Anterior axillary muscle-sparing thoracotomy for lung transplantation

Nowadays open-chest surgery in the era of fast-track management

In more than a century, approaches to perform thoracic surgical procedures have had profound changes. A milestone of those changes has been the advent of video-assisted techniques which rapidly evolved from minor diagnostic procedures to the performance by video-assisted thoracic surgery (VATS) of almost any major thoracic surgery. Nevertheless, indications remain for open chest procedures along with the fact that thoracotomy techniques have also evolved to minimally invasive ways, far different from the full thoracotomy of the past. This chapter reviews the evolution of open chest techniques and describes in detail present way to perform low invasiveness open chest surgery leading to excellent results through a mild postoperative course. Unsolved issues regarding the comparison of video-assisted and open techniques, particularly in lung cancer surgery are also considered.

Lung transplant

The ICU period is only one time point among many in the complex, multidisciplinary postoperative management required for patient survival and improved QOL. The care required on step-down units and after discharge to home each has unique care aspects that impact successful patient outcomes.

Adult lung transplantation: technical considerations

The technical details of lung transplantation have seen considerable refinement with two decades of experience. Recent efforts to expand the donor pool are an exciting development. The technical details of donor organ procurement and the implantation are discussed here with a note to common pitfalls encountered.

Modified lateral thoracotomy

Lateral thoracotomies include many different variants with a common final pathway, consisting of an intercostal incision. They are the most frequent incisions in daily thoracic procedures. We will describe the lateral muscle-sparing thoracotomy in the Weissmuller's position which is, according to us, the universal thoracotomy. Surgical techniques, indications, pitfalls and tips are described. Discussion and an overview of the literature for this incision are developed.

Muscle-splitting posterolateral thoracotomy: a novel technique

PURPOSE

In an effort to decrease the morbidity of a standard posterolateral thoracotomy, numerous muscle-sparing approaches have been developed. However, these incisions have been limited by the need for excessive muscle retraction with resultant neuropraxia, difficulty with exposure, and postoperative wound seroma. We report our results of a novel muscle-splitting thoracotomy incision, which affords excellent exposure without significant morbidity.

METHODS

We conducted a retrospective chart review of 37 consecutive patients who underwent "muscle-splitting" thoracotomy from June 1997 to June 1998. The technique, which involves a bidirectional spread of the latissimus dorsi and serratus anterior muscles, was performed by the same attending surgeon in all patients.

RESULTS

There were 22 male and 15 female patients, aged 26 to 81 (mean, 58), with a body mass index ranging from 18 to 40 kg/m(2) (mean, 25 kg/m(2)). Procedures included lobectomy/segmentectomy (19), wedge resection (5), pneumonectomy (2), Belsey IV fundoplication (5), Ivor-Lewis esophagogastrectomy (1), T8/T9 thoracic exposure (1), and miscellaneous thoracic cases (4). Operative time ranged from 90 minutes to 420 minutes (mean, 176), which was comparable with similar procedures through a standard incision. No patients required conversion to a muscle-cutting thoracotomy.

CONCLUSIONS

Our technique of muscle-splitting posterolateral thoracotomy appears to provide excellent operative exposure and to avoid problems seen with current muscle-sparing incisions. A prospective, randomized trial to compare this technique with a standard thoracotomy incision would be useful in determining its viability as an alternative thoracic approach.

Minithoracotomy combined with mechanically stapled bronchial and vascular ligation for anatomical lung resection

BACKGROUND

The most appropriate approach to anatomic pulmonary resection has been debated with the advance of minimally invasive techniques and especially the common use of mechanical staplers. Video assisted surgery and muscle-sparing thoracotomy are established options of surgical approach for lung resection. We utilize a combined technique of vertical muscle sparing minithoracotomy and mechanical closure of the hilum structures to accomplish lung resection.

METHODS

From December 1995 through January 2002, 713 patients (mean age, 65 +/- 11, 44.6% male) underwent anatomic pulmonary resection including 64 pneumonectomies, 514 lobectomies, and 135 formal segmental resections. Pulmonary resection was approached though a direct access, vertical, minithoracotomy (< 10 cm), and vascular ligation was performed with port-access endostapling instrumentation. Full mediastinal lymph node sampling was performed for primary lung cancer.

RESULTS

The average operative time was 55 minutes for lobectomy-formal segmentectomy and 62 minutes for pneumonectomy. An average of 3.6 staple applications were utilized to ligate the pulmonary vasculature (n = 2548 for 713 patients). Operative vascular complications included 5 minor intimal fractures, 1 posterior segmental arterial avulsion, and 1 staple misfiring for an adverse event rate during stapler application of 0.27%. Only one conversion to standard thoracotomy was necessary to control bleeding from the pulmonary vein. There were no intraoperative deaths.

CONCLUSIONS

Vertical minithoracotomy is a safe and expedited approach for anatomic lung resection. Direct visualization for dissection and effective pulmonary hilum mechanical closure with staplers were demonstrated. This approach is a reasonable option when a complete video-assisted surgery seems to be hazardous and a full open thoracotomy could represent an additional morbidity.

Critical care aspects of lung transplantation

Lung transplantation currently is the preferred treatment option for a variety of end-stage pulmonary diseases. Remarkable progress has occurred through refinements in technique and improved understanding of transplant immunology and microbiology. As a result, recipients are surviving longer after their transplant. Despite improvements in short- and intermediate-term survival, long-term success with lung transplantation remains limited by chronic allograft rejection, also known as bronchiolitis obliterans syndrome. Despite its long-term limitations, lung transplantation remains the only hope for many with end-stage pulmonary disease, and during the past 20 years, it has become increasingly accepted and used. As a result, clinicians working in an intensive care unit (ICU) are more likely to be exposed to these patients both in the immediate postoperative period as well as throughout their remaining lives. It is thus important that the ICU team have a working knowledge of the common complications, when these complications are most likely to occur, and how best to treat them when they do arise. The main focus of this review is to address the variety of potential graft and life-threatening problems that may occur in lung transplant recipients. Because the ICU is also the most common setting where a potential donor is identified, donor issues will briefly be addressed.

Technical considerations in lung transplantation

The technical aspects of lung transplantation have been refined over the past two decades. Anomalous donor anatomy and suboptimal harvests do not preclude transplantation, but they must be appropriately dealt with to ensure good outcomes. New techniques have been developed to increase the donor pool. Techniques for recipient pneumonectomy and graft implantation have been optimized, and ways of dealing with difficult exposures and anatomic variants have been designed. Novel methods for prevention of ischemia-reperfusion injury have been developed based on experimental studies, but more complete clinical scrutiny is needed to determine their impact.

Bilateral versus single lung transplantation for chronic obstructive pulmonary disease: intermediate-term results

BACKGROUND

There is controversy regarding the transplant procedure of choice in chronic obstructive pulmonary disease. We reviewed our intermediate-term outcomes with single lung transplantation (SLT) versus bilateral lung transplantation (BLT).

METHODS

We retrospectively reviewed 130 patients with chronic obstructive pulmonary disease: 84 underwent SLT, 46 BLT. The mean age was 51.1 +/- 1.2 years for those who underwent BLT and 56.2 +/- 0.7 years for those who underwent SLT (p < 0.0001). Male patients represented 65% of the BLT group and 46% of the SLT group (p = 0.04). Spirometry and 6-minute walk tests were obtained preoperatively and at 3- to 6-month intervals. Posttransplant survival and survival from time of onset of bronchiolitis obliterans syndrome were calculated by Kaplan-Meier method. The mean follow-up was 32.4 months.

RESULTS

The 90-day mortality rate was 13.0% For BLT and 15.5% for SLT (p = 0.71). Actuarial survival rates at 1, 3, and 5 years were 82.6%, 74.6%, and 61.9% for BLT and 72.2%, 63.4%, and 57.4% for SLT; the favorable survival trend with BLT did not achieve statistical significance. There were no differences in preoperative spirometry or 6-minute walk tests. The improvements in forced expiratory volume in one second, forced vital capacity (FVC), and 6 MWT were significantly greater following BLT. The incidence of bronchiolitis obliterans syndrome was 22.4% in SLT and 22.2% in BLT; survival following onset of bronchiolitis obliterans syndrome was similar.

CONCLUSIONS

For patients with chronic obstructive pulmonary disease, BLT is associated with superior lung function, exercise tolerance, and a trend toward enhanced survival. Younger candidates may be best suited for BLT. Given the limited donor lungs, SLT remains the preferred alternative for all other patients.