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Transplants

Imagine having a windpipe donated from a dead person. Today, it seems that nothing is impossible, from transplants of whole body organs to the growing of a whole new organs in a laboratory. You'd need to be pretty skilled to perform that kind of surgery though!

Back in the early days, it was thought that the best surgeons were the ones who could operate the fastest. The trick was getting the operation finished before the assistants holding down the screaming patient ran out of strength. Even if the assistants didn’t run out of breath, sometimes the patients would die of shock anyway.

Face off!

The Romans and the Greeks were the first people to perform surgery. The legionary surgeons in the Roman Army became very good at setting bones and controlling bleeding. In fact, the Romans were so good at performing surgery that the soldiers would often live much longer than the general population.

Roman Legion

They became so skilled that they were able to perform procedures such as rhinoplasty and otoplasty by removing skin from the back of the arm and suturing it into place. These were the very first transplants. Sadly though, it would be over a thousand years before surgery would be performed so well again.

So, what do you need to do successful transplants?

You’ll need a good set of surgical instruments that will allow you to do basic surgery. After that, you need to be able to do three things:

  • Anaesthetise the patient (Make sure the patient won’t wake up!)
  • Prevent infection (Make sure the patient doesn’t get infected!)
  • Control bleeding and transfuse blood (Make sure the patient doesn’t bleed to death!)

Anaesthetise the patient

The first thing you need to do is make sure the patient won’t wake up in the middle of the surgery and die of shock!

The first really effective anaesthetic was nitrous oxide (N2O). This was also called ‘laughing gas’. The intoxicating effects of nitrous oxide had been known about for over 50 years. In fact, the Victorians used to have ‘laughing gas’ parties. Inhaling the gas would make them feel drunk. They also noticed that the gas could stop toothache.

Laughing Gas

It wasn’t until much later that anyone thought of using the gas during surgery. This helped, but the discovery of stronger anaesthetics allowed surgeons to try much more complex procedures. The patient would stay ‘under’ for much longer and surgeons didn’t need assistants to hold down their patients!

Prevent infection

The next problem you need to solve is infection. Most patients survived the surgery but would later die of infection. People thought that just exposing the wound to the air caused the problem. They thought ‘bad air’ would get into the wound and kill the patient.

Joseph Lister

It wasn’t until Joseph Lister, a British surgeon, noticed that wearing clean clothes and washing his hands before performing surgery gave his patients a better chance of surviving. At first, Lister didn’t understand why cleanliness was important until he read some work by Louis Pasteur who had been using a new microscope. Pasteur noticed that there were tiny living things in the environment all around us. He called them microbes or germs.

Microbes

Lister realised that these were probably what was getting into the open wounds and causing the problem. He used carbolic acid to kill the germs and survival rates among his patients hugely increased. Soon, steam-sterilising surgical instruments and dressings would improve things further.

Control bleeding and transfuse blood

You’ll also need to make sure your patient won’t bleed to death! Tying cut blood vessels with a fine thread called a ligature was the first method used to control bleeding. This was a major improvement, but the big breakthrough came with effective blood transfusions.

Surgeons and doctors had been attempting blood transfusions since the 17th century. They were often performed using animal blood and the patient nearly always died. Human to human transfusions were also tried. They were sometimes successful but more often than not failed just as dramatically as those using animal blood.

The problem with blood transfusions is that the body has the ability to recognise all foreign cells and attack them. This is called the 'immune response'.

Immune Response

It is really useful in fighting infection from microbes but can be disastrous if you need a blood transfusion. The body sees the transfused blood in the same way as it would see a germ cell. It attacks and destroys it. If red blood cells are destroyed, haemoglobin is released into the system in large quantities. This causes the kidneys to fail. Not a good outcome!

It doesn’t happen in every case though. This is because blood comes from eight different groups. If you get blood from the right group, then it’s likely you’ll survive.

There are four main groups, O, A, B, and AB. Each one has a factor called the Rhesus(Rh) factor associated with it. This factor is referred to as being positive (+) or negative (-). This is why blood groups are written as A+ or O- etc.

In Britain the most common blood group is O+. About 37 per cent of the population has this blood group. The least common is AB-. Only about one per cent of the population has this group. Different countries have different proportions of their populations with different groups.

World blood groups

Blood Groups

So, as you can see from the table, if you’re visiting South Korea and need an AB- transfusion it may be difficult to find a donor!

So, we now have the knowledge to do good general surgery, but transplant surgery has one really difficult problem to overcome. The immune response to transplanted tissue can cause big problems. It is called 'rejection'. It's really just the same effect as we had with early blood transfusions. The body sees the organ as being alien, therefore dangerous, and starts destroying it. To minimise 'rejection', tissues need to be the right ‘type’.

How do we prevent the body from rejecting transplanted organs?

Tissue typing is very similar to blood grouping. The only problem is that there are hundreds of different tissue types. The chance of getting a perfect tissue match is practically zero. Even if the donor of the organ is a brother or sister, there is only a one in four chance of a 'good match'. Hundreds of potential donors need to be 'tissue typed' to get a good match.

Even when you have a good match, the immune response will try to destroy the organ. To prevent this, drugs are given to the patient to suppress the immune system. This stops the patient rejecting the organ but increases their chances of getting an infection from microbes.

This is in fact what the Human Immunodeficiency Virus (HIV) does: it suppresses the immune system so that even minor infections can kill the patient. It is not the HIV that kills the patient, it’s the germs that they would normally be able to fend off that do the damage.

HIV

The drugs that stop the body from rejecting the organ cause the greatest risk to transplant patients: infection. Of course, it would be brilliant if you could get around the need to suppress the immune system. Fortunately, this is what a team of European surgeons and scientists have just achieved!

The bronchus transplant

The bronchus is the air way that leads from the trachea (windpipe) into the lung. It can easily be damaged by respiratory diseases like Tuberculosis (TB). To replace this section of tube is very difficult. The risk of rejection is very high. So what the team did was construct a new bronchus from the patient’s own cells. These are not seen as foreign so they are not attacked. No immune response is produced and the transplant will not be rejected!

How do you transplant a bronchus?

Bronchus Transplant

1. Take a trachea from a dead donor. The trachea is used instead of the bronchus because it is stronger.

2. Strip away all the living cells in a chemical bath. This leaves the springy collagen skeleton of the trachea. Collagen is a tough protein that cartilage is made out of.

3. Take some stem cells from the patient’s own bone marrow and lodge them in the collagen skeleton.

4. Introduce a few normal cells from the patient’s trachea.

5. Place in a special nutrient chemical bath until the stem cells multiply and become normal trachea cells.

6. Cut to shape.

7. Transplant into patient with no anti-rejection drugs.

This is a brilliant outcome and will hopefully lead us into a future where organs can be manmade rather than borrowed from a donor.

Another recent first was an ovary transplant. After having the surgery the woman started her menstrual cycle for the first time in 22 years and is now expecting a baby. The donor was her identical twin sister. Why do you think there were no rejection problems?

The big questions:

The greatest stitcher of body parts of all time is Victor Frankenstein. He made his first appearance in 1818 in Mary Shelley’s novel ‘Frankenstein'. Here Victor makes his ‘perfect’ human from scavenged body bits. Of course, things go very wrong and he gets his comeuppance for tampering with nature. Do you think the story has any relevance to what is happening in science today? Have you heard any references to Frankenstein monsters in the media?