Dr. Bassam Redwan, FRCP, FACS, is a leading specialist in the field of thoracic surgery and, as a senior consultant at Klinikum Westfalen, plays a central role in the treatment of diseases of the chest. His expertise includes in particular the surgical treatment of lung cancer, bronchovascular reconstructions, tracheal surgery and minimally invasive procedures such as uniportal video-assisted thoracic surgery (VATS). These state-of-the-art procedures enable tumors to be treated gently and precisely at an early stage, which offers patients a faster recovery and a better quality of life.
With over 15 years of experience and more than 50 scientific publications, Dr. Redwan has contributed significantly to the advancement of his field. His membership as a Fellow of the Royal College of Physicians (FRCP) and the American College of Surgeons (FACS) underscores his high professional standards and his recognition by the world's leading specialist societies. Dr. Redwan's specialties include lung cancer surgery as well as procedures for mediastinal masses and lesions of the chest wall, pleura and diaphragm.
His expertise also extends to the use of artificial lung support systems (ECMO), which can be life-saving in critical cases. As a multilingual doctor, fluent in Arabic, English, Spanish and German, he cares for a wide range of patients and is able to take their individual needs and cultural backgrounds fully into account. Dr. Redwan is not only involved in clinical practice, but also as an academic lecturer at various universities, where he passes on his knowledge to the next generation of doctors.
His work at the Lung Cancer Center of the Knappschaft Clinics in Lünen, which is characterized by state-of-the-art equipment and the highest medical standards, enables him to offer patients optimal, multidisciplinary care. This center, which was founded in 2017 and has since been certified by the German Cancer Society, stands for close cooperation between the Clinic for Thoracic Surgery, the Pneumology Department and other specialized partners. With his commitment and passion for thoracic surgery, he makes a decisive contribution to offering patients with complex chest diseases new perspectives and innovative treatment options.
In an interview with the experienced thoracic specialist, the editors of the Leading Medicine Guide were able to find out more about the artificial lung replacement procedure in the context of lung operations.
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Lung diseases are among the most common and serious health problems worldwide. They range from chronic complaints such as asthma and COPD to life-threatening conditions such as lung cancer or acute lung failure. What many people don't know: Thanks to modern medicine, there are now innovative approaches that offer hope, even if the patient's own lungs can no longer adequately fulfill their function. Lung replacement procedures, such as extracorporeal membrane oxygenation (ECMO), open up new perspectives for patients with severe lung damage. These highly developed technologies can not only save lives, but also provide time for healing processes or transitions to other forms of therapy.
A lung replacement procedure, such as extracorporeal membrane oxygenation (ECMO), is a medical technology that temporarily takes over the function of the lungs when they are no longer able to transport sufficient oxygen into the blood or remove carbon dioxide from the body.
“The concept of the lung replacement procedure is based on the principle of nature. This is because every expectant mother also functions as an artificial lung for the unborn child. A child cannot breathe with its lungs in the womb because it is under water. And so the most natural artificial lung is the umbilical cord. The child also produces so-called waste products such as carbon dioxide, and the blood that is low in oxygen and high in carbon dioxide is returned to the mother via the umbilical cord vein. She takes over the exchange in her body via her lungs and returns oxygen-rich blood to the child via the umbilical artery. The concept is therefore very simple. Translating this for medical use began as early as the 1930s, but the idea was pursued more intensively on a larger scale from the 1950s onwards. What is not yet possible today is the complete outpatient treatment of patients with end-stage lung failure with an implantable artificial lung, as is otherwise known from patients with artificial hearts, although this will certainly come in the future. In the lung replacement procedure used today, blood is taken from the patient, usually via a vein in the groin using an inserted cannula. The blood is enriched with oxygen in the machine through an artificial membrane and at the same time excess carbon dioxide is removed before it is pumped back into the body. This lung replacement procedure, initially known as ECMO (extracorporeal membrane oxygenation), is now referred to by the generic term ECLS (extracorporeal lung support),” explains Dr. Redwan.
VV-ECMO (veno-venous ECMO) and VA-ECMO (veno-arterial ECMO) are forms of extracorporeal membrane oxygenation that are used in cases of severe lung or heart failure. VV-ECMO exclusively supports lung function by extracting venous blood, enriching it with oxygen and returning it to a vein. It is mainly used in cases of severe lung failure such as ARDS, when the heart is still working adequately. VA-ECMO, on the other hand, takes over both lung and heart function. Here, blood is taken from a vein, oxygenated and then pumped back into an artery. It is used in cases of severe heart failure or cardiogenic shock, as it also stabilizes the circulation. Whether VV- or VA-ECMO is used depends on whether only the lungs or also the heart require support.
The duration of treatment varies depending on the cause and severity of the disease. While in surgical procedures the procedure is often only used for the duration of the operation, in cases of severe lung failure it can take several days to weeks to give the lungs time to regenerate or to bridge the gap until a possible transplant. Once lung function has stabilized, the patient is gradually weaned off the machine. During this process, the support of the device is reduced to test the lungs' own performance.
A lung replacement procedure such as extracorporeal membrane oxygenation (ECMO) is used for patients whose lung function is so severely restricted that they are no longer able to supply the body with sufficient oxygen or remove excess carbon dioxide.
“Patients who are eligible for a lung replacement procedure can be divided into two groups. On the one hand, there is the group of patients with classic lung failure, known as acute respiratory distress syndrome (ARDS), which occurs more frequently in the colder months of the year and is ultimately an inflammation of the lungs. A lung replacement procedure similar to dialysis for kidney failure helps here. The second group of patients includes people with lungs that are so severely diseased that they are already on a waiting list for an organ transplant and their health deteriorates to such an extent that artificial ventilation becomes necessary. However, this can be harmful in the long term, as it places additional strain on the lung tissue and causes further damage. An example of this is patients with severe pulmonary hyperinflation (emphysema), where the so-called respiratory pump fails and artificial ventilation is then an option. Artificial ventilation is not beneficial for such patients, so we try to avoid long-term artificial ventilation and in some cases even use the lung replacement procedure while the patient is awake,” says Dr. Redwan, explaining the procedure in more detail:
“For patients with classic lung failure, one session of the lung replacement procedure is usually sufficient. As a rule, these patients are already in the intensive care unit, where the artificial lung is inserted for regeneration - a process that can take several weeks to months. For example, a young patient aged 18 was treated with a lung replacement procedure in our intensive care unit for 53 days and was able to fully regenerate. The patient's age plays an important role here - a long-term lung replacement procedure is often less suitable for people over 70, as previous illnesses, a reduced ability to regenerate and higher complication rates reduce the chances of success."
Patients with advanced irreversible lung diseases, who have no prospect of recovery even with ECMO, or those with severe concomitant diseases, such as uncontrolled infections, end-stage malignancies or severe multi-organ failure, generally do not benefit from this procedure. The risk of complications such as bleeding, thrombosis, infections or mechanical problems with the device must also be taken into account when selecting patients.
The availability of artificial lung replacement procedures, in particular extracorporeal membrane oxygenation (ECMO), has revolutionized thoracic surgery by making the performance of high-risk procedures considerably safer and more successful.
“The lung replacement procedure is used as part of complex thoracic surgical interventions, which is also my focus at the clinic in Lünen. When using the lung replacement procedure, a distinction is made between functional and technical reasons. In patients with impaired lung function, for example if the left lung had to be removed due to a tumor operation and the patient develops a new tumor in the right lung years later. Due to the absence of the second lung, an operation to remove the lung tumor is only possible using a lung replacement procedure,” explains Dr. Redwan.
In thoracic surgery, there are numerous situations in which lung function cannot be temporarily maintained during a procedure, such as the removal of large tumors, bronchovascular reconstructions or tracheal surgery. In the past, such procedures were associated with a high risk of intraoperative complications such as severe hypoxia (lack of oxygen) or cardiovascular instability.
“Patients with emphysema as a result of chronic obstructive pulmonary disease (COPD) also benefit from the lung replacement procedure. It is important to know that there is normally no problem when breathing in, as the airways expand. Chronic inflammation causes the airways to become narrower because there is increased tissue formation in the airways. As a result, a certain amount of air remains in the lungs with every breath. A person breathes about 16 times per minute and inhales about half a liter of air per breath. If some of the air remains in the lungs each time, this gradually increases and leads to significant over-inflation of the lung tissue (pulmonary emphysema). If these sick people then require lung surgery, whether due to cancer or because lung volume reduction surgery has to be performed, and they are put on conventional ventilation, this could lead to additional damage to the lungs. The use of a lung replacement procedure creates a much more relaxed atmosphere during the necessary operation because the lung to be ventilated does not have to be ventilated too strongly or not at all if the patient is operated on almost awake. Another advantage of the lung replacement procedure is of a technical nature, for example when we have to access the branch of the trachea during extensive cancer surgery. So if something is removed here, there is no ventilation at that moment. Of course, a breathing tube can also be used here. Personally, I am a 'lazy' surgeon and would like to have as few tubes as possible in my operating field so that I can work on the patient in peace and have as few restless moments as possible during the procedure,” Dr. Redwan explains.
In recent years, several technical developments in lung replacement procedures have considerably improved intraoperative application and significantly increased patient safety.
“One of the most significant recent innovations is the introduction of the twin-port cannula. This technology enables efficient gas exchange and optimized blood circulation via a single vascular access. A special cannula is inserted into the body: either into the neck or into the groin. The blood is drawn in via lateral openings and pumped to the artificial membrane, where the gas exchange takes place outside the body. The blood is then returned to the same vessel via the tip of the cannula. This eliminates the need for a second cannula, as is usual in the classic ECMO procedure. Twin-port technology therefore also improves safety and comfort for patients, and we can operate much more easily and even achieve oxygenation, thanks to so-called apnoeic oxygenation, which makes it possible to maintain the oxygen content in the blood,” describes Dr. Redwan.
An interdisciplinary panel of experts consults on the use of extracorporeal membrane oxygenation (ECMO) in critically ill patients. This team typically consists of intensive care physicians, cardiologists, thoracic and vascular surgeons, anaesthetists, cardiotechnicians, nurses and physiotherapists who specialize in ECMO.
The integration of portable ECMO devices into surgical and intensive care workflows has also increased flexibility in the operating room. These devices can be adapted to the specific requirements of a surgical procedure, which is particularly advantageous in complex thoracic operations. The improved manageability of the systems allows the surgical team to concentrate more on the procedure itself, while the lung support works reliably in the background.
The safe use of cannulas requires precise technique and experience, as improper handling can lead to complications. “It can happen that vessels are damaged when using the cannulas, but this can be avoided if you follow the rules. This is the classic Seldinger puncture, which is used for venous access in surgery, anesthesia and interventional radiology. There is a procedure-specific risk of blood clot formation, which can be reduced by administering blood thinners (heparin). Bleeding and inflammatory reactions can also occur. Due to these possible risks, it is absolutely essential that these procedures are only carried out with a high level of expertise,” emphasizes Dr. Redwan.
The use of lung replacement procedures such as extracorporeal membrane oxygenation (ECMO) not only has a direct impact on the course of the operation, but also influences the post-operative rehabilitation and long-term prognosis of patients with serious lung diseases.
“If the lung replacement procedure is used during an operation, the prognosis is very good, also from my own experience with lung volume reduction surgery. This is because possible risks of mechanical ventilation can be reduced and the whole procedure is also much gentler on the patient. Of course, surgical interventions can still be performed without a lung replacement procedure, but the advantages cannot be denied and I am glad to have been introduced to this method early on,” says Dr. Redwan, who would also like to see further improvements:
“It would be great if we could one day manage to insert a completely artificial lung implant, although I don't think we're that far off. There is a drastic shortage of organs - patients sometimes wait five years or more for lungs and unfortunately often die before that. Patients who need a new heart are better off because of all the artificial heart systems. We have an artificial lung in hospital, but the patient can't go home with it. It would be nice if we could support patients with an artificial mobile lung system. Unfortunately, this is not yet possible due to a lack of space, because membranes need space. This is different from the heart, where everything can be kept small and compact. We don't yet know how this can be implemented. However, many studies are underway and I hope to see a positive result before I retire (in about 22 years). But I am positive about this”. We conclude our conversation with this positive outlook.
Thank you very much, Dr. Redwan, for this exciting insight!
