Surgical management of bronchial stumps in lobar lung transplantation

Lobar graft evaluation in cadaveric lobar lung redo transplantation after living-donor lobar lung transplantation: a case report

BACKGROUND

Lung transplantation is a vital option for patients with end-stage lung disease. However, it faces a significant challenge due to the shortage of compatible donors, which particularly affects individuals with small chest cavities and pediatric patients. The novel approach of cadaveric lobar lung transplantation is a promising solution to alleviate the donor shortage crisis. Both the mid-term and long-term outcomes of lobar lung transplantation are comparable to those of standard lung transplantation. However, patients undergoing lobar lung transplantation reported a significantly higher rate of primary graft dysfunction compared to patients undergoing standard lung transplantation. Therefore, careful donor selection is critical to improve outcomes after lobar transplantation. However, no established method exists to evaluate each lung lobar graft of deceased donors. This case report describes a case of cadaveric lobar lung transplantation to overcome size mismatch and donor shortage, with particular emphasis on lobar graft evaluation.

CASE PRESENTATION

A 39-year-old woman with scleroderma-related respiratory failure was listed for deceased donor lung transplantation due to a rapidly progressing disease. Faced with a long waiting list and impending mortality, she underwent bilateral living-donor lobar lung transplantation donated by her relatives. Post-transplant complications included progressive pulmonary vein obstruction and pleural effusion, which ultimately required retransplantation. An oversized donor with pneumonia in the bilateral lower lobes was allocated. Lung ultrasound was used to evaluate each lung lobar graft during procurement. The right upper and middle lobes and left upper lobe were confirmed to be transplantable, and lobar lung redo transplantation was performed. The patient's post-transplant course was uneventful, and she was discharged home and returned to her daily activities.

CONCLUSIONS

This case highlights the clinical impact of cadaveric lobar lung transplantation as a feasible and effective strategy to overcome the shortage of donor lungs, especially in patients with small thoracic cavities. By establishing donor lung evaluation techniques and overcoming anatomical and logistical challenges, cadaveric lobar lung transplantation can significantly expand the donor pool and offer hope to those previously considered ineligible for transplantation.

Lobar Lung Transplantation: A Single-Center 10-Year Experience

BACKGROUND

The shortage of donors for lung transplants is the main limitation of the preceding. Lobar transplantation is an alternative especially useful in patients with short stature and small thoracic cavities. The aim of this study was to perform a descriptive analysis of Portuguese patients who underwent lobar lung transplantation.

METHODS

A retrospective study was conducted, and patients submitted to lobar lung transplantation from January 2012 to December 2023 were evaluated. A descriptive analysis was made, including demographic data, lung diseases, waiting list dynamics, pre-transplant evaluations, and post-transplant outcomes.

RESULTS

Sixteen lobar transplants were performed with a predominance of female patients and a median age of 47 years. Most patients had interstitial lung disease or bronchiectasis either due to cystic fibrosis or non-cystic fibrosis. The median predicted total lung capacity (pTLC) ratio was 0.73. The median waiting list time was 6 months with 9 urgent transplants and 1 emergent lobar retransplant. Extracorporeal membrane oxygenation (ECMO) was used in pre-, intra-, and postoperative periods. Most transplanted lobes were the median lobe (ML) + right upper lobe (RUL) and left upper lobe (LUL). The median length of stay was 58 days, with complications such as PDG grade 3, bronchial tree ischemia, and concentrical stenosis of bronchial anastomosis. Six patients died in this period, 1 in the immediate postoperative period and 5 during the post-transplant hospitalization, with a median survival of 20.7 months and a 1-year and 5-year survival rate of 60%.

CONCLUSION

Our results show a population with an increased waiting list converging in many urgent cases, with an early mortality and high primary graft dysfunction rate. Nevertheless, mid- and long-term survival are promising.

Various combinations of living and deceased donors for lung retransplantation-a single institutional retrospective study

OBJECTIVES

Lung retransplantation has been performed as a treatment option mainly for chronic lung allograft dysfunction; however, the outcomes of lung retransplantation have been reported to be worse than those of primary lung transplantation. Because of the scarcity of deceased donors in our country, our lung transplant experience includes both living and deceased donors. Therefore, we have experienced lung retransplantation cases with various combinations of living and deceased donors. The aim of this study was to explore technical pitfalls and outcomes of lung retransplantation in this unique environment.

METHODS

We performed 311 lung transplantation procedures between April 2002 and October 2022. Eight lung retransplantation cases (2.6%) were analysed retrospectively.

RESULTS

At lung retransplantation, the age of the recipient patients ranged from 11 to 61 years (median, 33 years). The combinations of donor sources (primary lung transplantation/lung retransplantation) were as follows: 2 living/living, 2 deceased/living, 3 living/deceased and 1 deceased/deceased. Seven of 8 patients received lung retransplantation for chronic lung allograft dysfunction. Hospital death occurred in 2 patients (25.0%). The 1-, 3- and 5-year survival rates after lung retransplantation (n = 8) were 75.0%, 75.0% and 75.0%, respectively, while those after primary lung transplantation (n = 303) were 92.8%, 83.4% and 76.4%, respectively (P = 0.162).

CONCLUSIONS

Lung retransplantation with various combinations of living and deceased donors is a technically difficult but feasible procedure with acceptable outcomes.

Short-Term Outcomes of Fiberoptic Bronchoscopy-guided Resection and Anastomosis Control in Thoracic Surgery

BACKGROUND

In thoracic surgery practice, bronchial closure and anastomosis are relatively easy in technical terms; however, it is also the procedure that is most open to the development of complications with high morbidity. This study aimed to investigate the effect of simultaneous evaluation of bronchial closure under fiberoptic bronchoscopy guidance during lung resection on the development of complications.

MATERIALS AND METHODS

Patients aged over 18 years who underwent elective lung resection in our clinic between 2017 and 2021 were included in the study. Postoperative complications were recorded and statistically analyzed.

RESULTS

The mean age of the patients was 61.4±10.4 years, and 267 patients were male (75.4%) and 87 (24.6%) were female. Thoracotomy was performed in 258 (72.9%) patients and lung resection with the video-assisted thoracoscopic surgery technique in 96 (27.1%) patients. During the follow-up, complications were observed during the first 30 days in 78 (22.0%) of the patients and later in 9 (2.5%). Surgical mortality occurred in 11 patients (3.1%), and the rate of readmission to the intensive care unit was 5.6% (n=20).

CONCLUSION

We consider that the control of the resection line with the active use of fiberoptic bronchoscopy during surgery is important for the prevention of the development of bronchial morbidity. Complications in the early period can be reduced by ensuring that the remaining bronchus is not narrowed, there are no residual stump structures that may disrupt the bronchial line, such as cartilage, and bronchial washing is frequently undertaken.

Living-donor Segmental Lung Transplantation for Pediatric Patients

OBJECTIVE

The preset study evaluated the outcome of living-donor segmental lung transplantation for pediatric patients.

METHODS

Between August 2009 and May 2021, we performed living-donor segmental lung transplantation in 6 critically ill pediatric patients, including 1 patient on a ventilator alone and another patient on a ventilator and extracorporeal membrane oxygenation (ECMO). There were 4 male and 2 female patients, with a median age of 7 years (range, 4-15 years) and a median height of 112.7 cm (range, 95-125.2 cm). The diagnoses included complications of allogeneic hematopoietic stem cell transplantation (n = 4) and pulmonary fibrosis (n = 2). All patients received bilateral lung transplantation under cardiopulmonary bypass. A basal segment and a lower lobe were implanted in 3 patients, and a basal segment and an S6 segment were implanted in the other 3 patients. In 2 patients, the right S6 segmental graft was horizontally rotated 180° and implanted as the left lung.

RESULTS

Among the 9 segmental grafts implanted, 7 functioned well after reperfusion. Two rotated S6 segmental grafts became congestive, with 1 requiring graft extraction and the other venous repair, which was successful. There was 1 hospital death (14 days) due to sepsis and 1 late death (9 years) due to leukoencephalopathy. The remaining 4 patients are currently alive at 9 months, 10 months, 1.3 years, and 1.9 years.

CONCLUSIONS

Living-donor segmental lung transplantation was a technically difficult but feasible procedure with acceptable outcomes for small pediatric patients with chest cavities that were too small for adult lower lobe implantation.

Living-donor lobar lung transplantation

Living-donor lobar lung transplantation (LDLLT) has become an important life-saving option for patients with severe respiratory disorders, since it was developed by a group in the University of Southern California in 1993 and introduced in Japan in 1998 in order to address the current severe shortage of brain-dead donor organs. Although LDLLT candidates were basically limited to critically ill patients who would require hospitalization, the long-term use of steroids, and/or mechanical respiratory support prior to transplantation, LDLLT provided good post-transplant outcomes, comparable to brain-dead donor lung transplantation in the early and late phases. In Kyoto University, the 5- and 10-year survival rates after LDLLT were reported to be 79.0% and 64.6%, respectively. LDLLT should be performed under appropriate circumstances, considering the inherent risk to the living donor. In our transplant program, all living donors returned to their previous social lives without any major complications, and living-donor surgery was associated with a morbidity rate of <15%. Both functional and anatomical size matching were preoperatively performed between the living-donor lobar grafts and recipients. Precise size matching before surgery could provide a favorable pulmonary function and exercise capacity after LDLLT. Various transplant procedures have recently been developed in LDLLT in order to deal with the issue of graft size mismatching in recipients, and favorable post-transplant outcomes have been observed. Native upper lobe-sparing and/or right-to-left inverted transplantation have been performed for undersized grafts, while single-lobe transplantation has been employed with or without contralateral pneumonectomy and/or delayed chest closure for oversized grafts.

Impacts of single nucleotide polymorphisms in Fc gamma receptor IIA (rs1801274) on lung transplant outcomes among Japanese lung transplant recipients

This study aimed to analyze the influences of single nucleotide polymorphisms (SNPs) in Fc gamma receptor IIA (FCGR2A) on postoperative outcomes after lung transplantation (LTx). We enrolled 191 lung transplant recipients (80 undergoing living-donor lobar lung transplants [LDLLTs] and 111 undergoing deceased-donor lung transplants [DDLTs]) in this study. We identified SNPs in FCGR2A (131 histidine [H] or arginine [R]; rs1801274) and reviewed the infectious complication-free survival after ICU discharge. The SNPs in FCGR2A comprised H/H (n=53), H/R (n=24), and R/R (n=3) in LDLLT, and H/H (n=67), H/R (n=42), and R/R (n=2) in DDLT. Recipients with H/H (H/H group) and those with H/R or R/R (R group) were compared in the analyses of infectious complications. In multivariate analyses, the R group of SNPs in FCGR2A was associated with pneumonia-free survival (HR: 2.52 [95% confidence interval {CI}: 1.35-4.71], p=0.004), fungal infection-free survival (HR: 2.50 [95% CI: 1.07-5.84], p=0.035), and cytomegalovirus infection-free survival (HR: 2.24 [95% CI: 1.07-4.69], p=0.032) in LDLLT but it was not associated with infectious complication-free survival in DDLT. Therefore, in LDLLT, more attention to infectious complications might need to be paid for LTx recipients with H/R or R/R than for those with H/H.

Graft reduction surgery is associated with poorer outcome after lung transplantation: a single-centre propensity score-matched analysis

OBJECTIVES

Implanted lung volume-reduction surgery due to donor/recipient size mismatch could affect both lung function and survival. We examined the outcomes of lung volume-reduction procedures post-lung transplant.

METHODS

We retrospectively reviewed 366 consecutive adult lung transplants carried out between January 2014 and December 2018 at one single centre. Patients were divided into either a non-reduced-size lung transplant or a reduced-size lung transplant (RT) group. To adjust for covariates, a propensity score analysis was performed. Survival was estimated using the Kaplan-Meier method. Differences were considered significant with P-values <0.05.

RESULTS

In the RT group, 45 patients (12.3%) had some type of graft reduction surgery: 31 (68.9%) patients had pulmonary lobectomies and 14 (31.1%) wedge resections. Of the total cohort, 30 patients (8.2%) were prioritized, 23% of whom required graft reduction surgery. The propensity score analysis matched 41 patients in each group. In the RT group, there was an increased need for cardiopulmonary bypass (P = 0.017) during surgery and extracorporeal membrane oxygenation (P = 0.025) after lung transplant. Furthermore, the median length of mechanical ventilation was higher (P = 0.008), and lung function at discharge, 3 and 6 months post-lung transplant was significantly lower in the RT group (P < 0.05). Survival analysis demonstrated a significantly poorer overall outcome at 1, 3 and 5 years post-lung transplantation in patients with a reduced graft (P = 0.007), while the 1-year conditional survival was also worse in this group (P = 0.025).

CONCLUSIONS

Graft reduction surgery in lung transplant recipients is associated with lower pulmonary function and poorer overall survival. However, it does allow transplantation in prioritized recipients for whom it might otherwise be impossible to find an organ of suitable size.

Comparison of de novo donor-specific antibodies between living and cadaveric lung transplantation

BACKGROUND

Despite growing interest in donor-specific antibodies (DSAs) and antibody-mediated rejection (AMR) in lung transplantation (LTx), no study evaluating the outcomes in recipients with de novo DSAs (dnDSAs) in living-donor lobar LTx (LDLLT) exists. We compared various characteristics of DSAs in LDLLT with those in cadaveric LTx (CLT) based on prospectively collected data.

METHODS

Between October 2009 and September 2019, 211 recipients underwent LTx (128 CLTs and 83 LDLLTs). We reviewed 108 CLTs and 74 LDLLTs to determine the characteristics and clinical impact of dnDSAs. Eighteen data-deficient cases, 7 cases with preformed DSAs, and 4 re-transplants were excluded.

RESULTS

There were significant differences between CLT and LDLLT patients in age, primary disease, ischemic time, and number of human leukocyte antigen mismatches per donor. The dnDSA incidence in LDLLT (6.8%) was significantly lower than that in CLT (19.4%, p = 0.02). The dnDSAs appeared later in LDLLT (mean 1,256 days) than in CLT (mean 196 days, p = 0.003). According to Cox models analyzed using dnDSA as a time-dependent covariate, dnDSA positivity was significantly associated with a poor overall survival (OS; hazard ratio [HR] 3.46, 95% confidence interval [CI] 1.59-7.57, p = 0.002) and poor CLAD-free survival in case of CLT (HR: 2.23, 95% CI: 1.08-4.63, p = 0.003). However, no such significant associations were noted in case of LDLLT.

CONCLUSIONS

The dnDSA occurrence was significantly lower and later in LDLLT than in CLT. Furthermore, dnDSA-positivity was significantly associated with worse OS and CLAD-free survival after CLT but not after LDLLT.

Efficacy of three-dimensional computed tomography volumetry for recipients in downsizing oversized grafts in brain-dead donor lung transplantation

Objective

Brain-dead donor lung transplantation frequently requires reduction in the size of oversized lung grafts for patients with a small chest cavity. We focused on the role of three-dimensional computed tomography (3D-CT) volumetry for recipients on downsizing oversized lung grafts.

Methods

We performed 53 brain-dead donor bilateral lung transplantations, including 15 lobar lung transplants (Lobar group) and 38 standard lung transplants with full-sized grafts (Full group), between December 2010 and December 2018. Recipient chest volume before transplantation was measured using 3D-CT volumetry, and donor lung volume was evaluated by predicted total lung capacity. Post-transplant outcomes and pulmonary function were retrospectively compared between the groups.

Results

The ratio of the recipient chest volume to the donor lung volume was significantly lower in the Lobar group (0.42 ± 0.15) than in the Full group (0.77 ± 0.30, P < 0.01). The calculated size matching between the donor and recipient after downsizing the grafts was significantly correlated to the ratio of the recipient chest volume to the donor lung volume (Spearman r = 0.69; P < 0.01). Early post-transplant outcomes did not significantly differ between the groups. Although the Full group showed slightly better pulmonary function after transplantation, the 1-, 3-, and 5-year overall survival rates were similar to the Lobar group (100%, 93%, and 81% in the Lobar group vs. 92%, 78%, and 70% in the Full group; P = 0.50).

Conclusions

Brain-dead donor lobar lung transplantation showed favorable post-transplant outcomes. The assessment of recipient chest cavity volume using 3D-CT volumetry may help surgeons precisely downsize oversized lung grafts prior to transplantation.

Postoperative outcomes of lung transplant recipients with preformed donor-specific antibodies

OBJECTIVES

Few studies have evaluated the outcomes of lung transplantation (LTx) in recipients with preformed donor-specific antibodies (DSAs). This study investigated the postoperative changes in preformed DSAs based on prospectively collected data of DSAs, and the influences of preformed DSAs on postoperative outcomes among LTx recipients.

METHODS

Between July 2010 and December 2019, 216 recipients underwent LTx (81 living-donor lobar lung transplants and 135 deceased-donor lung transplants). We reviewed 8 cases with preformed DSAs to determine postoperative changes in DSAs and compared postoperative outcomes between recipients with and without DSAs.

RESULTS

The preoperative mean fluorescence intensity of preformed DSAs ranged from 1141 to 14 695. Two recipients experienced antibody-mediated rejection within 2 weeks after LTx. DSAs disappeared in 7 recipients; however, 1 recipient experienced the relapse of DSAs and died from chronic lung allograft syndrome (CLAD), whereas 1 recipient had persisting DSAs within the study period and died from CLAD. Neither overall survival (OS) nor CLAD-free survival was significantly different between recipients with and without DSAs (P = 0.26 and P = 0.17, respectively). However, both OS and CLAD-free survival were significantly lower in recipients with DSAs against HLA class II than in those without these antibodies {5-year OS: 25.0% [95% confidence interval (CI): 0.9-66.5%] vs 72.1% (95% CI: 63.8-78.9%), P = 0.030 and 5-year CLAD-free survival: 26.7% (95% CI: 1.0-68.6%) vs 73.7% (95% CI: 66.5-79.5%), P = 0.002}.

CONCLUSIONS

Prognosis in recipients experiencing the relapse of preformed DSAs and those with persisting DSAs may be poor. The recipients with anti-HLA class II preformed DSAs had a significantly worse prognosis.

Protective Effects of a Hydrogen-Rich Preservation Solution in a Canine Lung Transplantation Model

BACKGROUND

Molecular hydrogen (H₂) has protective effects against ischemia-reperfusion injury in various organs. Because they are easier to transport and safer to use than inhaled H₂, H₂-rich solutions are suitable for organ preservation. In this study, we examined the protective effects of an H₂-rich solution for lung preservation in a canine left lung transplantation (LTx) model.

METHODS

Ten beagles underwent orthotopic left LTx after 23 hours of cold ischemia followed by reperfusion for 4 hours. Forty-five minutes after reperfusion, the right main pulmonary artery was clamped to evaluate the function of the implanted graft. The beagles were divided into two groups: control group (n = 5), and H₂ group (n = 5). In the control group, the donor lungs were flushed and immersed during cold preservation at 4°C using ET-Kyoto solution, and in the H₂ group, these were flushed and immersed using H₂-rich ET-Kyoto solution. Physiologic assessments were performed during reperfusion. After reperfusion, the wet-to-dry ratios were determined, and histology examinations were performed.

RESULTS

Significantly higher partial pressure of arterial oxygen and significantly lower partial pressure of carbon dioxide were observed in the H₂ group than in the control group (P = .045 and P < .001, respectively). The wet-to-dry ratio was significantly lower in the H₂ group than in the control group (P = .032). Moreover, in histology examination, less lung injury and fewer apoptotic cells were observed in the H₂ group (P < .001 and P < .001, respectively).

CONCLUSIONS

Our results demonstrated that the H₂-rich preservation solution attenuated ischemia-reperfusion injury in a canine left LTx model.

Backtable bronchoplasty for donor tracheal bronchus in lung transplantation

The management of a tracheal bronchus in lung transplantation is poorly studied and ill-defined. We report a case of lung transplantation performed using a donor right lung graft with an apical tracheal bronchus and propose a novel anastomosis technique for this procedure. The neo-upper lobe bronchus created by suturing the apical tracheal bronchus and the upper lobe bronchus of the donor was anastomosed to the upper lobe bronchus of the recipient in a double-barrel fashion. A follow-up at 19 months demonstrated no stenosis of the anastomosis. The advantages and potential disadvantages of this procedure are discussed.

Diameter of the dilated main pulmonary artery in patients with pulmonary hypertension decreases after lung transplantation

PURPOSE

The pulmonary artery (PA) in patients with pulmonary hypertension (PH) becomes dilated. We analyzed the postoperative changes of the main PA after lung transplantation (LuTx).

METHODS

The subjects of this retrospective study were 68 LuTx recipients, divided into a PH group (n = 36) and a non-PH group (n = 32), based on preoperative right heart catheterization findings. The PA diameter was measured on chest computed tomography. We evaluated the correlation between the mean pulmonary arterial pressure (mPAP) and the main PA diameter and compared the main PA diameters before and 3 months after LuTx.

RESULTS

The main PA diameter was significantly correlated with the mPAP (r = 0.423, P < 0.001). Preoperatively, the mean main PA diameter in the PH group was significantly greater than that in the non-PH group. However, by 3 months after LuTx, the main PA diameter in the PH group had decreased significantly from 32.4 ± 6.7 to 26.9 ± 4.8 mm (P < 0.001), while that in the non-PH group had decreased minimally from 28.3 ± 4.9 to 26.4 ± 4.6 mm (P < 0.001), resulting in no significant difference in postoperative main PA diameters between the two groups.

CONCLUSIONS

The main PA diameter in recipients with PH was enlarged and correlated with the mPAP. The dilated main PA diameter in PH patients decreased shortly after LuTx.