Thursday, April 28, 2011

Book Review: Breathless



The history of lung transplantation is inexorably linked to the University of Toronto in the 1980s and the surgeons and medical team there at that time. The first lung transplant was performed in Mississippi in 1967, and patients with end-stage lung disease started receiving successful heart-lung transplants at Stanford and Pittsburgh in the early 1980s, but Toronto developed the procedures of single and double lung transplants as they're done today. The names of Drs. Joel Cooper, Alec Patterson, and Griff Pearson are mentioned most as the pioneers, but another member of this team, Dr. Thomas Todd, has documented the history of lung transplantation firsthand in his book Breathless: A Transplant Surgeon's Journal.

Breathless is almost a Midnight's Children of lung transplantation; when the first lung transplant in Toronto is performed, Dr. Todd is a senior resident still in training, and when the field is mature, Dr. Todd is retiring. In between, he takes on the roles of doctor to many lung transplant patients, donor surgeon traveling the country to procure lungs, a position at another hospital, and finally the director of the thoracic surgery department in Toronto. Compared to many books by physicians, he doesn't focus extensively on the medical details of his experience, but does a great job telling the stories of the hospital environment, the politics, and the patients. Some of the stories are inspiring (the first patient's recovery), some are frustrating (departure of the pioneering surgeons), and some are funny (a patient's question of "Can we have sex?").
One downside of the book is that the author's role was somewhat outside the historical limelight, so it's sometimes challenging to connect the stories he tells with the history of lung transplants as it's usually reported. He also takes some diversions into the non-transplant work of a general thoracic surgery service, but I found these to be interesting as well. Overall, this book provides a very interesting account of the history of lung transplantation and how it became the field it is today.

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Monday, April 25, 2011

Pediatric vs. Adult Transplants

Pediatric transplantation has been a focus of this blog, mainly because I'm especially interested in the stories and unique issues of children who need organ transplants. Many aspects of transplantation are similar between children and adults, but there are some key differences.


Kidney

Percent pediatric: 5%

Indications in adults

  • Diabetes
  • Hypertension
  • Glomerulonephritis

Indications in children

  • Renal dysplasia
  • Posterior urethral valve
  • Focal segmental glomerulosclerosis

Differences in surgical approach

In adults, a kidney transplant is placed in the pelvis and attached to the blood vessels going to the leg (usually the external iliac vessels). For children between 10 kg and 20 kg, the kidney is placed in the abdomen and attached to the main blood vessels in the body (aorta and inferior vena cava). For children under 10 kg, dialysis is generally preferred to a kidney transplant. Young children actually do better with adult kidneys rather than kidneys from other children.


Liver

Percent pediatric: 12%

Indications in adults

  • Hepatitis C infection
  • Alcoholic cirrhosis
  • Primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC)

Indications in children

  • Biliary atresia
  • Metabolic diseases
  • Fulminant hepatic failure

Differences in surgical approach

Children can often receive the left lateral lobe of an adult liver, either from a deceased donor (split liver transplant) or a living donor (living donor liver transplant). The left lateral lobe is relatively easier to identify and divide than the right lateral lobe (relatively easier--both are very challenging operations!), and children were the first recipients of partial liver transplants. Children can also receive a whole organ liver transplant from another child.


Heart

Percent pediatric: 13%

Indications in adults

  • Ischemic cardiomyopathy
  • Idiopathic cardiomyopathy

Indications in children

  • Cardiomyopathy (particularly dilated cardiomyopathy)
  • Congenital heart disease (particularly hypoplastic left heart syndrome)

Differences in surgical approach

Patients receiving heart transplants for congenital heart diseases (usually children, sometimes adults) often need a longer segment of donor aorta with the transplant. The native aorta may have been part of the original problem and reconstructed as a "neoaorta" as part of the Norwood operation, so the aorta may also need replaced at the time the heart needs replaced.


Lung

Percent pediatric: 4%

Indications in adults

  • COPD (chronic obstructive pulmonary disease)
  • Cystic fibrosis
  • Idiopathic pulmonary fibrosis

Indications in children

  • Cystic fibrosis
  • Pulmonary hypertension
  • Congenital lung malformations

Differences in surgical approach

The younger and smaller a lung transplant patient is, the more likely they are to receive a double lung transplant and need cardiopulmonary (heart-lung) bypass for the operation. However, the operation is generally the same in children and adults.


Small bowel

Percent pediatric: 57%

Indications in adults

  • Mesenteric ischemia
  • Crohn's disease
  • Intestinal tumors (desmoid and carcinoid)

Indications in children

  • Gastroschisis
  • Necrotizing enterocolitis (NEC)
  • Malrotation and midgut volvulus

Differences in surgical approach

One of the challenges with intestinal transplants is that the donor usually needs to be of a smaller body size than the recipient. Since children needing intestinal transplants are small already (because of their intestinal failure and...because they're children), finding a smaller donor than the recipient can be especially challenging.

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