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Cooper broke lung transplant barrier

Cooper broke lung transplant barrier

Joel Cooper, M.D., the revered lung transplant surgeon, rattles off the patient's name and transplant date as if it were yesterday. "Tom Hall. Nov. 7, 1983."

Doctors and their medicine could offer little hope for Hall, a 58-year-old Canadian hardware executive who was dying of a progressive lung disease called pulmonary fibrosis. He lived confined to a wheelchair and tethered to an oxygen tank.

Hall needed a new lung. But at a time when surgeons regularly were transplanting hearts, livers and kidneys, no surgeon successfully had broken the lung transplant barrier.

When Cooper, then head of thoracic surgery at the University of Toronto, told Hall that only 44 lung transplants had been attempted worldwide and none of the patients lived more than a few weeks, Hall eagerly responded, "I'm grateful to have the opportunity to be No. 45," Cooper recalled.

Lung transplant patients who made it through the tedious surgery routinely ran into fatal trouble several weeks later when their airway connections stubbornly refused to heal. Cooper and his co-workers retreated to the lab to find out why. The airway problem was thought to be a sign of organ rejection, but Cooper wasn't so sure.

In a series of experiments, Cooper removed one lung from each of several dogs and then gave the lung back to the same dog from which it came. The airway connections healed normally. But when he gave the dogs prednisone, an anti-rejection drug commonly prescribed in high doses to stem the tide of invading immune cells, the airway connections fell apart.

Prednisone, a steroid, stops the inflammation crucial to wound healing, Cooper noted. When cyclosporin, a more powerful anti-rejection drug, became available in 1983, Cooper demonstrated that it could be substituted for prednisone without the adverse airway effects. With the airway problem solved, Cooper was ready to give lung transplants another try.

So on the night of Nov. 7, 1983, in a surgery led by Cooper, Hall received his transplant. Several weeks later, while Hall was still in the hospital, Cooper got the phone call he had hoped would never come. Hall appeared to have developed an air leak in the new lung --a sign that the airway connection was failing.

"My heart absolutely sank," Cooper recalled. "We had worked for years on that problem and if we were going to lose him, I didn't want it to be from an airway complication. That would have set us back very badly."

When Cooper examined Hall a short time later, he was relieved to find the airway connections intact. A small air pocket had broken on the surface of Hall's transplanted lung, but the condition was not serious.

"It was one of those situations where you are afraid to hope," Cooper said. "You don't allow yourself to imagine that the transplant is going to be successful because you don't want to be too disappointed."

Hall beat the dismal lung transplant odds. He returned to work several months after his surgery and lived for seven active and enjoyable years before dying of kidney failure. Cooper was credited with performing the world's first successful single-lung transplant.

Developing a world-renowned transplant program

Cooper, who now is the Joseph C. Bancroft Professor of Surgery and head of the section of general thoracic surgery, left Toronto in 1988 to establish a lung transplant program at Washington University. Shortly after his arrival in St. Louis, he performed the world's first successful double-lung transplant. The procedure, which involves transplanting two lungs into one patient, offered the first glimmer of hope for cystic fibrosis patients who suffer from infections in both lungs.

Today, many patients who otherwise would have died from end-stage lung diseases are benefiting from lung transplants. Last year alone, some 700 patients in the United States received lung transplants. Seventy-six of those surgeries were performed at Barnes and St. Louis Children's hospitals.

Cooper's vision and drive for excellence helped him to create the School of Medicine's world-renowned lung transplant program. The program, now headed by Cooper's colleague Alec Patterson, M.D., professor of surgery, enjoys an unprecedented 94 percent success rate.

Part of the success of the lung transplant program at Washington University is directly due to the program Joel Cooper developed in Toronto, said Patterson, who followed Cooper from Toronto to St. Louis. "Joel is incredibly bright and energetic, and extremely generous with his time and ideas. He recruited top people here and insisted upon having the specially trained staff and facilities crucial to an outstanding program. A less visionary person would not have been as successful."

Surgery helps emphysema patients breathe easier

Cooper's extensive experience with lung transplants recently has led to the early success of a new surgery for patients with severe emphysema. The procedure, called volume reduction surgery, involves removing the most damaged portions of emphysema patients' lungs. Reducing the size of the lungs dramatically improves lung function and helps patients breathe easier.

Cooper performed the first procedure in January 1993. Since then, more than 100 patients have undergone the surgery at Barnes Hospital. The overall improvement in patients' breathing capacity is 65 percent. "For these severely disabled patients, this translates into a marked improvement in the quality of their lives," Cooper said.

Emphysema, most often caused by cigarette smoking, afflicts an estimated 1.6 million Americans. The irreversible disease causes the lungs to loose their elasticity, damaging their ability to expand and relax as a person breathes. Over time, less oxygen gets into the bloodstream, and, to compensate, the lungs enlarge until they fill the chest cavity.

"Emphysema is like breathing in as far as you can and living with your chest in that position for the rest of your life," Cooper said. "That's what happens to these patients -- their lungs are fully expanded and they can barely breathe."

Until now, the only hope for patients with end-stage emphysema was a lung transplant. "Had it not been for the observations made in our transplant program, we would not have had the confidence to think emphysema surgery may be beneficial," Cooper said.

During lung transplants, Cooper found that an emphysema patient's overextended rib cage and flattened diaphragm immediately returned to a more normal configuration following surgery. He also noticed that the severity of emphysema damage often varied from one portion of the lung to another.

But Cooper is quick to caution that the surgery is not a cure for emphysema. "These patients may continue to experience deterioration from emphysema, but if we can reset the clock by two, three, four or five years, maybe more, then we think it will be very worthwhile."

Cooper and his co-workers are continuing follow-up studies on patients who have undergone the surgery. "The bottom line is we're enthusiastic," Cooper said. So far, four patients have died following the surgery. Two were over the age of 70, which has caused Cooper to re-evaluate the criteria for surgery in this age group.

Since Cooper first presented results of the new surgery at a meeting of the American Association for Thoracic Surgery in April 1994, his office has fielded more than 1,000 phone calls from patients interested in learning more about the procedure. Only patients who have quit smoking are considered for the surgery.

Cooper was born and raised in Charleston, W.Va., the son of an orthodox Jewish rabbi. As a teen-ager, Cooper dreamt of becoming a neurosurgeon. He studied pre-med courses at Harvard College and graduated with honors in 1960. He then enrolled in Harvard Medical School, where he initially pursued his interest in neurosurgery. But his enthusiasm was dampened after he saw firsthand the grim prospects for caring for these young patients, many of whom suffered from brain tumors or other devastating neurological conditions.

Cooper retained an interest in surgery and after graduating from Harvard Medical School in 1964, he accepted a surgery internship at Massachusetts General Hospital. The Harvard-affiliated hospital had one of the few respiratory care units in the country, and it was there that Cooper developed an interest in pulmonary physiology and respiratory care.

Under the direction of Hermes Grillo, M.D., a well-known pioneer in surgery of the airway, Cooper conducted research on airway injuries that occur in patients on ventilators. He traced the injury to a rigid cuff around the airway tube. That observation led the pair to develop a soft cuff, a version of which is used today in virtually all endotracheal and tracheostomy tubes.

"He was among the best," said Grillo. "He was a very bright guy. I saw him as a coming star."

In order to get the proper training in thoracic surgery, Cooper trained in Boston and London before settling in Toronto in 1972. After building a successful lung transplant program at the University of Toronto, Cooper said he was ready to move on. He and his wife, Janet, wanted their four sons to be educated in the United States, and the Canadian government's cutbacks in medical research funding were beginning to hurt the university's research program. "And, too, I think I was beginning to coast a little bit and I'm not a coaster. I like a challenge," he said.

"As it turns out, I was able to have my cake and eat it, too," Cooper said. "I've found an extremely supportive environment here. And we have a stronger program here than I ever could have had in Toronto."

Cooper's love for his work appears to have had at least some influence on his oldest son, Josh, who is a fourth-year medical student at Washington University. The younger Cooper, who is trying to decide between a career in internal medicine or surgery, said his father has taught him a lot about caring for patients. "Your involvement and care for patients never ends," said Josh Cooper. "You don't punch out at the end of the day and leave the care of your patients with someone else. My dad is notorious for being on the phone when he's away from the hospital. I think his patients understand how much he cares for them."

Cooper generously credits his wife for playing a leading role in raising their children and providing stability in their household while he spent long hours at the hospital. Even today, he rarely arrives home from work before 9 p.m., which is a problem for someone who also is an avid gardener.

He and Janet have installed floodlights in their backyard, which enable them to enjoy their hobby even at night. "We sometimes plant flowers at two o'clock in the morning. The neighbors think we're a little crazy."

-- Caroline Decker


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