For those suffering from end-stage lung diseases, a lung transplant is a life-saving surgery and can be a great source of relief. Lung transplant surgery is a complex and life-saving procedure that is used to treat certain types of lung diseases, such as chronic obstructive pulmonary disease (COPD), pulmonary fibrosis, bronchiectasis and cystic fibrosis. Although still in its infancy, Lung transplant surgery in India has made tremendous progress in recent years, with many highly qualified and experienced doctors taking up this challenge. This guide will provide a comprehensive overview of the process of a lung transplant surgery in India, the different types of surgeries available, the success rates, and the cost involved. It will also address the risks and complications associated with the procedure. With this guide, you will have all the information you need to make an informed decision about whether a lung transplant is right for you and how to proceed with the procedure in India.
Overview of Lung Transplant in India
Lung transplantation is used to treat certain types of lung diseases, such as chronic obstructive pulmonary disease (COPD), pulmonary fibrosis, bronchiectasis, cystic fibrosis, pulmonary arterial hypertension etc. These diseases can cause damage to the patient’s lungs, leading to shortness of breath, a decreased ability to exercise, and an increased risk of infection.
In 1999, Dr. KM Cherian performed the first double-lung transplantation and the first combined heart–lung transplantation in India. This marked the beginning of the era of Lung transplantation in India. However the initial enthusiasm soon lost steam, until 2011 when another single lung transplant was done in Chennai. India has seen a tremendous growth in the numbers of lung transplants 2017 onwards with more and more centres taking up this challenge.
A report published in Lancet Global Health suggests that the burden of chronic respiratory disease in India accounts for 32% of the global burden. Clearly these numbers indicate an unmet need for more trained transplant professionals and transplant centres across India. Thankfully many new transplant centres are coming up and India is slowly but surely coming of age as regards lung transplant.
For people with advanced lung diseases termed as “End Stage Lung Disease”, lung transplantation may be the only option for a long-term cure. Lung transplant surgery is a life-saving procedure that can significantly improve quality of life for patients as well as their longevity. However, it is a complex procedure that carries certain risks. Therefore, it is essential to be fully informed about the procedure and its associated risks before making a decision about whether to proceed with Lung Transplant Surgery in India.
For all general information related to lung transplant, you can watch this video in Hindi:
Types of Lung Transplant Surgery
There are broadly four types of transplant surgeries that may be used to treat end stage lung diseases:
- Single Lung Transplant
- Double Lung Transplant or Bilateral lung Transplant
- Living Donor Lobar Lung Transplant
- Heart-Lung Transplant
The type of Lung Transplant Surgery in India is determined by the extent of damage to the patient’s lungs, underlying etiology, availability of donor lungs and patient profile. Both single and double lung transplants have been performed for common indications including chronic obstructive pulmonary disease (COPD), interstitial lung disease (ILD), and primary pulmonary hypertension. Lung transplant operations, unlike other solid organ transplants, are somewhat unique in the fact that the donor block may be utilized for one recipient for a bilateral transplant or split to potentially benefit two patients with a single lung transplant each.
Single-lung transplant:
In this surgery, the diseased lung is removed and replaced with a healthy lung from another donor (cadaveric). The better out of the two lungs of the recipient is preserved. The donor lung is connected to the patient’s pulmonary veins and arteries to provide blood flow to the new lung and to the bronchus (airway). This surgery can be done on ECMO/heart-lung machine or off-pump.
Double-lung transplant:
This is the most common form of lung transplantation worldwide as well as in India. In this surgery a pair of donor lungs are required from a brain-dead donor. The diseased patient’s lungs are removed one after the other and the healthy donor lungs are sequentially connected to the patient’s pulmonary blood vessels and bronchus. Double Lung transplant is the only acceptable transplant modality in patients with septic lung disease like cystic fibrosis or bronchiectasis for obvious concerns about contaminating the new lung with preexisting infection. This surgery can also be done on ECMO/heart-lung machine or off-pump.
Living Donor Lobar Lung Transplant:
In living lobar lung transplantation, two healthy donors are selected—one to undergo removal of the right lower lobe and the other to undergo removal of the left lower lobe. These lobes are then implanted in the recipient in place of whole right and left lungs.
Heart Lung Transplant:
A heart-lung transplant is a major operation to replace a person’s diseased heart and lungs with those from a donor. It’s offered to people with both heart and lung failure when all other treatment options have failed. This surgery is done on a heart-lung bypass machine. The donated heart and lungs will be put en-bloc in place and connected to the surrounding blood vessels and the windpipe (trachea)
Indications for Lung Transplant Surgery in India
Most candidates for lung transplant surgery will have been diagnosed with an End Stage Lung Disease. These are the common diagnosis for which lung transplantation is done:
- Chronic obstructive pulmonary disease (COPD)
- Interstitial lung disease including pulmonary fibrosis
- Pulmonary hypertension (Know more: Lung Transplant in Pulmonary Hypertension)
- Bronchiectasis
- Sarcoidosis
- Alpha-1-antitrypsin deficiency
- Cystic fibrosis
- Lymphangioleiomyomatosis
- COVID-19 ARDS or Post COVID Fibrosis
Eligibility Criteria for Lung Transplant
Patients need to meet a broad range of criteria to be eligible for Lung Transplant Surgery in India. They must:
- Be physiologically 65 years of age or less for a double lung transplant and 70 years of age or less for a single lung transplant. This means that their physical condition must meet the typical condition of someone age 65 or younger (or 70 or younger for single lung transplantation). The chronological age is not a factor.
- Have a poor prognosis, with a life expectancy of 18 to 24 months.
- Not have any other life-threatening systemic disease.
- Have demonstrated absolute compliance with taking their medications and following other medical recommendations, and have good rehabilitation potential.
- Demonstrate emotional stability and a realistic understanding of the implications of organ transplantation.
- Have a good social support system.
Pre-operative Preparation for Lung Transplant Surgery
Preparation for lung transplant surgery includes both medical and psychological aspects.
Medical: The medical team will assess your overall health to determine whether you are a good candidate for surgery. This is called “Lung Transplant Evaluation”. Based on the assessment you will be ‘listed’ for a lung transplant with the national and regional organ regulatory bodies (ROTTO, SOTTO, NOTTO) , if found fit. They will then monitor your progress while you are on the waiting list to see if you continue to meet the criteria to proceed with surgery. You will be required to demonstrate compliance, build up a minimum level of endurance through rehab programs, meet the ideal weight requirements, stay substance & tobacco free.
Psychological: The psychological team will work with you to identify any emotional factors that may affect your recovery. They will also help you prepare for the various challenges you may face during and after surgery.
You will be required to meet with the medical and psychological teams from time to time as per the institutional policy. Being in the best possible physical and mental shape at the time of your surgery will help with your recovery and transition to a more active life.
The Process of Lung Transplant Surgery in India
Once you are deemed to be a good lung transplant candidate, you are listed with the national and regional transplant bodies. The process of lung transplant begins with a donor alert. The donor lungs may be available in the same hospital, same city, another city in the same state or some neighbouring state. As soon as a donor call is received, two teams are formed: Retrieval team (which harvests the donor organs) and Implantation team (which prepares the recipient and will implant the new lungs).
After verifying the initial donor details presented to your treating team, the retrieval unit will leave for the donor hospital for onsite evaluation of lungs. Since lungs must be transplanted soon after donation, so timing is critical. Because you may receive the call at any time day or night, you and your support person must be ready at a moment’s notice to leave for your transplant centre. So it is always advisable to live in close proximity of the hospital if feasible. When you get a call that a potentially compatible lung is available for you, you’ll need to go straight to the hospital without eating or drinking anything.
Before surgery, your transplant team will check your vitals and perform tests including a chest X-ray, electrocardiogram (EKG), and blood analysis. You’ll be asked to sign a consent form. Your family can stay with you for most of the time before you go to the operating room.
While you’re being prepared for the procedure, your transplant team is in close contact with the donor retrieval team to ensure that the donor lung is right for you. If it’s not compatible, the surgery will be canceled. If the donor lung is a match, you’ll be taken to the operating room. The anaesthesiologist will give you medicines to ensure you are unconscious and don’t feel pain throughout the procedure. The timing of anaesthesia and skin incision are coordinated according to progress made by retrieval team at the donor hospital. An incision is made on the side of the chest for single lung transplantation or on both sides of the chest going across the sternum (breastbone) for double and heart-lung transplantation. The Implantation team will keep the native diseased lungs dissected and as soon as the donor organs reach the recipient hospital, one of your diseased lung will be removed and the corresponding donor lung would be attached in your body by means of three anastomosis (bronchus, pulmonary artery, pulmonary vein). This will be followed by removal of your other diseased lung and implantation of the remaining donor lung in similar fashion. The incisions are then closed and two or more chest tubes are placed around the new lung to help drain blood, fluid and air. A single-lung transplant surgery usually takes three to five hours; a double-lung transplant typically requires six to ten hours.
Recovery from a Lung Transplant
Immediately after the surgery, you’ll be cared for in the intensive care unit (ICU). If the transplant was done on Extracorporeal membrane oxygenation, or ECMO, it may have already been removed at the end of the surgery if the newly transplanted lungs are working satisfactorily. If not ECMO support may be continued in the post operative period for a few days to support patients until donor lung function recovers. ECMO is a temporary life support machine that allows for oxygenation and removal of carbon dioxide. It can also provide blood pressure support if cardiac function is temporarily decreased due to stress from the surgery.
You’ll be on a ventilator (breathing machine) until you can breathe on your own. Usually, patients can breathe without the ventilator within 24-48 hours after surgery, but sometimes patients may need to use the ventilator for days or even weeks. While you’re in the ICU, drains (chest tubes) will remove any fluid that collects around your lungs and heart.
You’ll also be administered antimicrobials (antibiotics, antifungals, antivirals) to prevent infection and immunosuppressant medications to ensure that your body’s immune system doesn’t attack the “foreign” lung or lungs. A delicate balance needs to be maintained between antimicrobial medicines and anti-rejection medicines.
As you recover, you’ll feel some pain at your incision site on the chest, since it is a big cut and the ribs were spread apart for a long period of time. Your doctors will use different analgesics including acetaminophen, non-narcotic pain medications, and small doses of narcotic medications in different combinations. The goal is to keep you as pain free as possible. Adequate pain management early on helps patients cough, breathe, and walk to allow a new lung to fully inflate. Your discomfort should gradually decrease over a few days.
Cardio-pulmonary rehab will be instituted in a phase wise manner. A physical therapist will be helping you to get you out of bed and mobilize you as soon as possible. You may also work with a respiratory therapist, occupational therapist, and speech therapist during your recovery.
Risks and Complications of Lung Transplant Surgery
Lung transplant surgery is a complex procedure that carries certain risks. The risks will vary based on the extent of the damage to the patient’s lungs, the type of surgery performed, and the patient’s overall medical condition. Some of the potential complications include: –
- Bleeding
- PGD – Primary Graft Dysfunction
- Rejection
- Infection
- Arrhythmias
- Acute Kidney Injury
- Risk to life
Post-operative Care After Lung Transplant Surgery
Post-operative care will vary based on the type of surgery performed and the patient’s overall medical condition. Some patients may be discharged after a few days, while others may stay in the hospital for several weeks.
The following are some common post-operative care instructions:
Rest: You will be required to rest as much as possible during the first few weeks after surgery.
Medication: You will probably be given medications to manage pain, reduce swelling, prevent infection, and speed up healing. You will also be on anti-rejection and anti-microbial drugs.
Diet: You will be prescribed a low-sodium diet during the early post-operative period. Your diet will be gradually re-introduced as you are able to eat more.
Recovery time-line: It usually takes at least 3 to 6 months to fully recover from transplant surgery.
For the first 6 weeks after surgery, avoid pushing, pulling or lifting anything heavy. You’ll be encouraged to take part in a rehabilitation programme involving exercises to build up your strength. You should be able to drive again 4 to 6 weeks after your transplant, once your chest wound has healed and you feel well enough. Depending on the type of job you do, you’ll be able to return to work around 3 months after surgery.
Cost of Lung Transplant Surgery in India
The cost of lung transplant surgery in India is determined by a number of factors, including the type of surgery being performed, pre-transplant medical condition of the patient, use of pre or post transplant ECMO, any untoward complications leading to increase in the length of stay. The cost of Lung transplant surgery in India can range from $30,000 to $50,000. Keep in mind that these are just estimates and will vary from patient to patient. In addition, you will have to account for the cost of travel and accommodation, if you do not live in the same city as the transplant centre. Any post-operative care provided outside of the surgical centre, professional fees of physical therapist or rehab specialist after transplant, and the cost of life long immunosuppressants also needs to be factored in.
Choosing the Right Lung Transplant Surgeon & Hospital in India
It is vital that for a successful outcome of a lung transplant you chose the right surgeon, the right team and the right hospital. Lung Transplant Surgery in India is only offered at a handful of centres since it is a highly specialised form of treatment. Only about 5 teams or so in India have perform more than 10 lung transplants an year. These handful of accomplished and mature units perform routine and complex Lung Transplant cases, including ECMO bridge to Lung Transplant as well as managing post-transplant graft rescue therapy with ECMO. Most other centres do just 1 or 2 transplants per year.
The intricacies of lung transplant demand a team that is exclusively focussed on the management of lung failure and end stage lung diseases. So it is always better to place your life in the hands of experienced teams who have formally trained in lung transplantation, have real world experience of managing complex lung transplant cases and its complications.
Dr. Kamran Ali is an experienced Lung Transplant Surgeon in India who underwent rigorous training at Medical University of Vienna, Austria in all aspects of transplantation. He along with his team of Pulmonologists, Intensivists and other specialists is passionate about the treatment of End Stage Lung Diseases.
Read more about Dr. Kamran Ali
