Improved technique for bilateral lung transplantation: rationale and initial clinical experience

Thoracic Trauma: Current Approach in Emergency Medicine

Chest trauma is the leading cause of death in people under 40. It is estimated to cause around 140,000 deaths each year. The key aims are to reduce mortality and the impact of associated complications to expedite recovery and to restore patient's conditions. The recognition of lesions through appropriate imaging and early treatment already in the emergency department are fundamental. The majority can be managed in a non-surgical way, but especially after traumatic cardiac arrest, a surgical approach is required. One of the most important surgical procedures is the Emergency Department Thoracotomy (EDT). The aim of this review is to provide a comprehensive synthesis about the management of thoracic trauma, the surgical procedures, accepted indications, and technical details adopted during the most important surgical procedures for different thoracic trauma injuries. Literature from 1990 to 2023 was retrieved from multiple databases and reviewed. It is also important to emphasize the medico-legal implications of this type of trauma, both from the point of view of collaboration with the judicial authority and in the prevention of any litigation.

Lung Transplant for Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) carries a high burden of morbidity and mortality to patient and a high cost to health care systems. Lung transplantation is a last resort available for end-stage COPD patients interested in pursuing it and meeting the strict transplant requirements. It requires commitment from patients and their loved ones to support them through this tough process. This review will cover history of transplant, indications, candidate selection, evaluation testing, transplant listing, type of transplant (single versus bilateral), posttransplant complications, immunosuppression, and rejection. It is tailored to the COPD patient when applicable; however, many aspects of lung transplantation are shared amongst all lung diseases eligible for transplant.

Pain trajectories after bilateral orthotopic lung transplantation surgery performed via a clamshell incision

INTRODUCTION

The nature, intensity, and progression of acute pain after bilateral orthotopic lung transplantation (BOLT) performed via a clamshell incision has not been well investigated. We aimed to describe acute pain after clamshell incisions using pain trajectories for the study cohort, in addition to stratifying patients into separate pain trajectory groups and investigating their association with donor and recipient perioperative variables.

METHODS

After obtaining IRB approval, we retrospectively included all patients ≥18 years old who underwent primary BOLT via clamshell incision at a single center between January 1, 2017, and June 30, 2022. We modeled the overall pain trajectory using pain scores collected over the first seven postoperative days and identified separate pain trajectory classes via latent class analysis.

RESULTS

Three hundred one adult patients were included in the final analysis. Three separate pain trajectory groups were identified, with most patients (72.8%) belonging to a well-controlled, stable pain trajectory. Uncontrolled pain was either observed in the early postoperative period (10%), or in the late postoperative period (17.3%). Late postoperative peaking trajectory patients were younger (p = .008), and sicker with a higher lung allocation score (p = .005), receiving preoperative mechanical ventilation (p < .001), or VV-ECMO support (p < .001).

CONCLUSION

Despite the extensive nature of a clamshell incision, most pain trajectories in BOLT patients had a well-controlled stable pain profile. The benign nature of pain profiles in our patient population may be attributed to the routine institutional practice of early thoracic epidural analgesia for BOLT patients unless contraindicated.

A Comparative Study of a Sternum-Sparing Procedure and Clamshell Incision in Bilateral Lung Transplantation

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.

Single vs Bilateral Lung Transplant in the Management of Patients With Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Analysis

BACKGROUND

Lung transplantation is recommended for select patients with end-stage chronic obstructive pulmonary disease (COPD). However, a consensus has not been reached regarding the optimal choice of lung transplantation: single lung transplants (SLTs) vs bilateral lung transplants (BLTs). This meta-analysis aimed to evaluate the safety and efficacy of SLT compared with BLT in managing end-stage COPD.

METHODS

Cochrane, Embase, PubMed, and Scopus were searched for articles by 2 independent reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-analysis system. The review was registered prospectively with PROSPERO (CRD42022343408).

RESULTS

Seven studies of 311 screened met the eligibility criteria, with a total of 10,652 patients with end-stage COPD, SLT (n = 6233), or BLT (n = 4419). Overall survival rates of BLT group were more favorable than SLT group at 1 (odds ratio [OR] = 1.29, 95% CI: 1.16, 1.43, I2 = 0%), 5 (OR = 1.46, 95% CI: 1.35, 1.58, I2 = 23%), and 10 years (OR = 1.71, 95% CI: 1.57, 1.87, I2 = 12%) as well as the hazard ratio (HR = 0.73, 95% CI: 0.70, 0.76, I2 = 40%). Subgroup analysis on survival rates of alpha-1 antitrypsin deficiency also displayed a trend favoring BLT compared with SLT at 1 (OR = 1.60, 95% CI: 1.24, 2.08, I2 = 28%), 5 (OR = 1.84, 95% CI: 1.50, 2.26, I2 = 42%), and 10 years (OR = 1.98, 95% CI: 1.59, 2.48, I2 = 47%) as well as the HR (HR = 0.67, 95% CI: 0.35, 1.28, I2 = 82%).

CONCLUSION

Compared with SLT, BLT seems to demonstrate more favorable trends in survival rates for the management of end-stage COPD. Despite the promising results, the groups have significant heterogeneity in baseline characteristics. Further prospective studies with extended follow-up periods are needed to ascertain the efficacy of treatment.

History of Lung Transplantation

Lung transplantation remains the only available therapy for many patients with end-stage lung disease. The number of lung transplants performed has increased significantly, but development of the field was slow compared with other solid-organ transplants. This delayed growth was secondary to the increased complexity of transplanting lungs; the continuous needs for surgical, anesthetics, and critical care improvements; changes in immunosuppression and infection prophylaxis; and donor management and patient selection. The future of lung transplant remains promising: expansion of donor after cardiac death donors, improved outcomes, new immunosuppressants targeted to cellular and antibody-mediated rejection, and use of xenotransplantation or artificial lungs.

Bilateral sequential lung transplantation: technical aspects

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.

Current Management of Sternal Wounds

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Describe the pathogenesis, classification, and risk factors of sternal wound infection. 2. Discuss options for sternal stabilization for the prevention of sternal wound infection, including wiring and plating techniques. 3. Discuss primary surgical reconstructive options for deep sternal wound infection and the use of adjunctive methods, such as negative-pressure wound therapy.

SUMMARY

Poststernotomy sternal wound infection remains a life-threatening complication of open cardiac surgery. Successful treatment relies on timely diagnosis and initiation of multidisciplinary, multimodal therapy.

Blood Lactate During Double-Lung Transplantation: A Predictor of Grade-3 Primary Graft Dysfunction

OBJECTIVE

Many prognostic factors of grade-3 primary graft dysfunction at postoperative day 3 (PGD3-T72) have been reported, but intraoperative blood lactate level has not been studied. The present retrospective study was done to test the hypothesis that intraoperative blood lactate level (BLL) could be a predictor of PGD3-T72 after double-lung transplantation.

DESIGN

Retrospective monocentric cohort study.

SETTING

Foch University Hospital, Suresnes, France.

PARTICIPANTS

Patients having received a double-lung transplantation between 2012 and 2019. Patients transplanted twice during the study period, having undergone a multiorgan transplantation, or cardiopulmonary bypass, and those under preoperative extracorporeal membrane oxygenation, were excluded.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Analysis was performed on a cohort of 449 patients. Seventy-two (16%) patients had a PGD3-T72. Blood lactate level increased throughout surgery to reach a median value of 2.2 (1.6-3.2) mmol/L in the No-PGD3-T72 group and 3.4 (2.3-5.0) mmol/L in the PGD3-T72 group after second lung implantation. The best predictive model for PGD3-T72 was obtained adding a lactate threshold of 2.6 mmol/L at the end of surgery to the clinical model, and the area under the curve was 0.867, with a sensitivity = 76.9% and specificity = 85.4%. Repeated-measures mixed model of BLL during surgery remained significant after adjustment for covariates (F ratio= 4.22, p < 0.001 for interaction).

CONCLUSIONS

Blood lactate level increases during surgery and reaches a maximum after the second lung implantation. A value below the threshold of 2.6 mmol/L at the end of surgery has a high negative predictive value for the occurrence of a grade-3 primary graft dysfunction at postoperative day 3.

Lung transplantation: how we do it

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.

Different-team procurements: A potential solution for the unintended consequences of change in lung allocation policy

The new lung allocation policy has led to an increase in distant donors and consequently enhanced logistical burden of procuring organs. Though early single-center studies noted similar outcomes between same-team transplantation (ST, procuring team from transplanting center) and different-team transplantation (DT, procuring team from different center), the efficacy of DT in the contemporary era remains unclear. In this study, we evaluated the trend of DT, rate of transplanting both donor lungs, 1-year graft survival, and risk of Grade 3 primary graft dysfunction (PGD) using the Scientific Registry of Transplant Recipient (SRTR) database from 2006 to 2018. A total of 21619 patients (DT 2085, 9.7%) with 19837 donors were included. Utilization of DT decreased from 15.9% in 2006 to 8.5% in 2018. Proportions of two-lung donors were similar between the groups, and DT had similar 1-year graft survival as ST for both double (DT, HR 1.108, 95% CI 0.894-1.374) and single lung transplants (DT, HR 1.094, 95% CI 0.931-1.286). Risk of Grade 3 PGD was also similar between ST and DT. Given our results, expanding DT may be a feasible option for improving lung procurement efficiency in the current era, particularly in light of the COVID-19 pandemic.

Clamshell thoracotomy for en bloc resection of a 3-level thoracic chordoma: technical note and operative video

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.

Operating room extubation: A predictive factor for 1-year survival after double-lung transplantation

BACKGROUND

Operating room (OR) extubation has been reported after lung transplantation (LT) in small cohorts. This study aimed to evaluate the prognosis of OR-extubated patients. The secondary objectives were to evaluate the safety of this approach and to identify its predictive factors.

METHODS

This retrospective single-center cohort study included patients undergoing double lung transplantation (DLT) from January 2012 to June 2019. Patients undergoing multiorgan transplantation, repeat transplantation, or cardiopulmonary bypass during the study period were excluded. OR-extubated patients were compared with intensive care unit (ICU)-extubated patients.

RESULTS

Among the 450 patients included in the analysis, 161 (35.8%) were extubated in the OR, and 4 were reintubated within 24 hours. Predictive factors for OR extubation were chronic obstructive pulmonary disease (COPD)/emphysema (p = .002) and cystic fibrosis (p = .005), recipient body mass index (p = .048), and the PaO₂/FiO₂ ratio 10 minutes after second graft implantation (p < .001). OR-extubated patients had a lower prevalence of grade 3 primary graft dysfunction at day 3 (p < .001). Eight (5.0%) patients died within the first year after OR extubation, and 49 (13.5%) patients died after ICU extubation (log-rank test; p = .005). After adjustment for OR extubation predictive factors, the multivariate Cox regression model showed that OR extubation was associated with greater one-year survival (adjusted hazard ratio = 0.40 [0.16-0.91], p = .028).

CONCLUSIONS

OR extubation was associated with a favorable prognosis after DLT, but the association should not be interpreted as causality. This fast-track protocol was made possible by a team committed to developing a comprehensive strategy to enhance recovery.

Historical Observations on Clamshell Thoracotomy

Bilateral transverse thoracosternotomy, known colloquially as "clamshell thoracotomy," provides quick and extensive exposure to the thoracic organs. The origins of the radical incision are unclear, and its influence on historical developments in surgery has not been elaborated. Transsternal extension to bilateral thoracotomy likely occurred during World War I and was designated as Tuffier's method by 1922. Théodore Tuffier had already solidified his reputation as a trailblazing thoracic surgeon in Paris when the French army summoned him to design triage systems for trauma patients during the Great War. Following World War II, cardiac surgery grew tremendously during the 1950s, and many pioneering open-heart procedures utilized the bilateral incision for safe exposures with satisfactory results. Median sternotomy became the incision of choice for open-heart surgery by the early 1960s; however, thoracotomy remained important to the trauma surgeon's repertoire. Transsternal conversion was only briefly mentioned in trauma literature through the 1980s, although up to one-half of reported emergency thoracotomies at busy trauma centers were clamshells. The moniker clamshell thoracotomy came in 1994 when thoracic surgical oncology and lung transplantation flourished with complex operations requiring larger incisions. The twenty-first century has brought two iterations of evidence-based guidelines for emergency thoracotomy, but incision choice has not been formally discussed. Renewed conversation in recent years has advocated for the clamshell as arguably the best approach for patients in extremis. Given these trends, the tortuous history of this controversial incision deserves attention.

Emergency Department Resuscitative Thoracotomy: Indications, surgical procedure and outcome. A narrative review

BACKGROUND

Emergency Department Thoracotomy (EDRT) after traumatic Cardio-pulmonary Arrest (CPR) can be used to salvage select critically injured patients. Indications of this surgical procedure are widely debated and changed during last decades. We provide the available literature about EDRT in the effort to provide a comprehensive synthesis about the procedure, likelihood of success and patient's outcome in the different clinical setting, accepted indications and technical details adopted during the procedure for different trauma injuries.

METHODS

Literature from 1975 to 2020 was retrieved from multiple databases and reviewed. Indications, contraindications, total number and outcome of patients submitted to EDRT were primary endpoints.

RESULTS

A total number of 7236 patients received EDRT, but only 7.8% survived. Penetrating trauma and witnessed cardiopulmonary arrest with the presence of vital signs at the trauma center are the most favorable conditions to perform EDRT.

CONCLUSIONS

EDRT should be reserved for acute resuscitation of selected dying trauma patient. Risks of futility, costs, benefits of the surgical procedure should be carefully evaluated before performing the surgical procedure.

Sternotomy versus thoracotomy lung transplantation: key tips and contemporary results

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.

Pathophysiology and Predictors of Bronchial Complications After Lung Transplantation

Bronchial anastomotic breakdown was a major complication in the early days of lung transplantation. Their solution, achieved through an understanding of airway ischemia from the laboratory, was key to the initial clinical success. Subsequently, risk factors, such as prolonged ventilation in both donor and recipient, primary graft dysfunction, and recipient age, have emerged. Innovations, such as local tissue wrapping, telescoping the anastomosis, and bronchial artery revascularization, have not stood the test of time. The short donor bronchus, with a suture line at the level of the lobar bronchus carina, is a proven technique that should be adopted by surgeons.

Historical perspectives of lung transplantation: connecting the dots

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.

Comprehensive Cross-sectional Imaging of the Pulmonary Veins

The pulmonary veins carry oxygenated blood from the lungs to the heart, but their importance to the radiologist extends far beyond this seemingly straightforward function. The anatomy of the pulmonary veins is variable among patients, with several noteworthy variant and anomalous patterns, including supernumerary pulmonary veins, a common ostium, anomalous pulmonary venous return, and levoatriocardinal veins. Differences in pulmonary vein anatomy and the presence of variant or anomalous anatomy can be of critical importance, especially for preoperative planning of pulmonary and cardiac surgery. The enhancement or lack of enhancement of the pulmonary veins can be a clue to clinically important disease, and the relationship of masses to the pulmonary veins can herald cardiac invasion. The pulmonary veins are also an integral part of thoracic interventions, including lung transplantation, pneumonectomy, and radiofrequency ablation for atrial fibrillation. This fact creates a requirement for radiologists to have knowledge of the pre- and postoperative imaging appearances of the pulmonary veins. Many of these procedures are associated with important potential complications involving the pulmonary veins, for which diagnostic imaging plays a critical role. A thorough knowledge of the pulmonary veins and a proper radiologic approach to their evaluation is critical for the busy radiologist who must incorporate the pulmonary veins into a routine "search pattern" at computed tomography (CT) and magnetic resonance imaging. This article is a comprehensive CT-based imaging review of the pulmonary veins, including their embryology, anatomy (typical and anomalous), surgical implications, pulmonary vein thrombosis, pulmonary vein stenosis, pulmonary vein pseudostenosis, and the relationship of tumors to the pulmonary veins. Online supplemental material is available for this article. ^©RSNA, 2017.

Single-lung and double-lung transplantation: technique and tips

The first successful single-lung and double-lung transplantations were performed in the eighties. Since then both surgical and anesthesiological management have improved. The aim of this paper is to describe the surgical technique of lung transplantation: from the anesthesiological preparation, to the explantation and implantation of the lung grafts, and the preparation of the donor lungs. We will also describe the main surgical complications after lung transplantation and their management. Each step of the surgical procedure will be illustrated with photos and videos.

Severe pulmonary arterial hypertension: stratification of medical therapies, mechanical support, and lung transplantation

Severe pulmonary hypertension is recognized by focusing on the clinical signs and tests that demonstrate decompensated right ventricular failure or, in the worst-case scenario, shock. An aggressive treatment regimen including a prostacyclin infusion is required for these patients. Once admitted to the hospital, or the ICU for decompensated right ventricular failure, the short- and long-term outcomes for PAH patients are poor. For those who are candidates, urgent lung transplantation, or extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation may be rescue therapy.

History of lung transplantation

Lung transplantation nowadays is a well-accepted and routine treatment for well selected patients with terminal respiratory disease. However, it took several decades of experimental studies and clinical attempts to reach this success. In this paper, we describe the early experimental activity from the mid-forties until the early sixties. The first clinical attempt in humans was reported by Hardy and Webb in 1963 followed by others with short survival only except for one case by Derom et al. who lived for 10 months. Long-term successes were not reported until after the discovery of cyclosporine as a new immunosuppressive agent. Successful heart-lung transplantation (HLTx) for pulmonary vascular disease was performed by the Stanford group starting in 1981 while the Toronto group described good outcome after single-lung transplantation (SLTx) for pulmonary fibrosis in 1983 and after double-lung transplantation for emphysema in 1986. Further evolution in surgical techniques and in transplant type for the various forms of end-stage lung diseases are reviewed. The evolution in lung transplantation still continues nowadays with the use of pulmonary allografts coming from living-related donors, from donors after circulatory death, or after prior assessment and reconditioning during ex vivo lung perfusion (EVLP) in an attempt to overcome the critical shortage of suitable organs. Early outcome has significantly improved over the last three decades. Better treatment and prevention of chronic lung allograft dysfunction will hopefully result in further improvement of long-term survival after lung transplantation.

Effect of Upper Limb Rehabilitation Compared to No Upper Limb Rehabilitation in Lung Transplant Recipients: A Randomized Controlled Trial

OBJECTIVE

To investigate the effect of a supervised upper limb (UL) program (SULP) compared to no supervised UL program (NULP) after lung transplantation (LTx).

DESIGN

Randomized controlled trial.

SETTING

Physiotherapy gym.

PARTICIPANTS

Participants (N=80; mean age, 56±11y; 37 [46%] men) were recruited after LTx.

INTERVENTIONS

All participants underwent lower limb strength thrice weekly and endurance training. Participants randomized to SULP completed progressive UL strength training program using handheld weights and adjustable pulley equipment.

MAIN OUTCOME MEASURES

Overall bodily pain was rated on the visual analog scale. Shoulder flexion and abduction muscle strength were measured on a hand held dynamometer. Health related quality of life was measured with Medical Outcomes Study 36-item Short Form health Survey and the Quick Dash. Measurements were made at baseline, 6 weeks, 12 weeks, and 6 months by blinded assessors.

RESULTS

After 6 weeks of training, participants in the SULP (n=41) had less overall bodily pain on the visual analog scale than did participants in the NULP (n=36) (mean VAS bodily pain score, 2.1±1.3cm vs 3.8±1.7cm; P<.001) as well as greater UL strength than did participants in the NULP (mean peak force, 8.4±4.0Nm vs 6.7±2.8Nm; P=.037). At 12 weeks, participants in the SULP better quality of life related to bodily pain (76±17 vs 66±26; P=.05), but at 6 months there were no differences between the groups in any outcome measures. No serious adverse events were reported.

CONCLUSIONS

UL rehabilitation results in short-term improvements in pain and muscle strength after LTx, but no longer-term effects were evident.

Use of aprotinin in lung transplantation

Although the use of aprotinin has been well documented for cardiac surgical procedures, its use in lung transplantation has received less attention. Herein is the experience at Washington University with aprotinin in patients undergoing lung transplantation (most with cystic fibrosis). In these patients, bleeding from the chest wall is a major problem due to the dense adhesions from chronic infection. Aprotinin has a dramatic effect in reducing bleeding.

Left Ventricular Dysfunction After Lung Transplantation for Pulmonary Arterial Hypertension

BACKGROUND

Lung transplantation (LT) is the final treatment option for patients with pulmonary arterial hypertension (PAH). Perioperative challenges after LT are unique and commonly include excessive bleeding, arrhythmias, and primary graft dysfunction. Transient left ventricular dysfunction (LVD) is a known postoperative complication, but not fully explored. We describe our experiences at a single institution.

METHODS

We reviewed our database for patients with PAH who underwent LT from July 2008 to July 2012. The data were analyzed for preoperative inotrope use, intravenous prostacyclin, cardiac catheterization, and imaging. Also measured were perioperative ischemic time, bypass time, primary graft dysfunction, ventilator days, length of stay, and mortality. LVD is defined as acute cardiopulmonary compromise (acute worsening of hypoxia with new bilateral infiltrates on imaging) with a drop in LV systolic function of 15% from baseline. We compared data between patients with LVD and without LVD.

RESULTS

Sixteen patients met the criteria, the majority of patients (10) with World Health Organization (WHO) group 1 PAH. Thirteen received intravenous prostacyclin therapy, and 6 required inotropes before surgery. Five patients (31%) developed LVD after transplantation. Average time to onset of LVD was 4.2 days. Preoperative vasopressors were required in 60% of those developing LVD. Patients with LVD had lower right and left ventricular ejection fraction with higher left ventricular end diastolic volume before surgery. All patients recovered from LVD within 4 months after LT.

CONCLUSIONS

LVD is a phenomenon observed mostly in patients with WHO group 1 PAH receiving LT. Prompt recognition and treatment of this condition reduced morbidity.

Critical Care Aspects of Lung Transplant Patients

Major strides have been made in lung transplantation during the 1990s and it has become an established treatment option for patients with advanced lung disease. Due to improvements in organ preservation, surgical techniques, postoperative intensive care, and immunosuppression, the risk of perioperative and early mortality (less than 3 months after transplantation) has declined [1]. The transplant recipient now has a greater chance of realizing the benefits of the long and arduous waiting period.

Despite these improvements, suboptimal long-term outcomes continue to be shaped by issues such as opportunistic infections and chronic rejection. Because of the wider use of lung transplantation and the longer life span of recipients, intensivists and ancillary intensive care unit (ICU) staff should be well versed with the care of lung transplant recipients.

In this clinical review, issues related to organ donation will be briefly mentioned. The remaining focus will be on the critical care aspects of lung transplant recipients in the posttransplant period, particularly ICU management of frequently encountered conditions. First, the groups of patients undergoing transplantation and the types of procedures performed will be outlined. Specific issues directly related to the allograft, including early graft dysfunction from ischemia-reperfusion injury, airway anastomotic complications, and infections in the setting of immunosuppression will be emphasized. Finally nonpulmonary aspects of posttransplant care and key pharmacologic points in the ICU will be covered.

Outcomes of minimally invasive lung transplantation in a single centre: the routine approach for the future or do we still need clamshell incision?

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.

Managing central venous obstruction in cystic fibrosis recipients--lung transplant considerations

BACKGROUND

The superior vena cava (SVC) syndrome in cystic fibrosis (CF) patients is rare, but presents unique challenges in the peri-transplant period. We reviewed our experience of SVC syndrome in CF recipients undergoing lung transplantation.

METHODS

This is a retrospective case series from a single center chart-review. SVC obstruction is defined by clinically significant stenosis or obstruction of the SVC as detected by contrast studies.

RESULTS

We identified SVC obstruction in seven post-transplant cases and one pre-transplant case. All eight patients had previous or current history of indwelling central venous catheters. Three recipients experienced operative complications. Five of the seven recipients suffered at least one episode of post-operative SVC obstruction or bleeding despite prophylactic anticoagulation. At a median follow-up of 29 months, six of the seven patients transplanted are well.

CONCLUSIONS

Strategies are available to minimize the risks of intra/peri-operative acute life-threatening SVC obstruction in CF patients.

Exercise limitation following transplantation

Organ transplantation is one of the medical miracles or the 20th century. It has the capacity to substantially improve exercise performance and quality of life in patients who are severely limited with chronic organ failure. We focus on the most commonly performed solid-organ transplants and describe peak exercise performance following recovery from transplantation. Across all of the common transplants, evaluated significant reduction in VO2peak is seen (typically renal and liver 65%-80% with heart and/or lung 50%-60% of predicted). Those with the lowest VO2peak pretransplant have the lowest VO2peak posttransplant. Overall very few patients have a VO2peak in the normal range. Investigation of the cause of the reduction of VO2peak has identified many factors pre- and posttransplant that may contribute. These include organ-specific factors in the otherwise well-functioning allograft (e.g., chronotropic incompetence in heart transplantation) as well as allograft dysfunction itself (e.g., chronic lung allograft dysfunction). However, looking across all transplants, a pattern emerges. A low muscle mass with qualitative change in large exercising skeletal muscle groups is seen pretransplant. Many factor posttransplant aggravate these changes or prevent them recovering, especially calcineurin antagonist drugs which are key immunosuppressing agents. This results in the reduction of VO2peak despite restoration of near normal function of the initially failing organ system. As such organ transplantation has provided an experiment of nature that has focused our attention on an important confounder of chronic organ failure-skeletal muscle dysfunction.

Lung transplant in end-staged chronic obstructive pulmonary disease (COPD) patients: a concise review

Lung transplantation is commonly used for patients with end-stage lung disease. However, there is continuing debate on the optimal operation for patients with chronic obstructive pulmonary disease (COPD) and pulmonary fibrosis. Single-lung transplantation (SLT) provides equivalent short- and medium-term results compared with bilateral lung transplantation (BLT), but long-term survival appears slightly better in BLT recipients (especially in patients with COPD). The number of available organs for lung transplantation also influences the choice of operation. Recent developments suggest that the organ donor shortage is not as severe as previously thought, making BLT a possible alternative for more patients. Among the different complications, re-implantation edema, infection, rejection, and bronchial complications predominate. Chronic rejection, also called obliterative bronchiolitis syndrome, is a later complication which can be observed in about half of the patients. Improvement in graft survival depends greatly in improvement in prevention and management of complications. Despite such complications, graft survival in fibrosis patients is greater than spontaneous survival on the waiting list; idiopathic fibrosis is associated with the highest mortality on the waiting list. Patients should be referred early for the pre-transplantation work-up because individual prognosis is very difficult to predict.

Current status of lung transplantation

Lung transplantation is a well-established treatment option for selected patients with end-stage lung disease, leading to improved survival and improved quality of life. The last 20 years have seen a steady growth in number of lung transplantation procedures performed worldwide. The increase in clinical activity has been associated with tremendous progress in the understanding of cellular and molecular processes that limit both short- and long-term outcomes. This review gives a comprehensive overview of the current status of lung transplantation for the referring physician. It demonstrates that careful selection of potential recipients, optimisation of their condition prior to transplant, use of carefully assessed donor organs, excellent surgery and meticulous long-term follow-up are all essential ingredients in determining a successful outcome.

The management of bronchus intermedius complications after lung transplantation: a retrospective study

Background

Airway complications following lung transplantation remain a significant cause of morbidity and mortality. The management of bronchial complications in Bronchus Intermedius (BI) is challenging due to the location of right upper bronchus. The aim of this study was to analyze the results of BI Montgomery T-tube stent in a consecutive patients with lung transplantations.

Methods

Between January 2007 and December 2010, 132 lung transplantations were performed at Foch Hospital, Suresnes, France. All the patients who had BI Montgomery T-tube after lung transplantation were included in this retrospective study. The demographic and interventional data and also complications were recorded.

Results

Out of 132 lung transplant recipients, 12 patients (9 male and 3 female) were entered into this study. The indications for lung transplantation were: cystic fibrosis 8 (67%), emphysema 3 (25%), and idiopathic pulmonary fibrosis 1 (8%). Most of the patients (83%) had bilateral lung transplantation. The mean interval between lung transplantation and interventional bronchoscopy was 11.5 ± 9.8 (SD) months. There was bronchial stenosis at the level of BI in 7 patients (58.3%). The Montgomery T-tube number 10 was used in 9 patients (75%). There was statistically significant difference in Forced Expiratory Volume in one second (FEV1) before and after stent placement (p = 0.01). The most common complication after stent placement was migration (33%).

Conclusion

BI complications after lung transplantation are still a significant problem. Stenosis or malacia following lung transplantation could be well managed with modified Montgomery T-tube.

Impact of anastomotic techniques on airway complications after lung transplant

BACKGROUND

Airway complications are a source of morbidity and expense after lung transplant. Posttransplant stenosis can occur when the donor bronchus is rendered ischemic and is dependent upon collateral flow from the pulmonary capillary system. By shortening the donor bronchus, the tissue at risk for ischemia is reduced. In an effort to reduce airway complications, one surgeon at our institution began dividing the donor bronchus at the lobar carina.

METHODS

This is a retrospective analysis of all transplanted patients over the 2-year period before and after the institution of the technique change. To adjust for covariates, we performed a propensity score analysis. Outcome endpoints were postoperative airway complications, specifically, the need for therapeutic bronchoscopy, dilation, stenting, or retransplant.

RESULTS

After instituting the practice of dividing the bronchus at the lobar carina, the incidence of airway complication for the principle surgeon decreased from 13.2% (7 of 53) to 2.1% (1 of 48), resulting in an improved freedom from airway complication for that surgeon. Compared with all transplants performed during this period, the modified anastomosis resulted in fewer airway complications: 2.1% (1 of 48) versus 8.2% (19 of 231). The propensity analysis matched the 48 patients who received the modified anastomosis with 48 patients who received the standard two ring length anastomosis by surgical colleagues. The modified anastomosis group had fewer required interventions for airway complications and had significantly better freedom from airway complication when followed over time.

CONCLUSIONS

Decreasing the amount of potentially ischemic tissue implanted from the donor bronchus can reduce posttransplant airway complications.

Sternum Sparing Thoracotomy Incisions in Lung Transplantation Surgery a Superior Technique to the Clamshell Approach

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.

Gastrointestinal complications after lung transplantation

BACKGROUND

Gastrointestinal complications after lung transplantation remain a common yet poorly defined problem. In this study we examine our experience with gastrointestinal complications after lung transplantation.

METHODS

Between August 1990 and June 2005, we retrospectively analyzed 208 patients who had undergone lung transplantation (single, 65% [137 of 212]; double, 34% [72 of 212]; heart-lung, 0.5% [2 of 212]; living related, 0.5% [1 of 212]). Four patients were retransplanted. Gastrointestinal complications were defined as any post-transplant diagnosis related to the gastrointestinal tract.

RESULTS

Ninety of 208 (43%) transplant patients developed 113 gastrointestinal complications during follow-up (median 3.5 years [62 days to 10.0 years]). Biliary etiology was the most common (12% [25 of 208]), requiring cholecystectomy in 13 patients. Diarrheal syndromes occurred in 21 patients (10%) with 2 patients requiring laparotomies. Small bowel obstruction and/or gastroparesis were present in 17 (5%) and 12 (6%) patients, respectively. Fourteen patients required surgical lysis of adhesions for small bowel obstruction and 7 patients underwent gastric drainage procedures. Three patients had peptic ulcer disease with 2 patients requiring laparotomy for perforated duodenal ulcer. Ten patients developed gastrointestinal bleeding with 1 requiring a colectomy. Three patients presented with diverticulitis and 2 required colectomy. Three patients required laparotomy due to intraperitoneal leakage of gastric secretions after gastromy tube placement. Eleven (16%) deaths were directly related to gastrointestinal complications. Of those patients who required a laparotomy for indications other than cholelithiasis, 9 (35%) died within 8 weeks.

CONCLUSIONS

Gastrointestinal complications are common after lung transplantation and are associated with considerable morbidity and mortality. Vigilance is required for early recognition and prompt treatment.

Transplantation in Chronic Obstructive Pulmonary Disease

Lung transplantation is a surgical option for patients who fail optimization of medical treatment for the severe symptoms that result from COPD. This review will discuss patient selection, transplant listing, and the surgical technique for transplantation in COPD. Furthermore, it will describe transplant outcomes and its effects on recipient survival, pulmonary function, exercise capacity, respiratory muscle function, and quality of life. The respective roles of transplantation and lung volume reduction surgery as therapies for advanced disease will be outlined.

Overview of lung transplantation

Although significant gains have been made in improving lung function and survival in cystic fibrosis (CF), ultimately respiratory failure is the leading cause of mortality in these patients. For CF patients with end stage lung disease, lung transplantation is an option for treatment. The field of lung transplantation has progressed markedly in the last 20 years. Nonetheless it remains a technically complex and challenging procedure, and patients are at risk for numerous short term and long term complications. Potential transplant recipients must be physically and psychologically prepared for the arduous process involved in lung transplantation. This article will review the history of lung transplantation, indications for transplantation, surgical techniques, and complications of transplantation.

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.