1
|
Barron JO, Jain N, Mubashir M, Elgharably H, Raymond DP, Schraufnagel DP. Novel Repair of Clamshell Thoracotomy Sternal Dehiscence after Lung Transplant: A Case Report. J Chest Surg 2024; 57:213-216. [PMID: 38221730 DOI: 10.5090/jcs.23.099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 10/31/2023] [Accepted: 11/10/2023] [Indexed: 01/16/2024] Open
Abstract
Bilateral transverse thoracosternotomy, or "clamshell" thoracotomy, can be complicated by dehiscence. A 65-year-old male underwent lung transplantation via clamshell thoracotomy, with subsequent sternal dehiscence on postoperative day 11. Upon repair, the previous sternal wires had pulled through, so a Sternal Talon connected to a Recon Talon was utilized to re-approximate the inferior sternum. On follow-up at 3 months, the patient recovered well. Use of the Sternal Talon provides an effective technique for repairing transverse sternal dehiscence.
Collapse
Affiliation(s)
- John O Barron
- Department of Thoracic and Cardiovascular Surgery, Division of Thoracic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Nethra Jain
- Department of Thoracic and Cardiovascular Surgery, Division of Thoracic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Mujtaba Mubashir
- Department of Thoracic and Cardiovascular Surgery, Division of Thoracic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Haytham Elgharably
- Department of Thoracic and Cardiovascular Surgery, Division of Thoracic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Daniel P Raymond
- Department of Thoracic and Cardiovascular Surgery, Division of Thoracic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Dean P Schraufnagel
- Department of Thoracic and Cardiovascular Surgery, Division of Thoracic Surgery, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
2
|
Park JM, Son J, Kim DH, Son BS. A Comparative Study of a Sternum-Sparing Procedure and Clamshell Incision in Bilateral Lung Transplantation. Yonsei Med J 2023; 64:730-737. [PMID: 37992745 PMCID: PMC10681828 DOI: 10.3349/ymj.2023.0104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 08/08/2023] [Accepted: 08/21/2023] [Indexed: 11/24/2023] Open
Abstract
PURPOSE Clamshell incision offers excellent exposure and access to the pleural spaces and is a standard incision for lung transplantation. However, due to its high sternal complication rate, the clamshell incision is considered a procedure that requires improvement. In this study, we aimed to investigate the outcomes of transverse sternotomy with clamshell incision in comparison to sternum-sparing bilateral anterolateral thoracotomy (BAT). MATERIALS AND METHODS In total, 134 bilateral sequential lung transplants were performed from May 2013 to June 2022. The clamshell incision was used between May 2013 and December 2017, and the BAT was introduced in January 2018. Thirty-four patients underwent clamshell surgery, and 100 patients underwent BAT. We retrospectively compared patient characteristics and perioperative and postoperative outcomes between the two groups. RESULTS The clamshell group required an operation time of 745.18±101.76 min, which was significantly longer than that of the BAT group at 669.90±134.09 min (p=0.003). The mechanical ventilation period after surgery was 17.26±16.04 days in the clamshell group, significantly longer than the 11.35±12.42 days in the BAT group (p=0.028). Intensive care unit stay was also significantly longer in the clamshell group (21.54±15.23 days vs. 15.03±14.28 days; p=0.033). In-hospital mortality rates were 26.5% in the clamshell group and 22.0% in the BAT group. CONCLUSION Less-invasive lung transplantation via sternum-sparing BAT is a safe procedure with low morbidity and favorable outcomes. Preventing sternal instability enables more stable breathing after surgery, earlier weaning from mechanical ventilation, and faster recovery to routine activities.
Collapse
Affiliation(s)
- Jong Myung Park
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
- Transplantation Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Joohyung Son
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
- Transplantation Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Do Hyung Kim
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
- Transplantation Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Bong Soo Son
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
- Transplantation Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.
| |
Collapse
|
3
|
Sunder T, Ramesh Thangaraj P, Kumar Kuppusamy M, Balasubramanian Sriraman K, Selvi and
Srinivasan Yaswanth Kumar C. Lung Transplantation for Pulmonary Artery Hypertension. NEW INSIGHTS ON PULMONARY HYPERTENSION [WORKING TITLE] 2023. [DOI: 10.5772/intechopen.1002961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
This manuscript discusses the role of lung transplantation in patients with pulmonary hypertension. The indications and timing for referral to a transplant unit and timing for wait-listing for lung transplantation are discussed. The type of transplantation—isolated (single or double) lung transplantation and situations when combined heart and double lung transplantation is indicated—will be elaborated. Escalation of medical therapy with the need and timing for bridging therapies such as extracorporeal membrane oxygenation until an appropriate organ becomes available will be discussed. Challenges in the postoperative period, specific to lung transplantation for pulmonary artery hypertension, will be reviewed. The outcomes following lung transplantation will also be considered in greater detail.
Collapse
|
4
|
Jiao W, Yang R, Zhao Y, Ge N, Qiu T, Sun X, Liu Y, Li K, Li Z, Yu W, Qin Y, Liu A. Robot-assisted single lung transplantation. Chin Med J (Engl) 2023; 136:362-364. [PMID: 36989485 PMCID: PMC10106169 DOI: 10.1097/cm9.0000000000002462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Indexed: 03/31/2023] Open
Affiliation(s)
- Wenjie Jiao
- Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266003, China
| | - Ronghua Yang
- Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266003, China
| | - Yandong Zhao
- Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266003, China
| | - Nan Ge
- Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266003, China
| | - Tong Qiu
- Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266003, China
| | - Xiao Sun
- Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266003, China
| | - Yingzhi Liu
- Department of Anaesthetics, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266003, China
| | - Kun Li
- Intensive Care Unit, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266003, China
| | - Zhiqiang Li
- Center of Organ Transplantation, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266003, China
| | - Wencheng Yu
- Department of Respiratory Medicine, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266003, China
| | - Yi Qin
- Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266003, China
| | - Ao Liu
- Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266003, China
| |
Collapse
|
5
|
Abstract
Lung transplantation provides a treatment option for many individuals with advanced lung disease due to cystic fibrosis (CF). Since the first transplants for CF in the 1980s, survival has improved and the opportunity for transplant has expanded to include individuals who previously were not considered candidates for transplant. Criteria to be a transplant candidate vary significantly among transplant programs, highlighting that the engagement in more than one transplant program may be necessary. Individuals with highly resistant CF pathogens, malnutrition, osteoporosis, CF liver disease, and other comorbidities may be suitable candidates for lung transplant, or if needed, multi-organ transplant. The transplant process involves several phases, from discussion of prognosis and referral to a transplant center, to transplant evaluation, to listing, transplant surgery, and care after transplant. While the availability of highly effective CF transmembrane conductance regulator (CFTR) modulators for many individuals with CF has improved lung function and slowed progression to respiratory failure, early discussion regarding transplant as a treatment option and referral to a transplant program are critical to maximizing opportunity and optimizing patient and family experience. The decision to be evaluated for transplant and to list for transplant are distinct, and early referral may provide a treatment option that can be urgently executed if needed. Survival after transplant for CF is improving, to a median survival of approximately 10 years, and most transplant survivors enjoy significant improvement in quality of life.
Collapse
|
6
|
Elgharably H, Javorski MJ, McCurry KR. Bilateral sequential lung transplantation: technical aspects. J Thorac Dis 2022; 13:6564-6575. [PMID: 34992835 PMCID: PMC8662466 DOI: 10.21037/jtd-2021-22] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 06/02/2021] [Indexed: 12/02/2022]
Abstract
The surgical technique for lung transplantation has evolved dramatically over the last three decades. Significant improvements in short term outcomes in the early years of lung transplantation were due, in large part, to techniques developed to reduce airway anastomotic complications in single lung transplantation. Following development of the technique of en bloc double lung transplantation, evolution to the bilateral sequential technique further reduced airway complications for double lung transplantation. More recently, some programs have utilized the en bloc double lung transplant technique with bronchial artery revascularization to aid airway healing and potentially improve short- and long-term outcomes. The experience with bronchial artery revascularization remains limited to a few series, with the technique having not been widely adopted by most lung transplant programs. With the implementation of priority allocations schemes in many countries, patients with higher risk profiles are being prioritized for transplantation which results in more complex procedures in fragile recipients with multiple comorbidities. This includes the increased need for concomitant cardiac procedures as well as performing lung transplantation after prior cardiothoracic surgery. Different surgical approaches have been described for bilateral sequential lung transplantation with or without intra-operative mechanical circulatory support (MCS), such as sternotomy, clamshell (bilateral anterior thoracotomies with transverse sternotomy), and bilateral thoracotomy incisions. Herein, we aim, not only to describe the various surgical approaches for double lung transplantation, but to provide a comprehensive review of other aspects related to the recipient pathology and different anatomical variants as well as handling technical challenges that might be encountered during the procedure.
Collapse
Affiliation(s)
- Haytham Elgharably
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Michael J Javorski
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Kenneth R McCurry
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| |
Collapse
|
7
|
Murala JS, Hanif HM, Peltz M, Cheruku SR, Huffman LC, Hackmann AE, Jessen ME, Ring WS, Wait MA. Lung transplantation: how we do it. Indian J Thorac Cardiovasc Surg 2021; 37:454-475. [PMID: 34566281 PMCID: PMC8448665 DOI: 10.1007/s12055-021-01218-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 05/17/2021] [Accepted: 05/22/2021] [Indexed: 11/29/2022] Open
Abstract
Lung transplantation is considered the gold standard for patients with chronic end-stage pulmonary disease. However, due to the complexity of management and relatively lower median survival as compared to other solid organs, many programs across the world have been slow to adopt the same. In our institution, we started lung transplantation in September 1990. And since then, we performed close to 900 lung transplantations. Here, we describe in detail the operative steps adopted in our institution for a successful lung transplantation. There have been very few variations over the years. We believe that having a standardized technique is one of the important features for success of a lung transplant program.
Collapse
Affiliation(s)
- John Santosh Murala
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern (UTSW) Medical Center, 5959 Harry Hines Blvd., 10th Floor, Suite HP10.110, Dallas, TX 75390 USA
| | - Hashim Muhammad Hanif
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern (UTSW) Medical Center, 5959 Harry Hines Blvd., 10th Floor, Suite HP10.110, Dallas, TX 75390 USA
| | - Matthias Peltz
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern (UTSW) Medical Center, 5959 Harry Hines Blvd., 10th Floor, Suite HP10.110, Dallas, TX 75390 USA
| | - Sreekanth Reddy Cheruku
- Department of Anesthesiology and Pain Management, University of Texas Southwestern (UTSW) Medical Center, Dallas, TX USA
| | - Lynn Custer Huffman
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern (UTSW) Medical Center, 5959 Harry Hines Blvd., 10th Floor, Suite HP10.110, Dallas, TX 75390 USA
| | - Amy Elizabeth Hackmann
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern (UTSW) Medical Center, 5959 Harry Hines Blvd., 10th Floor, Suite HP10.110, Dallas, TX 75390 USA
| | - Michael Erik Jessen
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern (UTSW) Medical Center, 5959 Harry Hines Blvd., 10th Floor, Suite HP10.110, Dallas, TX 75390 USA
| | - William Steves Ring
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern (UTSW) Medical Center, 5959 Harry Hines Blvd., 10th Floor, Suite HP10.110, Dallas, TX 75390 USA
| | - Michael Alton Wait
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern (UTSW) Medical Center, 5959 Harry Hines Blvd., 10th Floor, Suite HP10.110, Dallas, TX 75390 USA
| |
Collapse
|
8
|
Burke JF, Chan AK, Mayer RR, Garcia JH, Pennicooke B, Mann M, Berven SH, Chou D, Mummaneni PV. Clamshell thoracotomy for en bloc resection of a 3-level thoracic chordoma: technical note and operative video. Neurosurg Focus 2021; 49:E16. [PMID: 32871571 DOI: 10.3171/2020.6.focus20382] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 06/16/2020] [Indexed: 11/06/2022]
Abstract
The clamshell thoracotomy is often used to access both hemithoraxes and the mediastinum simultaneously for cardiothoracic pathology, but this technique is rarely used for the excision of spinal tumors. We describe the use of a clamshell thoracotomy for en bloc excision of a 3-level upper thoracic chordoma in a 20-year-old patient. The lesion involved T2, T3, and T4, and it invaded both chest cavities and indented the mediastinum. After 2 biopsies to confirm the diagnosis, the patient underwent a posterior spinal fusion followed by bilateral clamshell thoracotomy for 3-level en bloc resection with simultaneous access to both chest cavities and the mediastinum. To demonstrate how the clamshell thoracotomy was used to facilitate the tumor resection, an operative video and illustrations are provided, which show in detail how the clamshell thoracotomy can be used to access both hemithoraxes and the mediastinum.
Collapse
Affiliation(s)
| | | | | | | | | | - Michael Mann
- 3Department of Surgery, Division of Adult Cardiothoracic Surgery, and
| | - Sigurd H Berven
- 4Department of Orthopedic Surgery, University of California, San Francisco, California
| | | | | |
Collapse
|
9
|
Zhao J, Liu D, Huang J, Jiang HC, Chen Y, Li HX, Li XS, Chen JY. The Low Utilization Rate of Donor Lungs in China: A Single-Center Experience. Ann Transplant 2021; 26:e931409. [PMID: 34373440 PMCID: PMC8364286 DOI: 10.12659/aot.931409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Despite the increasing number of organ donations, the utilization rate of donor lungs in China is much lower than that in many other countries. MATERIAL AND METHODS The donor lungs were evaluated before departure (stage 1), after on-site management (stage 2), and after harvesting (stage 3). Variables of donor lungs from medical institutions with lung transplant qualification (group A) and those without qualification (group B) were compared. The outcome measurements for lung recipients were early survival and primary graft dysfunction. RESULTS Among the 277 donor lungs, 140 (51%) were suitable for transplantation and 101 were sent to our institution for 62 single-lung transplantations and 50 double-lung transplantations. The acceptability rates at stage 1, stage 2, and stage 3 were 78%, 56%, and 51%, respectively. In addition, 69 (50.4%) donor lungs were abandoned for poor quality related to management, 24 (17.5%) for no adequate recipients, 15 (10.9%) for family refusal, 14 (10.2%) for organ procurement organization-related reasons, and 15 (10.9%) for other reasons. Donors in group A were ventilated longer and had longer ischemic time than those in group B. However, bronchoscopy, imaging, and oxygenation in group A achieved better results than in group B. No between-group difference in 30-day mortality or rate of grade 3 primary graft dysfunction was observed. CONCLUSIONS Problems at supply and demand ends contribute to the low utilization rate of donor lungs in China. The poor management of donor lungs and the short waiting list for lung transplantation are major reasons.
Collapse
Affiliation(s)
- Jin Zhao
- Wuxi Lung Transplant Center, Wuxi People's Hospital Affiliated with Nanjing Medical University, Wuxi, Jiangsu, China (mainland)
| | - Dong Liu
- Wuxi Lung Transplant Center, Wuxi People's Hospital Affiliated with Nanjing Medical University, Wuxi, Jiangsu, China (mainland)
| | - Jian Huang
- Wuxi Lung Transplant Center, Wuxi People's Hospital Affiliated with Nanjing Medical University, Wuxi, Jiangsu, China (mainland)
| | - Hua-Chi Jiang
- Wuxi Lung Transplant Center, Wuxi People's Hospital Affiliated with Nanjing Medical University, Wuxi, Jiangsu, China (mainland)
| | - Yuan Chen
- Wuxi Lung Transplant Center, Wuxi People's Hospital Affiliated with Nanjing Medical University, Wuxi, Jiangsu, China (mainland)
| | - Hui-Xing Li
- Wuxi Lung Transplant Center, Wuxi People's Hospital Affiliated with Nanjing Medical University, Wuxi, Jiangsu, China (mainland)
| | - Xiao-Shan Li
- Chinese Lung Transplantation Registry and Data Management Center, Wuxi, Jiangsu, China (mainland)
| | - Jing-Yu Chen
- Wuxi Lung Transplant Center, Wuxi People's Hospital Affiliated with Nanjing Medical University, Wuxi, Jiangsu, China (mainland)
| |
Collapse
|
10
|
Son H, Grigovich M, McCabe BE. Non-tumorous diseases of the sternum and its articulations: At the front gate of the chest. Curr Probl Diagn Radiol 2021; 51:628-638. [PMID: 34393035 DOI: 10.1067/j.cpradiol.2021.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 05/27/2021] [Accepted: 06/17/2021] [Indexed: 11/22/2022]
Abstract
Abnormalities of the sternal and peri-sternal regions are commonly seen in clinical practice and may be one of the important causes of chest pain particularly anterior chest wall pain. While reading computed tomography (CT) of the chest for evaluation of chest pain, the sternal region is either easily overlooked or its abnormality is often detected incidentally. This article will provide an overview of normal sternal anatomy and congenital variants as well as a variety of non-tumorous pathologic conditions of the sternum and adjacent joints, with emphasis on CT, to help radiologists, particularly thoracic radiologists, to make an accurate diagnosis in their daily practice. Non-tumorous abnormalities include trauma (fractures and dislocations), infection (osteomyelitis, septic arthritis), degenerative (osteoarthritis) and inflammatory conditions (rheumatoid arthritis, seronegative arthritides), and metabolic disorders (Paget's disease and renal osteodystrophy) as well as treatment related changes such as poststernotomy and its complications (dehiscence, nonunion) and postradiation changes of the sternum.
Collapse
Affiliation(s)
- Hongju Son
- Department of Radiology, Einstein Healthcare Network, Philadelphia PA 19401.
| | - Maria Grigovich
- Department of Radiology, Einstein Healthcare Network, Philadelphia PA 19401
| | - Bridgette E McCabe
- Department of Radiology, Einstein Healthcare Network, Philadelphia PA 19401
| |
Collapse
|
11
|
Boudreaux JC, Urban M, Berkheim DB, Moulton MJ, Small BL, Strah HM, Siddique A. Combination plate and band fixation for primary closure in bilateral lung transplantation. J Card Surg 2021; 36:3085-3091. [PMID: 34133049 DOI: 10.1111/jocs.15729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 05/19/2021] [Accepted: 05/20/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Sternal complications are common following transverse thoracosternotomy in patients undergoing bilateral lung transplantation. We present a single-institution experience using a next generation rigid fixation system for primary sternal closure following transverse sternotomy for bilateral lung transplantation. METHODS Retrospective review was performed on all patients who had bilateral sequential lung transplants utilizing a transverse thoracosternotomy from 2016 to 2020. Demographics, baseline characteristics, peri-operative data, and outcomes were collected, reviewed and summarized. Two groups of patients were identified: wire cerclage (Group A), combination plate-and-band rigid fixation (Group B). The primary outcome was sternal complications, which were divided into mechanical and non-mechanical. RESULTS Twenty-two patients met inclusion criteria. Three patients (13.6%) were in Group A, nineteen patients (86.4%) in Group B. Two patients in each Group A (66.6%) and Group B (10.5%) experienced a sternal complication. Sternal complications included sternal dehiscence (2), sternal malunion (1), and surgical site infection (1). One patient with plate-and-band fixation (5.2%) had a mechanical sternal complication. Three patients required reoperation secondary to sternal complication. CONCLUSIONS The utilization of a combination plate-and-band rigid fixation system for primary closure is safe and may be an effective method to reduce sternal complications following transverse thoracosternotomy for lung transplantation.
Collapse
Affiliation(s)
- Joel C Boudreaux
- University of Nebraska Medical Center, College of Medicine, Omaha, Nebraska, USA
| | - Marian Urban
- Department of Surgery, Division of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - David B Berkheim
- Department of Surgery, Division of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Michael J Moulton
- Department of Surgery, Division of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Bronwyn L Small
- Department of Internal Medicine, Pulmonary Critical Care, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Heather M Strah
- Department of Internal Medicine, Pulmonary Critical Care, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Aleem Siddique
- Department of Surgery, Division of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| |
Collapse
|
12
|
Parikh AN, Merritt TC, Carvajal HG, Shepard MS, Canter MW, Abarbanell AM, Eghtesady P, Nath DS. A comparison of cardiopulmonary bypass versus extracorporeal membrane oxygenation: Does intraoperative circulatory support strategy affect outcomes in pediatric lung transplantation? Clin Transplant 2021; 35:e14289. [PMID: 33714228 DOI: 10.1111/ctr.14289] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 03/05/2021] [Accepted: 03/09/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Data on adult lung transplantation suggest perioperative benefits of intraoperative extracorporeal membrane oxygenation (ECMO) compared to cardiopulmonary bypass (CPB). Information regarding their pediatric counterparts, however, is limited. This study compares outcomes of intraoperative ECMO versus CPB in pediatric lung transplantation. METHODS We reviewed all pediatric lung transplants at our institution from 2014 to 2019 and compared those supported intraoperatively on ECMO (n = 13) versus CPB (n = 22), plus a conditional analysis excluding re-transplantations (ECMO [n = 13] versus CPB [n = 20]). We evaluated survival, surgical times, intraoperative transfusions, postoperative support, complications, and duration of hospitalization. RESULTS Total time on ECMO support was significantly less than that of CPB support (P = .018). Intraoperatively, the ECMO group required fewer transfusions of fresh-frozen plasma (8.9 [5.8-22.3] vs 16.6 [11.4-39.0] mL/kg, P = .049) and platelets (4.2 [0.0-6.7] vs 8.0 [3.5-14.0] mL/kg, P = .049). When excluding re-transplantations, patients on ECMO required fewer packed red blood cells intraoperatively (12.6 [2.1-30.7] vs 28.2 [14.0-54.0] mL/kg, P = .048). There were no differences in postoperative support requirements, complications, or mortality at one, six, and twelve months. CONCLUSIONS Intraoperative ECMO support during pediatric lung transplantation appears to decrease intraoperative transfusion requirements when compared to CPB. Data from additional institutions may strengthen these observations.
Collapse
Affiliation(s)
- Amisha N Parikh
- Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Taylor C Merritt
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis School of Medicine/St. Louis Children's Hospital, St. Louis, MO, USA
| | - Horacio G Carvajal
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis School of Medicine/St. Louis Children's Hospital, St. Louis, MO, USA
| | - Mark S Shepard
- The Heart Center, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Matthew W Canter
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis School of Medicine/St. Louis Children's Hospital, St. Louis, MO, USA
| | - Aaron M Abarbanell
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis School of Medicine/St. Louis Children's Hospital, St. Louis, MO, USA
| | - Pirooz Eghtesady
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis School of Medicine/St. Louis Children's Hospital, St. Louis, MO, USA
| | - Dilip S Nath
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis School of Medicine/St. Louis Children's Hospital, St. Louis, MO, USA
| |
Collapse
|
13
|
Hever P, Singh P, Nikkhah D, Anikin V. Lower third chest wall reconstruction in a bilateral sequential lung transplant recipient. BMJ Case Rep 2021; 14:14/1/e238998. [PMID: 33462038 PMCID: PMC7813316 DOI: 10.1136/bcr-2020-238998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Reconstruction of the sternum following deep sternal wound infection (DSWI) can be challenging, and despite advances in reconstructive surgery, DSWI remains a significant cause of morbidity and mortality in cardiothoracic patients. Transplantation patients present an additional, unique challenge for the reconstructive surgeon. These patients are often on immunosuppressant therapy, with multiple comorbidities, and cannot tolerate prolonged operations for reconstruction. They often have a prior extensive surgical history, which may limit donor options; and their wounds are often in the lower third of the sternum, which is a challenging location to reconstruct with locoregional tissues.We report a case of successful lower third chest wall reconstruction in a bilateral lung transplant recipient with a combination of bilateral pectoralis advancement flaps and omentoplasty.
Collapse
Affiliation(s)
- Pennylouise Hever
- Plastics and Reconstructive Surgery, Royal Free London NHS Foundation Trust, London, London, UK
| | - Prateush Singh
- Plastics and Reconstructive Surgery, Royal Free London NHS Foundation Trust, London, London, UK
| | - Dariush Nikkhah
- Plastics and Reconstructive Surgery, Royal Free London NHS Foundation Trust, London, London, UK
| | - Vladimir Anikin
- Thoracic Surgery, Harefield Hospital, Middlesex, UK,Department of Oncology and Reconstructive Surgery, I M Sechenov First Moscow State Medical University, Moskva, Moskva, Russian Federation
| |
Collapse
|
14
|
Abstract
Lung transplantation (LT) is proved to be effective in patients with end-stage lung disease who are failing optimal therapy. Chronic obstructive pulmonary disease (emphysema) is the most common indication for adult lung transplantation. As most patients with emphysema (EMP) can survive long term, it could be difficult to decide which patient should be listed for LT. LT is a complex surgery. Therefore, it is extremely important to choose a recipient in whom expected survival is at less equal or comparable to the survival without surgery. This paper reviews patient selection, bridging strategies until lung transplantation, surgical approach and choice of the procedure, and functional outcome in emphysema recipients.
Collapse
Affiliation(s)
- Ilhan Inci
- Department of Thoracic Surgery, University Hospital, Raemistrasse, Zurich, Switzerland
| |
Collapse
|
15
|
Mody GN, Coppolino A, Singh SK, Mallidi HR. Sternotomy versus thoracotomy lung transplantation: key tips and contemporary results. Ann Cardiothorac Surg 2020; 9:60-64. [PMID: 32175244 DOI: 10.21037/acs.2020.01.01] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The purpose of this report is to provide an updated description of the technique of bilateral sequential lung transplant via median sternotomy. A sternotomy provides the advantage of less morbidity than the clamshell incision, as well as exposure to perform mechanical circulatory support and concurrent cardiac procedures. Our experience shows that lung transplantation via a midline sternotomy can be done with equivalent to better short-term outcomes than a clamshell incision, including earlier extubation and fewer transfusions. Familiarity with this technique is important for all surgeons managing end-stage lung disease.
Collapse
Affiliation(s)
- Gita N Mody
- Division of Cardiothoracic Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Anthony Coppolino
- Division of Thoracic Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Steve K Singh
- Trillium Health Partners, University of Toronto, Toronto, Canada
| | - Hari R Mallidi
- Division of Thoracic Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| |
Collapse
|
16
|
Lung Transplantation for Cystic Fibrosis. Respir Med 2020. [DOI: 10.1007/978-3-030-42382-7_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
17
|
Impact of Surgical Approach in Double Lung Transplantation: Median Sternotomy vs Clamshell Thoracotomy. Transplant Proc 2020; 52:321-325. [DOI: 10.1016/j.transproceed.2019.10.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 09/21/2019] [Accepted: 10/06/2019] [Indexed: 11/23/2022]
|
18
|
Off-Pump Bilateral Lung Transplantation via Median Sternotomy: A Novel Approach With Potential Benefits. Ann Thorac Surg 2019; 108:e137-e139. [DOI: 10.1016/j.athoracsur.2019.03.055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 03/15/2019] [Indexed: 11/20/2022]
|
19
|
Poststernotomy Complications: A Multimodal Review of Normal and Abnormal Postoperative Imaging Findings. AJR Am J Roentgenol 2018; 211:1194-1205. [DOI: 10.2214/ajr.18.19782] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
20
|
Panchabhai TS, Chaddha U, McCurry KR, Bremner RM, Mehta AC. Historical perspectives of lung transplantation: connecting the dots. J Thorac Dis 2018; 10:4516-4531. [PMID: 30174905 DOI: 10.21037/jtd.2018.07.06] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Lung transplantation is now a treatment option for many patients with end-stage lung disease. Now 55 years since the first human lung transplant, this is a good time to reflect upon the history of lung transplantation, to recognize major milestones in the field, and to learn from others' unsuccessful transplant experiences. James Hardy was instrumental in developing experimental thoracic transplantation, performing the first human lung transplant in 1963. George Magovern and Adolph Yates carried out the second human lung transplant a few days later. With a combined survival of only 26 days for these first 2 lung transplant recipients, the specialty of lung transplantation clearly had a long way to go. The first "successful" lung transplant, in which the recipient survived for 10.5 months, was reported by Fritz Derom in 1971. Ten years later, Bruce Reitz and colleagues performed the first successful en bloc transplantation of the heart and one lung with a single distal tracheal anastomosis. In 1988, Alexander Patterson performed the first successful double lung transplant. The modern technique of sequential double lung transplantation and anastomosis performed at the mainstem bronchus level was originally described by Henri Metras in 1950, but was not reintroduced into the field until Pasque reported it again in 1990. Since then, lung transplantation has seen landmark changes: evolving immunosuppression regimens, clarifying the definition of primary graft dysfunction (PGD), establishing the lung allocation score (LAS), introducing extracorporeal membrane oxygenation (ECMO) as a bridge to transplant, allowing donation after cardiac death, and implementing ex vivo perfusion, to name a few. This article attempts to connect the historical dots in this field of research, with the hope that our effort helps summarize what has been achieved, and identifies opportunities for future generations of transplant pulmonologists and surgeons alike.
Collapse
Affiliation(s)
- Tanmay S Panchabhai
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Udit Chaddha
- Department of Pulmonary and Critical Care Medicine, Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
| | - Kenneth R McCurry
- Department of Cardiothoracic Surgery, Sydell and Arnold Miller Family Heart and Vascular Institute
| | - Ross M Bremner
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Atul C Mehta
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
21
|
Olland A, Reeb J, Guinard S, Seitlinger J, Santelmo N, Kessler R, Falcoz PE, Massard G. Clamshell Closure With Absorbable Sternal Pins in Lung Transplant Recipients. Ann Thorac Surg 2017; 104:e207-e209. [DOI: 10.1016/j.athoracsur.2017.04.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 03/29/2017] [Accepted: 04/16/2017] [Indexed: 10/19/2022]
|
22
|
|
23
|
Marczin N, Popov AF, Zych B, Romano R, Kiss R, Sabashnikov A, Soresi S, De Robertis F, Bahrami T, Amrani M, Weymann A, McDermott G, Krueger H, Carby M, Dalal P, Simon AR. Outcomes of minimally invasive lung transplantation in a single centre: the routine approach for the future or do we still need clamshell incision? Interact Cardiovasc Thorac Surg 2016; 22:537-45. [PMID: 26869662 DOI: 10.1093/icvts/ivw004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 11/17/2015] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Minimally invasive lung transplantation (MILT) via bilateral anterior thoracotomies has emerged as a novel surgical strategy with potential patient benefits when compared with transverse thoracosternotomy (clamshell incision, CS). The aim of this study is to compare MILT with CS by focusing on operative characteristics, postoperative organ function and support and mid-term clinical outcomes at Harefield Hospital. METHODS It was a retrospective observational study evaluating all bilateral sequential lung transplants between April 2010 and November 2013. RESULTS CS was performed in 124 patients and MILT in 70 patients. Skin-to-skin surgical time was less in the MILT group [285 (265, 339) min] compared with CS [380 (306, 565) min] and MILT-cardiopulmonary bypass [426 (360, 478) min]. Ischaemic time was significantly longer (502 ± 116 vs 395 ± 145 min) in the MILT group compared with CS (P < 0.01). Early postoperative physiological variables were similar between groups. Patients in the MILT group required less blood [2 (0, 4) vs 3 (1, 5) units, P = 0.16] and platelet transfusion [0 (0, 1) vs 1 (0, 2) units, P < 0.01]. The median duration of mechanical ventilation was shorter (26 vs 44 h, P < 0.01) and intensive therapy unit stay was 2 days shorter (5 vs 7) in the MILT group. While overall survival was similar, fraction of expired volume in 1 s (FEV1) and forced vital capacity (FVC) were consistently higher in the MILT group compared with CS during mid-term follow-up after transplantation. Specifically, FEV1 and FVC were, respectively, 86 ± 21 and 88 ± 18% predicted in the MILT group compared with 74 ± 21 and 74 ± 19% predicted in the CS group (P < 0.01) at the 6-month follow-up. CONCLUSIONS MILT was successfully introduced at our centre as a novel operative strategy. Despite longer ischaemic times and a more complex operation and management, MILT appears to offer early postoperative and mid-term clinical benefits compared with our traditional approach of clamshell operations. These observations warrant larger definite studies to further evaluate the impact of MILT on physiological, clinical and patient-reported outcomes.
Collapse
Affiliation(s)
- Nandor Marczin
- Department of Anaesthetics, Harefield Hospital, Royal Brompton and Harefield NHS Foundation Trust, Harefield, Middlesex, UK Department of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK Department of Anaesthesia and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Aron-Frederik Popov
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support. Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust, Harefield, Middlesex, UK
| | - Bartlomiej Zych
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support. Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust, Harefield, Middlesex, UK
| | - Rosalba Romano
- Department of Anaesthetics, Harefield Hospital, Royal Brompton and Harefield NHS Foundation Trust, Harefield, Middlesex, UK Department of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Rudolf Kiss
- Department of Anaesthetics, Harefield Hospital, Royal Brompton and Harefield NHS Foundation Trust, Harefield, Middlesex, UK Department of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Anton Sabashnikov
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support. Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust, Harefield, Middlesex, UK
| | - Simona Soresi
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support. Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust, Harefield, Middlesex, UK
| | - Fabio De Robertis
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support. Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust, Harefield, Middlesex, UK
| | - Toufan Bahrami
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support. Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust, Harefield, Middlesex, UK
| | - Mohamed Amrani
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support. Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust, Harefield, Middlesex, UK
| | - Alexander Weymann
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support. Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust, Harefield, Middlesex, UK
| | - Grainne McDermott
- Department of Anaesthetics, Harefield Hospital, Royal Brompton and Harefield NHS Foundation Trust, Harefield, Middlesex, UK Department of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Heike Krueger
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support. Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust, Harefield, Middlesex, UK
| | - Martin Carby
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support. Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust, Harefield, Middlesex, UK
| | - Paras Dalal
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support. Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust, Harefield, Middlesex, UK
| | - André Ruediger Simon
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support. Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust, Harefield, Middlesex, UK
| |
Collapse
|
24
|
Mohite PN, Popov AF, Sabashnikov A, Weymann A, Simon AR. Utilization of a novel rib spreader for minimally invasive lung transplantation. Surg Innov 2014; 22:205-6. [PMID: 25107307 DOI: 10.1177/1553350614545242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Rack-and-pinion-type stainless steel rib spreader was innovated by Truffier in 1914, which was modified by Finochietto to have fenestrated blades and a hand-cranked lever to both separate the arms in a staged fashion and lock them in place at each stop. Its Burford-Finochietto variants with replaceable blades are ubiquitous in open thoracic surgery. Fehling Surgical Instrument, Inc (Acworth, GA) introduced a modified rib spreader-an assembly of movable and adjustable blades, a mobile bridge and spreader arms, which owing to its adaptation of thoracotomy incision provides an optimum exposure without injuring the ribs. The spreader is indispensible in lung transplantation surgery performed especially through minimally invasive (bilateral limited anterolateral thoracotomies with intact sternum) approach.
Collapse
Affiliation(s)
- Prashant Nanashaeb Mohite
- Royal Brompton & Harefield NHS Trust, Department of Cardiothoracic Transplantation and Mechanical Support, London, UK
| | - Aron-Frederik Popov
- Royal Brompton & Harefield NHS Trust, Department of Cardiothoracic Transplantation and Mechanical Support, London, UK
| | - Anton Sabashnikov
- Royal Brompton & Harefield NHS Trust, Department of Cardiothoracic Transplantation and Mechanical Support, London, UK
| | - Alexander Weymann
- Royal Brompton & Harefield NHS Trust, Department of Cardiothoracic Transplantation and Mechanical Support, London, UK
| | - Andre R Simon
- Royal Brompton & Harefield NHS Trust, Department of Cardiothoracic Transplantation and Mechanical Support, London, UK
| |
Collapse
|
25
|
Koster TD, Ramjankhan FZ, van de Graaf EA, Luijk B, van Kessel DA, Meijer RC, Kwakkel-van Erp JM. Crossed wiring closure technique for bilateral transverse thoracosternotomy is associated with less sternal dehiscence after bilateral sequential lung transplantation. J Thorac Cardiovasc Surg 2013; 146:901-5. [DOI: 10.1016/j.jtcvs.2013.04.033] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2012] [Revised: 04/04/2013] [Accepted: 04/18/2013] [Indexed: 10/26/2022]
|
26
|
Schuchert MJ, Souza AP, Abbas G, Pennathur A, Nason KS, Jack R, Horne ZD, Landreneau JR, Santana M, Wilson DO, Luketich JD, Landreneau RJ. Extended Chamberlain minithoracotomy: a safe and versatile approach for difficult lung resections. Ann Thorac Surg 2012; 93:1641-5; discussion 1646. [PMID: 22464035 DOI: 10.1016/j.athoracsur.2011.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2010] [Revised: 11/02/2011] [Accepted: 11/03/2011] [Indexed: 10/28/2022]
Abstract
BACKGROUND We present the perioperative outcomes of patients undergoing an anterior "extended Chamberlain" minithoracotomy as an alternative approach to a hemi-clamshell sternotomy or extended lateral thoracotomy for safe and reliable access to the pulmonary hilum and subsequent anatomic pulmonary resection. METHODS This study is a retrospective review of 162 patients undergoing anatomic lung resection through a mini anterior thoracotomy from 2002 to 2010. An 8-cm anterior thoracotomy was performed with the patient in a supine position, entering the chest through the second intercostal space. The pectoralis muscle fibers were split with preservation of the mammary artery medially and the thoracoacromial neurovascular bundle laterally. Primary outcome variables included hospital course, complications, and mortality rate. RESULTS The mean age was 63.9 (range, 20 to 85 years); female to male ratio was 71:91. Neoadjuvant therapy was used in 49 (30.2%) patients. Proposed resections were successful in 161 of 162 (99%) patients. Conversion to hemi-clamshell was required in 1 patient for vascular control. Complications occurred in 48 (29.6%) patients. Three (1.9%) perioperative deaths (2 pneumonectomies [6.3%], 1 lobectomy [1.0%]) occurred. Median length of stay was 8 days. CONCLUSIONS The "extended Chamberlain" mini anterior thoracotomy provides direct and expeditious, less-invasive access to the pulmonary hilum. This approach preserves muscle function and avoids partial sternotomy or extended lateral thoracotomy, and their associated incisional-related morbidity.
Collapse
Affiliation(s)
- Matthew J Schuchert
- Division of Thoracic and Foregut Surgery, Heart, Lung and Esophageal Surgery Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15232, USA.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
27
|
|
28
|
Jacobs JV, Hodges TN, Bremner RM, Walia R, Huang J, Smith MA. Hardware Preservation After Sternal Wound Infection in a Lung Transplant Recipient. Ann Thorac Surg 2011; 92:718-20. [DOI: 10.1016/j.athoracsur.2011.01.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2010] [Revised: 12/17/2010] [Accepted: 01/10/2011] [Indexed: 11/24/2022]
|
29
|
Motomura T, Bruckner B, La Francesca S, Mittelhaus S, Chike-Obi C, Leon-Becerril J, Ngo U, Loebe M. Experience of Sternal Secondary Closure by Means of a Titanium Fixation System After Transverse Thoracosternotomy. Artif Organs 2011; 35:E168-73. [DOI: 10.1111/j.1525-1594.2011.01295.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
30
|
Sternum Sparing Thoracotomy Incisions in Lung Transplantation Surgery a Superior Technique to the Clamshell Approach. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2011; 6:116-21. [DOI: 10.1097/imi.0b013e3182166163] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Objective Bilateral anterior transsternal thoracotomy incision (clamshell technique) is the standard approach used for bilateral sequential lung transplantation (LTX). The morbidity and wound complications of this large incision can be considerable and costly. Muscle sparing anterior thoracotomies without division of the sternum may lead to decreasing the sequelae of wound complications. The objective of this study was to determine the rate of wound complications in the nonsternal incising lung transplant patients. Methods We used the single-institution-based transplant data bank, phone questionnaire, and ambulatory care unit follow-up data to investigate retrospectively the incidence of wound healing complications following muscle and sternum sparing and mammary artery protecting limited access small submammary anterior thoracotomy incisions (AT) for LTX surgery. In the need for cardiopulmonary bypass, the femoral artery and vein were cannulated. Results After exclusion of seven clamshell operations for LTX combined with cardiac surgery, 91 recipients (65% male), aged 19 to 68 years (mean, 54 ± 8 years), underwent 84 AT and 48 lateral thoracotomies (LT) for idiopathic pulmonary fibrosis (IPF) (48%), obstructive disease (40%), cystic fibrosis (CF) (5%), and pulmonary arterial hypertension (PAH) (7%). AT ranged from 5.5 to 26 cm (mean, 20.3 ± 4.8 cm) and LT from 12 to 25 cm (mean, 19.8 ± 2.4 cm) and was not significantly different (P = 0.37). Warm ischemic times ranged from 30 to 92 minutes (mean, 56 ± 11 minutes). Four patients required rethoracotomy for bleeding/hematoma formation. Cardiopulmonary bypass/intraop extracorporeal membrane oxygenation (ECMO) was used in 64%. Superficial wound infection and subsequent drainage/care was needed in four LTX incisions. Reoperation for lung herniation using patch repair technique for thoracic wall stabilization was required in two AT and three LT. Conclusions Sternum sparing and mammary artery protecting limited access submammary anterior and lateral thoracotomy incisions for LTX surgery are safe and effective. This approach avoids complications related to sternal transaction and may minimize the development of severe wound complications following LTX surgery.
Collapse
|
31
|
Bittner HB, Lehmann S, Binner C, Garbade J, Barten M, Mohr FW. Sternum Sparing Thoracotomy Incisions in Lung Transplantation Surgery a Superior Technique to the Clamshell Approach. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2011. [DOI: 10.1177/155698451100600207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Hartmuth Bruno Bittner
- Division of Thoracic and Cardiovascular Surgery, Heart Center Leipzig of the University of Leipzig, Leipzig, Germany
| | - Sven Lehmann
- Division of Thoracic and Cardiovascular Surgery, Heart Center Leipzig of the University of Leipzig, Leipzig, Germany
| | - Christian Binner
- Division of Thoracic and Cardiovascular Surgery, Heart Center Leipzig of the University of Leipzig, Leipzig, Germany
| | - Jens Garbade
- Division of Thoracic and Cardiovascular Surgery, Heart Center Leipzig of the University of Leipzig, Leipzig, Germany
| | - Markus Barten
- Division of Thoracic and Cardiovascular Surgery, Heart Center Leipzig of the University of Leipzig, Leipzig, Germany
| | - Friedrich Wilhelm Mohr
- Division of Thoracic and Cardiovascular Surgery, Heart Center Leipzig of the University of Leipzig, Leipzig, Germany
| |
Collapse
|
32
|
Bonnette P. [Logistic, technic and postoperative complications of lung and heart-lung transplantations]. REVUE DE PNEUMOLOGIE CLINIQUE 2010; 67:15-20. [PMID: 21353969 DOI: 10.1016/j.pneumo.2010.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2010] [Accepted: 12/21/2010] [Indexed: 05/30/2023]
Abstract
In France, the "Agence de la biomédecine" distributes lung grafts. "Ideal" criteria for lung donor selection are not always respected, driven by the scarcity of suitable donor lungs (10% deaths while waiting). In single lung transplantation, three anastomoses are performed (bronchus near the lobar carina, pulmonary artery, left atrium). For double lung transplantation (twice as frequent around the world), two single lung transplantations are successively performed through two separate anterolateral thoracotomies, often without cardiopulmonary bypass. Heart lung transplantations are now rare (2% around the world). Postoperative mortality has improved (between 10 and 15%): less severe primary graft dysfunctions, treatable with ECMO, fewer bronchial complications, improvement in the diagnosis of hyperacute humoral rejection, improvement in antiviral prophylaxis.
Collapse
Affiliation(s)
- P Bonnette
- Chirurgie thoracique et groupe de transplantation pulmonaire, hôpital Foch, 40, rue Worth, 92150 Suresnes, France.
| |
Collapse
|
33
|
Puri V, Patterson GA. Adult lung transplantation: technical considerations. Semin Thorac Cardiovasc Surg 2008; 20:152-64. [PMID: 18707650 DOI: 10.1053/j.semtcvs.2008.05.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2008] [Indexed: 11/11/2022]
Abstract
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.
Collapse
Affiliation(s)
- Varun Puri
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri 63110, USA
| | | |
Collapse
|
34
|
Gandy KL, Moulton MJ. Sternal Plating to Prevent Malunion of Transverse Sternotomy in Lung Transplantation. Ann Thorac Surg 2008; 86:1384-5. [DOI: 10.1016/j.athoracsur.2008.03.039] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2007] [Revised: 03/12/2008] [Accepted: 03/20/2008] [Indexed: 11/29/2022]
|
35
|
Sternal wound dehiscence after transverse thoracosternotomy for bilateral lung transplantation: Report of a case. Surg Today 2008; 38:942-4. [DOI: 10.1007/s00595-007-3735-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2007] [Accepted: 11/04/2007] [Indexed: 10/21/2022]
|
36
|
Lung Transplantation. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_88] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
37
|
Oto T, Venkatachalam R, Morsi YS, Marasco S, Pick A, Rabinov M, Rosenfeldt F. A reinforced sternal wiring technique for transverse thoracosternotomy closure in bilateral lung transplantation: From biomechanical test to clinical application. J Thorac Cardiovasc Surg 2007; 134:218-24. [PMID: 17599512 DOI: 10.1016/j.jtcvs.2007.03.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2006] [Revised: 02/22/2007] [Accepted: 03/08/2007] [Indexed: 11/16/2022]
Abstract
OBJECTIVES A high incidence of failure of transverse thoracosternotomy closure, involving the loops of wire cutting through the sternum, remains a significant morbidity after bilateral lung transplantation. We postulated that placing peristernal wires inside the usual longitudinal wires could prevent the longitudinal wires from cutting through the sternum. The aims of this study were to investigate the biomechanical and clinical efficacy of the proposed reinforced sternal closure technique. METHODS In vitro, 24 artificial sternal models were wired with the reinforced or conventional wiring techniques and were tested either by means of longitudinal distraction or anterior-posterior shear (n = 6 per group). In vivo, the 6-month outcomes of 70 bilateral lung transplantations, including 27 reinforced and 43 conventional wiring techniques, were assessed. RESULTS Reinforced wiring was stronger than conventional wiring for both longitudinal distraction (yield load: 585 +/- 60 vs 334 +/- 21 N [P = .03]; maximum load: 807 +/- 60 vs 525 +/- 34 N [P = .03]; postyield stiffness: 91.0 +/- 22.0 vs 32.8 +/- 11.8 N/mm [P = .04]) and anterior-posterior shear (yield load: 405 +/- 9 vs 364 +/- 16 N [P = .03]; postyield stiffness: 47.4 +/- 6.1 vs 27.5 +/- 5.1 N/mm [P = .04]). In multivariate analysis, the use of the conventional wiring technique (odds ratio, 5.38; P = .04) and osteoporosis (odds ratio, 18.31; P = .0005) were significant risk factors associated with sternal dehiscence. In the patients with osteoporosis (n = 25), the incidence of sternal dehiscence in the reinforced wiring group (4/16 [25%]) was significantly lower than that in the conventional wiring group (7/9 [78%], P = .02). CONCLUSION Osteoporosis is a significant risk factor for sternal dehiscence after bilateral lung transplantation. The new reinforced sternal wiring technique provides biomechanically superior fixation of the sternum and clinically reduces the incidence of sternal dehiscence in high-risk osteoporotic patients undergoing bilateral lung transplantation.
Collapse
Affiliation(s)
- Takahiro Oto
- Department of Cardiothoracic Surgery, Heart and Lung Transplant Unit, The Alfred Hospital, Monash University, Melbourne, Australia.
| | | | | | | | | | | | | |
Collapse
|
38
|
Karnak D, Shah SS, Rozas MS, Murthy S, Mehta AC, Mason DP. Repair of sternal dehiscence after bilateral lung transplantation. J Thorac Cardiovasc Surg 2006; 132:425-6. [PMID: 16872975 DOI: 10.1016/j.jtcvs.2006.03.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2006] [Accepted: 03/15/2006] [Indexed: 11/24/2022]
Affiliation(s)
- Demet Karnak
- Department of Chest Diseases, Ankara University School of Medicine, Ankara, Turkey
| | | | | | | | | | | |
Collapse
|
39
|
Lau CL, Hoganson DM, Meyers BF, Damiano RJ, Patterson GA. Use of an apical heart suction device for exposure in lung transplantation. Ann Thorac Surg 2006; 81:1524-5. [PMID: 16564318 PMCID: PMC4160742 DOI: 10.1016/j.athoracsur.2005.02.050] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2005] [Revised: 02/09/2005] [Accepted: 02/17/2005] [Indexed: 11/29/2022]
Abstract
Cardiopulmonary bypass is not necessary for the performance of bilateral sequential lung transplantation in most circumstances. Inadequate exposure to the left hilum is occasionally the sole indication for institution of cardiopulmonary bypass. We report the use of a suction heart positioning device to allow lifting of the heart for improvement of left hilar exposure. This technique has decreased the need for cardiopulmonary bypass when bypass is indicated due to difficult operative exposure.
Collapse
Affiliation(s)
- Christine L Lau
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA.
| | | | | | | | | |
Collapse
|
40
|
Force SD, Miller DL, Pelaez A, Ramirez AM, Vega D, Barden B, Lawrence EC. Outcomes of Delayed Chest Closure After Bilateral Lung Transplantation. Ann Thorac Surg 2006; 81:2020-4; discussion 2024-5. [PMID: 16731123 DOI: 10.1016/j.athoracsur.2006.01.050] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2005] [Revised: 01/09/2006] [Accepted: 01/10/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND Delayed chest closure (DCC) may be used after bilateral lung transplantation when significant bleeding/coagulopathy or severe pulmonary edema exists. Primary chest closure (PCC) in these patients can lead to heart and lung compression causing cardiopulmonary instability. The purpose of this study is to describe factors associated with DCC and evaluate outcomes after DCC. METHODS We performed a retrospective review of all patients undergoing bilateral lung transplantation between September 2003 and March 2005. Statistical significance was determined by two-tailed t test or Fisher's exact test. RESULTS Twenty-eight bilateral lung transplantations were performed. Indication for transplant was chronic obstructive pulmonary disease (13), pulmonary fibrosis (5), cystic fibrosis (5), sarcoidosis (3), and pulmonary hypertension (1). Seven patients (25%) required DCC. Mean time to DCC was 5.3 days. Six patients (86%) with DCC required tracheostomy versus 4 patients (20%) with PCC (p = 0.003). Mean days to discharge was 44 in the DCC group and 21 in the PCC group (p = 0.03). Thirty-day survival was 100% in the DCC group and 95% in the PCC group (p = 1.0). There were no wound infections in either group, and 1 patient in the PCC group had sternal nonunion. Delayed chest closure was associated with cardiopulmonary bypass use (p = 0.006), cardiopulmonary bypass time longer than mean cardiopulmonary bypass time (mean, 224 minutes; p = 0.04), PaO2/FiO2 less than mean + 1 SD (value = 4.63, p = 0.0002), evidence of moderate/severe reperfusion injury on chest radiograph (p = 0.0002), and PaO2/FiO2 less than mean plus moderate/severe reperfusion injury on chest radiograph (p = 0.002). CONCLUSIONS Cardiopulmonary bypass use, prolonged cardiopulmonary bypass time, and significant reperfusion injury, as determined by chest radiograph and a low PaO2/FiO2 ratio were all associated with an increased incidence of DCC in our bilateral lung transplantation patients. These patients had no wound infections or sternal complications, and although they had longer hospital stays than PCC patients, DCC did not affect operative survival. Delayed chest closure can be employed safely, when necessary, after bilateral lung transplantation with outcomes similar to patients with PCC.
Collapse
Affiliation(s)
- Seth D Force
- Division of Cardiothoracic Surgery, Emory University Hospital and Clinic, Atlanta, Georgia, USA.
| | | | | | | | | | | | | |
Collapse
|
41
|
Dürrleman N, Massard G. Clamshell and hemiclamshell incisions. Multimed Man Cardiothorac Surg 2006; 2006:mmcts.2006.001867. [PMID: 24412942 DOI: 10.1510/mmcts.2006.001867] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Sternotomy is one of the most frequent accesses in cardio-thoracic surgery. Transverse sternotomy with bilateral thoracotomy and combined approaches are developed. Surgical techniques, indications and pitfalls of these incisions are described.
Collapse
Affiliation(s)
- Nicolas Dürrleman
- Hôpitaux Universitaires de Strasbourg, Département de Chirurgie Thoracique, Hôpital Civil, 1 Place de l'Hôpital, 67000 Strasbourg, France
| | | |
Collapse
|
42
|
Van Raemdonck D, Klepetko W, Verleden GM, Daenen W, Coosemans W, Decker G, De Leyn P, Nafteux P, Lerut T. [Surgical aspects of (cardio) pulmonary transplantation]. Rev Mal Respir 2005; 22:785-95. [PMID: 16272981 DOI: 10.1016/s0761-8425(05)85636-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
UNLABELLED INTRODUCTION AND STATE OF THE ART: Both short and long-term outcomes following lung transplantation have improved substantially in recent years as a result of advances in the selection and management of donors, organ preservation, immunosuppressive therapy, and the treatment of infectious and malignant complications. In addition surgical techniques have evolved over time and have contributed to this increase in success rates. PERSPECTIVES AND CONCLUSIONS This review outlines surgical aspects of lung transplantation including a historical note, techniques of lung harvesting, some anaesthetic considerations, the different transplant types and incisions, as well as anastomotic techniques and their pitfalls.
Collapse
Affiliation(s)
- D Van Raemdonck
- Département de Chirurgie Thoracique, Hôpital Universitaire de Leuven, Belgique.
| | | | | | | | | | | | | | | | | |
Collapse
|
43
|
Borro JM. [Lung transplants in Spain: an update]. Arch Bronconeumol 2005; 41:457-67. [PMID: 16117951 DOI: 10.1016/s1579-2129(06)60261-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- J M Borro
- Complejo Hospitalario Juan Canalejo, A Coruña, España.
| |
Collapse
|
44
|
|
45
|
Affiliation(s)
- Kalpaj Parekh
- Washington University School of Medicine, Department of Cardiothoracic Surgery, St. Louis, MO 63110, USA
| | | |
Collapse
|
46
|
McGiffin DC, Alonso JE, Zorn GL, Kirklin JK, Young KR, Wille KM, Leon K, Hart K. Sternal Approximation For Bilateral Anterolateral Transsternal Thoracotomy For Lung Transplantation. Ann Thorac Surg 2005; 79:e19-20. [PMID: 15680800 DOI: 10.1016/j.athoracsur.2004.09.039] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/19/2004] [Indexed: 11/18/2022]
Abstract
The traditional incision for bilateral sequential lung transplantation is the bilateral anterolateral transsternal thoracotomy with approximation of the sternal fragments with interrupted stainless steel wire loops; this technique may be associated with an unacceptable incidence of postoperative sternal disruption causing chronic pain and deformity. Approximation of the sternal ends was achieved with peristernal cables that passed behind the sternum two intercostal spaces above and below the sternal division, which were then passed through metal sleeves in front of the sternum, the cables tensioned, and the sleeves then crimped. Forty-seven patients underwent sternal closure with this method, and satisfactory bone union occurred in all patients. Six patients underwent removal of the peristernal cables: 1 for infection (with satisfactory bone union after the removal of the cables), 3 for cosmetic reasons, 1 during the performance of a median sternotomy for an aortic valve replacement, and 1 in a patient who requested removal before commencing participation in football. This technique of peristernal cable approximation of sternal ends has successfully eliminated the problem of sternal disruption associated with this incision and is a useful alternative for preventing this complication after bilateral lung transplantation.
Collapse
Affiliation(s)
- David C McGiffin
- Division of Cardiovascular and Thoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama 35294-0007, USA.
| | | | | | | | | | | | | | | |
Collapse
|
47
|
Abstract
The successes of thoracic transplantation have led to the expansion of indications and a subsequent growth in demand for a short supply of organs. In response to this disparity, the criteria for organ donation have been liberalized. Despite these difficult challenges, with advances in surgical techniques and perioperative care of both the donor and recipient, outcomes have continued to improve over time. This article focuses on the more recent surgical advances in donor selection and management, procurement and implantation, and the impact of these advances on patient outcome.
Collapse
Affiliation(s)
- Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
| | | |
Collapse
|
48
|
Coloni GF, Venuta F, Ciccone AM, Rendina EA, De Giacomo T, Filice MJ, Diso D, Anile M, Andreetti C, Aratari MT, Mercadante E, Moretti M, Ibrahim M. Lung transplantation for cystic fibrosis. Transplant Proc 2004; 36:648-50. [PMID: 15110621 DOI: 10.1016/j.transproceed.2004.03.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Lung transplantation is a robust therapeutic option to treat patients with cystic fibrosis. PATIENTS AND METHODS Since 1996, 109 patients with cystic fibrosis were accepted onto our waiting list with 58 bilateral sequential lung transplants performed in 56 patients and two patients retransplanted for obliterative bronchiolitis syndrome. RESULTS Preoperative mean FEV(1) was 0.64 L/s, mean PaO(2) with supplemental oxygen was 56 mm Hg, and the mean 6-minute walking test was 320 m. Transplantation was performed through a "clam shell incision" in the first 29 patients and via bilateral anterolateral thoracotomies without sternal division in the remaining patients. Cardiopulmonary bypass was required in 14 patients. In 21 patients the donor lungs had to be trimmed by wedge resections with mechanical staplers and bovine pericardium buttressing to fit the recipient chest size. Eleven patients were extubated in the operating room immediately after the procedure. Hospital mortality of 13.8% was related to infection (n = 5), primary graft failure (n = 2), and myocardial infarction (n = 1). Acute rejection episodes occurred 1.6 times per patient/year; lower respiratory tract infections occurred 1.4 times per patient in the first year after transplantation. The mean FEV(1) increased to 82% at 1 year after operation. The 5-year survival rate was 61%. A cyclosporine-based immunosuppressive regimen was initially employed in all patients; 24 were subsequently switched to tacrolimus because of central nervous system toxicity, cyclosporine-related myopathy, or renal failure, obliterative bronchiolitis syndrome, gingival hyperplasia, or hypertrichosis. Ten patients were subsequently switched to sirolimus. Freedom from bronchiolitis obliterans at 5 years was 60%. CONCLUSIONS Our results confirm that bilateral sequential lung transplantation is a robust therapeutic option for patients with cystic fibrosis.
Collapse
Affiliation(s)
- G F Coloni
- UO Chirurgia Toracica, II Clinica Chirurgica, Università La Sapienza, Rome, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
49
|
Abstract
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.
Collapse
Affiliation(s)
- Christine L Lau
- Division of Cardiothoracic Surgery, Washington University School of Medicine, 1 Barnes Hospital Plaza, Queeny Tower, Suite 3108, Box #8234, St. Louis, MO 63110, USA
| | | |
Collapse
|
50
|
Cassivi SD, Meyers BF, Battafarano RJ, Guthrie TJ, Trulock EP, Lynch JP, Cooper JD, Patterson GA. Thirteen-year experience in lung transplantation for emphysema. Ann Thorac Surg 2002; 74:1663-9; discussion 1669-70. [PMID: 12440627 DOI: 10.1016/s0003-4975(02)04064-x] [Citation(s) in RCA: 115] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Emphysema is the most common indication for lung transplantation. Recipients include younger patients with genetically determined alpha-1 antitrypsin deficiency (AAD) and, more commonly, patients with chronic obstructive pulmonary disease (COPD). We analyzed the results of our single-institution series of lung transplants for emphysema to identify outcome differences and factors predicting mortality and morbidity in these two groups. METHODS A retrospective analysis was undertaken of the 306 consecutive lung transplants for emphysema performed at our institution between 1988 and 2000 (220 COPD, 86 AAD). Follow-up was complete and averaged 3.7 years. RESULTS The mean age of AAD recipients (49 +/- 6 years) was less than those with COPD (55 +/- 6 years; p < 0.001). Hospital mortality was 6.2%, with no difference between COPD and AAD, or between single-lung transplants and bilateral-lung transplants. Hospital mortality during the most recent 6 years was significantly lower (3.9% vs 9.5%, p = 0.044). Five-year survival was 58.6% +/- 3.5%, with no difference between COPD (56.8% +/- 4.4%) and AAD (60.5% +/- 5.8%). Five-year survival was better with bilateral-lung transplants (66.7% +/- 4.0%) than with single-lung transplants (44.9% +/- 6.0%, p < 0.005). Independent predictors of mortality by Cox analysis were single lung transplantation (relative hazard = 1.98, p < 0.001), and need for cardiopulmonary bypass during the transplant (relative hazard = 1.84, p = 0.038). CONCLUSIONS AAD recipients, despite a younger age, do not achieve significantly superior survival results than those with COPD. Bilateral lung transplantation for emphysema results in better long-term survival. Accumulated experience and modifications in perioperative care over our 13-year series may explain recently improved early and long-term survival.
Collapse
Affiliation(s)
- Stephen D Cassivi
- Division of Cardiothoracic Surgery, Washington University Medical Center, St. Louis, Missouri 63110-1013, USA
| | | | | | | | | | | | | | | |
Collapse
|