scant vascularity at the suture line was countered by wrapping a pedicled graft of omentum around the anastomosis. Reperfusion injury to the lung was addressed by minimizing the ischemia time and the use of LPD Perfusion, developed in the laboratory by a young surgical resident named Shaf Keshavjee. This improved solution helped preserve the microcirculation, enhancing bronchial anastomotic healing. Anaesthesia and critical care problems were managed by careful analysis of previous experience, and the period of post-transplant injury to the lung was expertly managed by thoracic surgeon intensivist Tom Todd. Joined in 12 hour shifts by the other members of the thoracic surgery team who slept in the ICU beside the transplant patient, Tom Todd, Alex Paterson and Wilf DeMayo steered the patient through the inevitably stormy postoperative course, along with then thoracic fellow Shaf Keshavjee. Immunosuppression had been substantially improved by the introduction of cyclosporine and reduction in the use of steroids.

Left to right: Mel Goldberg, Joel Cooper, Shaf Keshavjee, Alec Patterson and Tom Todd

The next 30 years brought dramatic advances in lung transplantation under the leadership of the Toronto General team. These are outlined in the accompanying box.

At present, lung transplantation is remarkably effective. It is conducted in centers throughout the world, many of them headed by surgeons and respirologists trained in Toronto. The development of ex-vivo perfusion using high dose antibiotics and gene transfection is the latest advance (see Winter-Spring 2013 issue).

“We have continued to build the program by recruiting superb talent to look for solutions and to translate them into a series of innovations that we brought to the bedside. The future promises more and safer transplants with lungs that will outlive the recipients. The prepared minds and the reflective analysis of the Toronto General team have led to success. All living lung transplant patients were invited to the Gala as guests of the thoracic surgery group.

M.M.

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