An Overview of Lung Transplant Surgery

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Lung transplant surgery is an extremely complex procedure that replaces the patient’s diseased lungs with donated lungs in an effort to treat end-stage pulmonary disease. One or both lungs may be replaced with donor organs; the patient’s own lungs are surgically removed so the healthy lungs from a donor can be put in their place.

Who Needs a Lung Transplant?

Transplants are appropriate when lung disease is so severe that the lungs are no longer able to support the needs of the patient’s body and there are no medical interventions available that will correct the problem. This is referred to as end-stage pulmonary disease.

A lung transplant is the final option for treatment of severe pulmonary disease, and is appropriate when all other options have failed to improve lung function. The typical lung transplant patient requires oxygen and possibly a ventilator to meet their oxygen needs, is typically worsening with time, and will die if their lung function does not improve. 

Common lung conditions that lead to the need for a lung transplant include:

  • Cystic Fibrosis: A genetic condition; lung infections and increased mucus production are common, often leading to scarring and the need for a lung transplant.
  • COPD: Chronic obstructive pulmonary disease is a lung condition that makes breathing difficult, and can make it difficult for the lungs to expand properly. Typically caused by polluted air, including cigarette smoke and environmental pollution leading to poor air quality. Symptoms typically worsen over years and even decades.
  • Interstitial lung diseases: These conditions, which include pulmonary fibrosis, cause stiffening of the lungs, making it difficult for the lungs to expand and contract with each inhalation and exhalation. The alveoli are also affected, making gas exchange difficult.
  • Antitrypsin deficiency: A genetic condition that affects many areas of the body, a deficiency can lead to emphysema in the lungs that can cause permanent damage over time. Non-alpha 1 and alpha 1 antitrypsin deficiency can both lead to the need for transplantation.
  • Pulmonary hypertension: This is a condition where the arteries of the lungs have much higher blood pressure than they should. The pulmonary artery, the blood vessel carrying blood from the heart to the lungs, will have increasingly high blood pressure, making it difficult for blood to flow out of the heart and through the lung to pick up and drop off oxygen and carbon dioxide.
  • Sarcoidosis: A systemic disease, inflammation can occur in any organ, including the organ. In severe cases, the damage that is caused leads to shortness of breath, weakness and, eventually, pulmonary fibrosis. 

Before the Transplant

The Transplant List

The typical journey of a transplant patient starts with the diagnosis of a pulmonary problem. This may happen at birth, after a cough continues for too long, or during a hospitalization. A diagnosis may happen after an X-ray, or when shortness of breath becomes a problem. 

If the problem is severe, the patient is typically sent to a pulmonologist, a specialist in the area of lung disease. If treatment with pulmonology is unsuccessful, or if the disease continues to worsen despite treatment, the physician can refer the patient to a transplant center where they can potentially be added to the transplant list to wait for donated lungs to become available.

Common tests include:

  • Pulmonary function tests 
  • CT scan of the chest
  • Heart tests to determine if the heart is strong enough for anesthesia
  • Chest X-ray
  • Blood tests to check the function of other organs, CBC to check blood levels, CMP to check electrolyte levels and kidney function, as well as other blood tests that are needed
  • Blood type
  • Antibody tests for donor matching

Finding a Transplant Center

Transplant centers are typically selected by location. Depending on where the patient lives there may be several centers to choose from, or there may be one logical choice for treatment. Not all transplant centers offer all types of organ transplants. Major university transplant centers will typically offer more types of transplants, while smaller regional programs may only transplant kidneys or other abdominal organs. For this reason, you may be referred to a transplant center that is not the closest one to your home. The pulmonologist will typically choose the transplant center that will be most appropriate for the patient's needs.

How to Find a Transplant Surgeon

Most transplant centers have multiple surgeons who are trained and ready to perform the transplant surgery. If there is a preference for which surgeon will be primarily responsible for the care provided, it is acceptable to make that preference known, but the entire team will typically share responsibility for patient care during hospitalizations.

Getting on the Transplant List

The process starts with a referral to the transplant center, where there will be a thorough evaluation of the patient’s disease state, emotional state, insurance review and assistance, and the care needed after the surgery. Extensive testing is typically performed to make sure that the patient is a good candidate for a lung transplant, that a lung transplant is necessary, and the patient has the necessary skills to take care of themselves during and after the transplant. 

If the patient is a good candidate, they are placed on the transplant list and wait for a donated organ to become available.

Contraindications to Organ Transplant Surgery

Contraindications are dealt with on an individual basis, and in some cases may only be temporary. For example, an individual cannot have a transplant surgery while they have an active infection, but they would become eligible for transplant when they are well again. 

In the case of addiction, current alcoholism would prevent transplantation, but a history of alcohol abuse would typically not be an issue if the individual had been without alcohol for a period of time, typically longer than one to two years.

Other contraindications include:

  • Current addictive behavior, including the use of illegal drugs and legal ones, such as prescription drug abuse, cocaine, and alcohol abuse
  • Cancer that won’t be cured by the transplant and that is likely to return after the transplant
  • Dementia or Alzheimer’s disease
  • The presence of another disease that is severe or life-ending
  • Infection
  • Untreatable severe disease of another organ, but for some a dual transplant, such as a heart-lung combination, is possible
  • Smoking marijuana or tobacco/nicotine, including vaping
  • Inability to manage current medication regimen
  • Inability to manage post-transplant regimen
  • Incurable severe vascular disease, such as heart disease
  • No support system such as caregivers, friends, or family
  • Severe obesity
  • Critically ill (too sick to survive transplant surgery)

Organ Donation

Donated lungs must come from a deceased donor. Unfortunately, donation by a friend or relative is not possible with lungs like it is with the liver and kidneys. The lungs typically come from a donor who suffered an injury or medical problem that led to brain death. Once brain death is declared by a physician, the wishes of the donor or their family lead to the donation of their organs. 

Once the lungs are recovered by a surgeon, there is a short window of opportunity to transplant the lungs into a recipient. Modern technology is increasing the length of time that the lungs can be out of the body, but they typically must be transplanted into the recipient within four to six hours. This often means the organs travel by private jet in order to get to the transplant center to get there quickly enough to be safely used as a transplant.

Risks of Lung Transplant Surgery

In addition to common risks associated with surgery and the risks associated with general anesthesia, a lung transplant surgery poses additional risks that are unique to the procedure. These risks include:

  • Organ rejection
  • Infection
  • Bleeding
  • Scarring
  • Blood clots
  • Organ dysfunction

The medications given to prevent organ rejection after surgery are known to increase the risk of cancer, kidney problems, stomach upset, bone loss (osteoporosis), and diabetes, particularly when high doses are used for extended periods of time. For this reason, the minimum necessary dose is used whenever possible.

Lung Transplant Procedure

Lung transplant surgery requires two teams of surgeons, the surgeon who is recovering the donor lungs and the surgeon who is leading the surgery on the recipient. These two teams are necessary because the donor and the recipient may be in different cities or even different states. It is a rare occasion when they are both in the same hospital. 

The process starts when the transplant center accepts an offer for the donated organs made by the organ procurement team caring for the donor. If the lungs are a good genetic match, a good size match, and in suitable condition to be transplanted, arrangements are then made to have a surgeon and other staff go to the donor's operating room to recover the lungs. Meanwhile, the recipient is asked to report to the hospital if they are not already there. Upon arrival, blood work is done, IVs are placed, and any necessary testing is performed. 

The recipient typically goes to the operating room about the same time the donor goes to the operating room. A breathing tube is placed, they are put on the ventilator, and general anesthesia is given. While surgery begins on the recipient, nothing that cannot be reversed is done until two things happen: first, the surgeon operating on the donor verifies that the lungs are suitable for transplant by performing a bronchoscopy and visualizing the lungs in the chest once an incision is made. Second, the plane carrying the team and the donor's lungs is safely landed on the ground. This is because the worse case scenario would be removing the recipient’s lung(s) only to have the donor lungs destroyed in a plane crash or similar accident. 

An incision is made in the chest, and the sternum (breastbone) is cut in half, allowing the chest to be opened and surgery on the lungs can begin. Once the donor lungs and transplant recovery team have safely landed or arrived near the transplant center, the surgeons can safely proceed and remove the recipient’s own lungs and prepare for the final portion of the transplant procedure. During this part of the procedure, where the patient cannot oxygenate their blood, a heart-lung bypass machine is used to oxygenate the blood and the ventilator is not used. 

Surgical clamps are used to keep blood in the blood vessels while the new lungs are being transplanted. Once the new lungs are sewn into place, and the blood vessels are reconnected, the ventilator can be started again and oxygen is provided to the body by the new lungs and the heart-lung bypass machine is no longer needed. Chest tubes are placed, as needed, and the incision is closed. 

Recovery and Prognosis

The lung recipient is taken to the surgical intensive care unit where they are watched closely and slowly permitted to wake up from anesthesia. They may receive sedation to slow this process if the lungs are having issues that need to be addressed, but they could potentially be off the ventilator a day or two after surgery.

The typical patient is in the hospital a few weeks after surgery, possibly longer if there are complications after surgery. Some patients will need physical therapy and occupational therapy to regain their strength, as their lung disease may have led to significant weakness in the months or years before surgery. 

Nearly 80 percent of all recipients survive the first year after transplant, and over 50 percent are alive five years after transplantation. The recipient’s age at the time of transplant and the severity of their disease are the best predictors of survival, with younger and healthier recipients having better long-term outcomes.

The intensive care unit stay after surgery can also lead to the need for rehabilitation. Visits to the transplant center will initially be frequent after surgery, and less frequent as time passes. The risk of rejection is highest in the first few months after surgery, so frequent lab draws are also typical.

A Word From Verywell

Lung transplant surgery is a very serious and high-risk procedure that can extend the patient’s life for years or even decades. The lives of patients who have a lung transplant often change dramatically for the better after surgery, and they can often resume their normal activities within a few months of surgery. 

The decision to transplant one lung or both lies with the surgeon, but in either case, the patient can see enormous benefits. While there are significant risks that cannot be ignored with any major surgery, the risks of lung transplant are even more significant and should be considered before making the decision to be on the transplant list. Choosing to accept those risks and to pursue a lung transplant can also potentially lead to sweeping improvements in health and well-being. 

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