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CARLOS OSORIO/TORONTO STAR
Dr. Shaf Keshavjee of Toronto General Hospital has pioneered use of a mechanical lung and a system that keeps harvested lungs from deteriorating. (Feb. 3, 2010)
SUNDAY PROFILE: SHAF KESHAVJEE
The man who gives the gift of breath
February 21, 2010
Noor Javed
STAFF REPORTER
In a state-of-the-art presentation room in the new wing of Toronto General Hospital, wealthy donors mingle and snack on gourmet cheese, fancy pastries and fruit.
It's hoped they will donate big bucks to the hospital's foundation and research program. So the TGH has brought in its big hitter, thoracic surgeon Dr. Shaf Keshavjee.
Wearing a conservative suit and tie, the head of the lung transplant program looks like a businessman, but he speaks in a calming way that makes you wish he was your doctor. He begins by talking about TGH's illustrious lung transplant record: the first centre to do successful single and double lung transplants, the first to use an artificial lung to prolong life, and the first to repair donor lungs outside the body.
Murmurs of praise fill the room when Keshavjee shows before and after pictures of a teenage lung-transplant patient lying in her hospital bed and another of her surfing a few months later.
It's clear Keshavjee, who turns 49 this week, knows how to win over a crowd. And in this room, he has a head start.
Among the 200 or so guests are a few whose lives were saved by the surgeon. Like Merv Sheppard, 73, who says he is alive "years past his expiry date," breathing with a donated lung, because Keshavjee – or Shaf, as he likes to be called – thought he was worth the risk.
"I was one of the oldest people to undergo a lung transplant," says Sheppard, who was afflicted with idiopathic pulmonary fibrosis in one lung. "Most people told me I didn't have a chance because I was 65." The cut-off for lung transplants at the time was 55. In some hospitals, it still is.
Like most doctors, Keshavjee wants to improve his patients' quality of life. But he's also driven to probe beyond the obvious. Why are some donor lungs not suitable for donation? Why do others fail post-transplant? Can donor lungs, which start to deteriorate as soon as they're harvested, be repaired before transplantation?
Ultimately, Keshavjee hopes to eliminate donor organ shortages, and perhaps even get rid of the need for transplants altogether.
In pursuit of these goals, Keshavjee and his clinicians and researchers have revived one of the top lung transplant centres in the world – and the largest in North America. Last year, they did a record 102 transplants, surpassing the 1,000 mark for total number of surgeries. In January, they performed a record 14.
No small feat for an operation that takes six to 18 hours. "It is pretty intense, says Keshavjee. "You are working for that whole time. There are no coffee breaks, and you aren't going out to pee."
Despite having done so many, Keshavjee says it's difficult to not be moved.
"Every time I think this is a miracle. It's amazing that we can ... take the lungs out, and put them back in, and the person will be fine."
TRANSPLANTATION is risky work, but Keshavjee, who also performs other surgeries and devotes a lot of time to research, is clearly cut out for it – albeit with a little help from his mom, Gulshan.
She has been available night and day to look after 12-year-old Sara, Keshavjee's daughter with his wife, Dr. Donna McRitchie, medical director of critical care and division chief of general surgery at North York General Hospital.
"It was a great help," says Keshavjee. "It has helped us have some semblance of a balanced life. We try, but it's still not easy."
Keshavjee was 12 when he moved to Toronto from Kenya with his mother and his businessman father. The young Shaf was drawn to the sciences at North Toronto Collegiate. "I always knew I wanted to be a surgeon," he recalls. "Not just a doctor, but a surgeon."
He was a dedicated student and easily got into medical school at the University of Toronto. Transplant surgery had never been a consideration until the afternoon of Nov. 7, 1983, when he was driving over a bridge on Mount Pleasant Ave. and heard a radio news bulletin announcing that surgeon Dr. Joel Cooper and his team had conducted the world's first successful single lung surgery at TGH.
"I thought, wow, that's cool."
The risky procedure had been tried 44 times before without success. Three of those failures had been in Toronto. Most patients didn't survive more than two weeks
Three years later, Keshavjee was on hand when history was made the second time at TGH. He was a wide-eyed surgery resident when he scrubbed in to the operating room to witness the world's first successful double lung transplant surgery, on Nov. 26, 1986. That day, Keshavjee stayed mostly on the sidelines, watching the "giants" of thoracic surgery in action. On the operating table lay Canadian Ann Harrison, whose lungs had been virtually destroyed by emphysema.
Without the surgery, she had just a few months to live, doctors told her. With it, she might not make it beyond the operating table. She still said yes and lived another 14 years.
"By this time, all the other organs had been transplanted, but lungs hadn't," says Keshavjee. "The first kidney and heart transplants were done in the '50s."
For TGH, the 1980s were the golden age of lung transplants. Doctors flocked from all over the world to learn how to perform lung surgeries. The field boomed from a handful of transplants a year around the world to hundreds.
But as quickly as Toronto's lung program flourished, it ended. The city was dethroned by the brain drain of surgeons to the U.S. for greater opportunity and money.
That's when Keshavjee, by then a young thoracic surgeon, officially entered the scene. Despite offers to go to the U.S., he stayed, hoping to rebuild Toronto's reputation.
Pioneering lung surgeon Cooper had little doubt about his protegé's abilities. "There is no question there were some dark years there. But he ... was able to persevere."
THE LIFE OF a transplant surgeon is not for the weak-hearted. There are long hours, heart-wrenching cases and the burden of taking, or not taking, a chance on a patient who has nothing more to lose.
"The easier answer to give patients sometimes is no," says Keshavjee. "The tough one is to say we can try."
And even though the team has its share of high-profile successes, there are also stories of defeat, heartbreak and death. But even those, Keshavjee believes, are worth the risk.
"It's the ones where you stuck your neck out and they survived – they really make it worth it."
"Keshavjee is very open to new ideas and innovation," says Dr. Frank D'Ovidio, who trained at TGH and is an assistant professor of surgery and surgical director of the lung transplant centre at Columbia University. "He's really good at pushing the envelope and following his intuition."
Keshavjee started to push the bar in terms of increasingly complex cases in the mid-'90s. Among the first was Sheppard, who was beyond the age threshold.
A few years later, Keshavjee's team introduced Canada to the German-developed Novalung, an artificial lung to keep patients alive while they wait for donated lungs. It was first tried on Yen Tran, a 21-year-old mother of three whose health had quickly worsened from primary pulmonary hypertension. The tiny, box-like apparatus did the work of lungs for two days, giving her medical team enough time to find donor organs.
In 2008, Keshavjee and doctors at Sick Kids tried the Novalung on 16-year-old Katie Sutherland, who also suffered from pulmonary hypertension, which was constricting her veins and arteries and forcing her heart to work harder. In a matter of days, Sutherland's lungs began to give out. As she lay in the operating room, almost dead, the team had no option but to attach her to the artificial lung – giving her 30 days to wait for a donor lung.
"Boy, that case was high-risk," recalls Keshavjee. "But when you know that patient is alive because you took the decision to take the added risk, then you feel good."
The latest slew of high-profile cases has brought in more patients and garnered media attention (Keshavjee's mother still diligently keeps a scrapbook of newspaper clippings). And, as in the 1980s, it has brought researchers back to Toronto to learn from the best.
SITTING IN A glass dome on an operating table at the MARS Centre is a pair of pink, pert lungs from a pig breathing on their own.
This is Shaf Keshavjee's baby. Not the lungs per se, but the complicated mechanism that is keeping them breathing outside a living body.
Dubbed the Toronto XVIVO Lung Perfusion System, a fancy name for a Keshavjee-conceived set-up that allows lungs to remain outside the body for six hours – and holds the promise for the organs being able to repair themselves some day.
All morning, scientists at TGH have been teaching surgeons from Columbia University how to use the system. It enables lung transplant surgeons to figure out if a lung is suitable for transplantation. It also restores lungs after harvesting and keeps them alive longer, increasing the pool of donor lungs.
Last month, Keshavjee's team finished a clinical trial involving 22 patients who had received donated lungs treated with the Toronto XVIVO system. The technique could double the number of lung transplants at the hospital.
But in typical Keshavjee style, he had already moved on to another innovation before the XVIVO's success was proven. He and his team had begun looking at the possibility of treating lungs with the gene IL-10, which repairs the organs and strengthens their defences against injuries caused by swelling and the release of inflammatory enzymes.
"It's kind of like preventative medicine for our lungs," says Keshavjee, who notes that tests on rats have been very promising.
With one success story after another, Keshavjee concedes that there is a lot of pressure on him. Especially as hospitals, patients and those ever-important donors keep asking: Now what? What else you can do?
Keshavjee has some ideas that seem far-fetched, but in his mind are completely realistic.
He foresees the creation of an organ repair centre where organs would be "optimized" before transplants. Further down the road, there's the possibility that injured lungs could be taken out, repaired and then put back into a patient's body.
With Keshavjee's batting average so far, we can expect more life-saving innovations from his team.
Yet the pioneering surgeon is humble about what he's accomplished. "I just think about the work that needs to gets done," he says. "And then I have been lucky, because it just happens to work out."
Toronto Star