From kings to keyholes: surgical innovation in organ transplantation Written by Alan Barker, Freelance Writer, British Science Festival Organ Transplantation has come a long way in 50 years. Pankaj Chandak, recipient of the Charles Darwin Award Lecture for Agricultural, Biological and Medical Sciences at this year’s British Science Festival, is at the cutting edge – literally. He gave Alan Barker a glimpse of the future. Your talk is called “From ‘Kings to Keyholes’. Tell us about that story. I’m a transplant surgeon in training and currently doing a PhD at Guy’s and St Thomas and Great Ormond Street Hospitals and King’s College London. My work focuses on trying to overcome immunological and anatomical barriers to complex transplantation. For example, imagine a small child who desperately needs a kidney transplant, and their mum or dad is the donor. Imagine trying to fit that adult-sized kidney into a small baby’s abdomen. Not only is size discrepancy a problem but the child may also have anatomical problems with their blood vessels making stitching the donor kidney in, difficult. In addition, the childmight have antibodies against that donor too, which makes crossing the immunological barrier difficult. So this isThat’s probably the most difficult type of transplant we have to do on many levels. So how do you make it work? Essentially, I’m going to talk about three aspects of that problem, time permitting. First, I’m going to briefly chart the journey of how scientific surgery has evolved generally. For example, my whole surgical team was involved in the Netflix series, The Crown – we performed that lung operation on the King in episode 1. I got the director, Stephen Daldry, to donate that silicon body to our university medical school museum at Guy’s, and hopefully I will show the large cut surgeons would have to make to remove organs in the 1950’s. And that will show how surgery has progressed since then to doing minimally invasive surgery, keyhole surgery and indeed robotics. Infact we did the UK’s first robotic kidney transplant in September last year led by my supervisor, Prof Nizam Mamode with Prof Prajal Modi from India who has the largest experience of robotic transplantation worldwide. The second aspect is 3D printing. I centred my research on using a 3D printer to create pre-operative models of the parent’s kidney and the baby’s abdomen, so that you can work with an exact morphological model to plan very complex surgery and try to de-risk it as much as possible before the child is even on the operating table. And the last aspect is machine perfusion of organs and how we can potentially use this technology to manipulate organs before we do a transplant, to try and improve them or put drugs into them. Which means? Putting warm, oxygenated blood based fluid into an organ using a machine ex vivo (outside the human body). If a kidney looks full of blood on the machine, it’s well perfused. And you’re trying to perfuse kidneys mechanically? That’s right. We often get organs that aren’t deemed suitable for transplantation: they may be from elderly donors, or the kidney does not flush properly at the time of donor retrieval surgery. You can put that organ on a novel bypass machine, and pump warm oxygenated blood into it with nutrients and vitamins, to assess its viability and precondition it prior to transplant – and it’s amazing, you get a kidney producing urine outside the human body on the machine! Well, could we take that further? Can I put drugs into the system and introduce them into the kidney to prevent it rejecting when you do the transplant? If we can do that, we can possibly shift the paradigm away from the patient taking immunosuppressants, towards kidney ex vivo protection. And that means we could attempt to cross immunological barriers due to antibodies indeceased donor transplantation. This may increase the organ donor pool in the future. But – how do you fit an adult kidney into a baby’s abdomen?. Space is an issue. A baby’s kidneys are walnut-sized. The real problem is with children between 10 and 15kg. Normally the donor kidney goes into the pelvis, but with 3D printing we can assess exactly where to put it. We look at size, how we connect the blood vessels, and the best operative approach. Actually, we used the 3D printing idea as a world first with a little girl from Belfast. She was referred to us for a transplant with her father being a donorfather. She was only 10 kilograms. And she came to us after a lot of operations, so her abdomen was quite scarred. So we decided to do the modelling to work out how to do it. And how did it turn out? You’ll have to come to the lecture to find out! . From ‘Kings to Keyholes’ is on Friday 8 September at 14.30. Book tickets on the British Science Festival website.