February 3, 2017

A medical first: Patient survives transplant after six days without lungs

Daily Briefing

    In a medical first, doctors at Toronto General Hospital in April performed a procedure that allowed a patient to survive six days without lungs while she waited for a transplant.

    The doctors published the procedure in a November 2016 Journal of Thoracic and Cardiovascular Surgery paper, and shared the story at a news conference on Wednesday.

    'We had reached the end of the road'

    For three years, Melissa Benoit's lungs had been weakened by cystic fibrosis and recurring bacterial infections. Her condition worsened significantly after a case of swine flu last February, and the bacteria in her lungs eventually became resistant to most antibiotics.

    A doctor asks: Should physicians game the transplant rules?

    To help Benoit breathe, doctors placed her on Extra-Corporeal Lung Support. But her case continued to worsen, and sepsis "was shutting down her organs one by one," Cleve Wootson writes for the Washington Post's "To Your Health."

    Niall Ferguson of the University Health Network said, "She got into a spiral from which her lungs were not going to recover. Her only hope of recovery was a lung transplant."

    But because of her infections and resulting critical condition, Benoit was dropped from the transplant list. Shaf Keshavjee, one of three surgeons attending Benoit, said, "We had reached the end of the road."

    A 'radical decision'

    During this time, her doctors had been considering a "bold solution," Ashifa Kassam writes for The Guardian.

    They thought they could remove both of Benoit's lungs in an effort to eliminate the source of her infections. Atul Humar, director of the transplant program at Toronto General Hospital and president of the Canadian Society of Transplantation, said the idea "makes scientific sense."

    "We know that when you have infections anywhere in the body, if you can remove the source of the infection, it's often a good way to treat the infection," he said.

    But there were obvious risks to the procedure: First and foremost, it had never been done before. There was the risk of bleeding in the empty chest cavity and the uncertainty about whether Benoit's oxygen levels and blood pressure could be sustained when her lungs were removed.

    But with her family's permission, "we took both lungs out," Keshavjee said, noting that the infection in her lungs left them with few other options.

    Toronto General Hospital "was certainly the perfect place to try" the new procedure, CNN's Susan Scutti writes. Humar said the hospital performed the world's first successful single lung transplant and the first successful double lung transplant—and doctors there had been discussing the possibility of the new procedure for several years before Benoit was a patient there.

    The procedure

    Over nine hours, surgeons removed Benoit's lungs and placed her on "the most sophisticated life support possible for her heart and lungs." The artificial lung, called a Novalung, was connected to her heart and oxygenated her blood while removing carbon dioxide. Another device was used to help Benoit circulate the oxygen-rich blood throughout her body.

    Inside the 'Mother of All Surgeries'

    She was then put in a medically induced coma and sent to intensive care. Doctors saw positive signs almost immediately. "Once we took the lungs out and she got connected, literally within 20 minutes, we were able to remove all the blood-pressure-supporting drugs," Keshavjee said. "That told us that the concept is right. She's not going to die tonight, but we're not home free. Now can we keep this state until we get lungs?"

    After Benoit's sepsis resolved, she was re-added to the transplant list, and within a week donated lungs became available. Doctors successfully completed the transplant. "They brought me back from death," Benoit said.

    Benoit has spent months in physical therapy, and though she has a long road ahead, her condition is improving. "She has a very good prognosis," Keshavjee said. "The lungs are working well, she's gone through rehabilitation, and now she's walking around and living a more normal life and taking her daughter to school."

    The procedure was "a remarkable achievement ... and the world's first," Humar said (Wootson, "To Your Health," Washington Post, 1/27; Kassam, The Guardian, 1/25; Scutti, CNN, 1/31).

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