Outcomes of various transplant procedures (single, sparing, inverted) in living-donor lobar lung transplantation

Advances in lung transplantation: 60 years on

Lung transplantation is a well-established treatment for advanced lung disease, improving survival and quality of life. Over the last 60 years all aspects of lung transplantation have evolved significantly and exponential growth in transplant volume. This has been particularly evident over the last decade with a substantial increase in lung transplant numbers as a result of innovations in donor utilization procurement, including the use donation after circulatory death and ex-vivo lung perfusion organs. Donor lungs have proved to be surprisingly robust, and therefore the donor pool is actually larger than previously thought. Parallel to this, lung transplant outcomes have continued to improve with improved acute management as well as microbiological and immunological insights and innovations. The management of lung transplant recipients continues to be complex and heavily dependent on a tertiary care multidisciplinary paradigm. Whilst long term outcomes continue to be limited by chronic lung allograft dysfunction improvements in diagnostics, mechanistic understanding and evolutions in treatment paradigms have all contributed to a median survival that in some centres approaches 10 years. As ongoing studies build on developing novel approaches to diagnosis and treatment of transplant complications and improvements in donor utilization more individuals will have the opportunity to benefit from lung transplantation. As has always been the case, early referral for transplant consideration is important to achieve best results.

Potential Role of Computed Tomography Volumetry in Size Matching in Lung Transplantation

BACKGROUND

Accumulated knowledge on the outcomes related to size mismatch in lung transplantation derives from predicted total lung capacity equations rather than individualized measurements of donors and recipients. The increasing availability of computed tomography (CT) makes it possible to measure the lung volumes of donors and recipients before transplantation. We hypothesize that CT-derived lung volumes predict a need for surgical graft reduction and primary graft dysfunction.

METHODS

Donors from the local organ procurement organization and recipients from our hospital from 2012 to 2018 were included if their CT exams were available. The CT lung volumes and plethysmography total lung capacity were measured and compared with predicted total lung capacity using Bland Altman methods. We used logistic regression to predict the need for surgical graft reduction and ordinal logistic regression to stratify the risk for primary graft dysfunction.

RESULTS

A total of 315 transplant candidates with 575 CT scans and 379 donors with 379 CT scans were included. The CT lung volumes closely approximated plethysmography lung volumes and differed from the predicted total lung capacity in transplant candidates. In donors, CT lung volumes systematically underestimated predicted total lung capacity. Ninety-four donors and recipients were matched and transplanted locally. Larger donor and smaller recipient lung volumes estimated by CT predicted a need for surgical graft reduction and were associated with higher primary graft dysfunction grade.

CONCLUSION

The CT lung volumes predicted the need for surgical graft reduction and primary graft dysfunction grade. Adding CT-derived lung volumes to the donor-recipient matching process may improve recipients' outcomes.

Living-donor Segmental Lung Transplantation for Pediatric Patients

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Right lung transplantation with a left-to-right inverted anastomosis in a rat model

Objective

Right lung transplantation in rats has been attempted occasionally, but the technical complexity makes it challenging to apply routinely. Additionally, basic research on inverted lobar lung transplantation is scarce because of the lack of a cost-effective experimental model. We first reported right lung transplantation in a rat model using left-to-right inverted anastomosis to imitate the principle of clinically inverted lung transplantation.

Methods

Right lung transplantation was performed in 10 consecutive rats. By using a 3-cuff technique, the left lung of the donor rat was implanted into the right thoracic cavity of the recipient rat. The rat lung graft was rotated 180° along the vertical axis to achieve anatomic matching of right hilar structures. Another 10 consecutive rats had received orthotopic left lung transplantation as a control.

Results

All lung transplantation procedures were technically successful without intraoperative failure. One rat (10%) died of full pulmonary atelectasis after right lung transplantation, whereas all rats survived after left lung transplantation. No significant difference was observed in heart-lung block retrieval (8.6 ± 0.8 vs 8.4 ± 0.9 minutes), cuff preparation (8.3 ± 0.9 vs 8.7 ± 0.9 minutes), or total procedure time (58.2 ± 2.6 vs 56.6 ± 2.1 minutes) between the right lung transplantation and standard left lung transplantation groups (P > .05), although the cold ischemia time (14.2 ± 0.9 vs 25.5 ± 1.7 minutes) and warm ischemia time (19.8 ± 1.5 vs 13.7 ± 1.8 minutes) were different (P < .001).

Conclusions

Right lung transplantation with a left-to-right inverted anastomosis in a rat model is technically easy to master, expeditious, and reproducible. It can potentially imitate the principle of clinically inverted lung transplantation and become an alternative to standard left lung transplantation.

Living-donor lobar lung transplantation

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

New strategy to resume and taper epoprostenol after lung transplant for pulmonary hypertension

OBJECTIVE

The perioperative outcome of lung transplantation (LTx) for patients with severe pulmonary hypertension (PH) remains poor due to the occurrence of primary graft dysfunction (PGD) from left ventricular failure. We hypothesized that tapering pretransplant use of epoprostenol rather than abrupt discontinuation after transplantation might improve perioperative outcomes.

METHODS

We performed 23 LTxs for patients with severe PH who received epoprostenol therapy from 2008 until 2021. In the discontinued group (n = 6), epoprostenol was discontinued after the establishment of extracorporeal circulation. In the tapered group (n = 17), epoprostenol was discontinued and resumed after reperfusion, and then gradually tapered over the following 2 weeks. We assessed survival, bleeding, blood transfusion, re-opening of the chest, oxygenation, PGD score, extracorporeal membrane oxygenation (ECMO) requirement for recovery after transplantation, and duration of mechanical ventilation.

RESULTS

The PGD score was significantly lower in the tapered group than in the discontinued group at 0 h, 24 h, and 48 h after LTx. In addition, the discontinued group required longer mechanical ventilation than the tapered group. Delayed chest closure and post-transplant ECMO use for recovery occurred significantly more frequently in the discontinued group.

CONCLUSIONS

To resume and taper epoprostenol administration after reperfusion in patients with severe PH may be a valuable new strategy associated with better perioperative outcomes.

Outcomes of lung transplantation for idiopathic pleuroparenchymal fibroelastosis

PURPOSE

This study was performed to compare the outcome of lung transplantation (LT) for idiopathic pleuroparenchymal fibroelastosis (IPPFE) with that of LT for idiopathic pulmonary fibrosis (IPF).

METHODS

We reviewed, retrospectively, all adult patients who underwent LT for IPPFE or IPF in Japan between 1998 and 2018.

RESULTS

There were 100 patients eligible for this study (31 with IPPFE and 69 with IPF). Patients with IPPFE tended to have a significantly lower body mass index (BMI) than those with IPF (median, 16.7 vs. 22.6 kg/m², respectively; P < 0.01). However, Kaplan-Meier survival curves showed no significant difference in overall survival between the groups. The BMI did not increase in patients with IPPFE, even 1 year after LT (pretransplant, 16.5 ± 3.2 kg/m² vs. 1 year post-transplant, 15.6 ± 2.5 kg/m²; P = 0.08). The percent predicted forced vital capacity (%FVC) 1 year after LT was significantly lower in the IPPFE group than in the IPF group (48.4% ± 19.5% vs. 68.6% ± 15.5%, respectively; P < 0.01).

CONCLUSIONS

Despite extrapulmonary problems such as a flat chest, low BMI, and associated restrictive impairment persisting in patients with IPPFE, patient survival after LT for IPPFE or IPF was equivalent.

Native lung complications after living-donor lobar lung transplantation

BACKGROUND

Living-donor lobar lung transplantation (LDLLT) is viable for critically ill patients in situations of donor shortage. Because it is sometimes difficult to find 2 ideal living donors with suitable graft sizes, we developed native lung-sparing procedures, including single LDLLT and native upper lobe-sparing LDLLT. This study aimed to investigate native lung complications (NLCs) in native lung-sparing LDLLT.

METHODS

Between April 2002 and March 2019, 92 LDLLTs and 124 cadaveric lung transplantations (CLTs) were performed at the Kyoto University Hospital. Our prospectively maintained database and clinical records were reviewed to compare NLCs among recipients who underwent native lung-sparing LDLLT (n = 21) with those among recipients who underwent single CLT (n = 61).

RESULTS

Among 21 recipients who underwent native lung-sparing LDLLT, 11 NLCs occurred in 8 recipients. No fatal NLC was noted; however, 2 required surgical intervention. Post-transplant survival was not significantly different between native lung-sparing LDLLT recipients with NLCs and those without NLCs. The incidence of NLCs was comparable between native lung-sparing LDLLT recipients and single CLT recipients (8/21 vs 26/61, p = 0.80); however, NLCs occurred significantly later in LDLLT recipients than in CLT recipients (median: 665 vs 181.5 days after transplantation, p = 0.014).

CONCLUSIONS

NLCs after native lung-sparing LDLLT had favorable outcomes. Therefore, native lung-sparing LDLLT is a useful treatment option for severely ill patients who cannot wait for CLT. However, it is important to recognize that NLCs may occur later in LDLLT than in CLT.

Living-donor single-lobe lung transplantation for pulmonary hypertension due to alveolar capillary dysplasia with misalignment of pulmonary veins

This is a case report of a successful single-lobe lung transplantation for pulmonary hypertension secondary to alveolar capillary dysplasia with misalignment of pulmonary veins (ACD/MPV). A 6-year-old boy underwent living-donor single-lobe transplantation with the right lower lobe from his 31-year-old mother. The pretransplantation graft size matching was acceptable: the estimated graft forced vital capacity (FVC) was 96.5% of the recipient's predicted FVC, and the graft size measured by computed tomography (CT) volumetry was 166% of the recipient's chest cavity volume. Right pneumonectomy followed by implantation was performed under cardiopulmonary bypass (CPB). The pulmonary arterial pressure was significantly decreased to 31/12 mm Hg immediately after transplantation, and the first PaO₂ /FiO₂ in the intensive-care unit (ICU) was 422 mm Hg. Lung perfusion scintigraphy showed 97.5% perfusion to the right implanted lung 3 months after transplantation. Chest CT showed a mass rapidly growing in the native left upper lobe 6 months after transplantation, which was diagnosed as posttransplant lymphoproliferative disorder (PTLD) by a CT-guided biopsy. After immunosuppressant reduction and six courses of chemotherapy with rituximab, he underwent native left upper lobectomy for salvage lung resection 13 months after transplantation. Seven months after lobectomy, he has returned to normal school life without any sign of tumor recurrence.

Hanging donor lungs give good short-, mid- and long-term results in lung transplantation

BACKGROUND

Hanging donors are considered as marginal donors and frequently unsuitable for lung transplantation. However, there is no evidence of higher lung transplantation (LTx) morbidity-mortality with lungs providing by hanging donor.

METHODS

Between January 2010 and July 2015, we performed a retrospective study at Foch hospital. We aimed to assess whether hanging donor grafts are suitable for lung transplantation.

RESULTS

A total of 299 LTx were performed. Subjects were allocated to a hanging group (HG) (n = 20) and a control group (CG) (n = 279). Donor and recipient characteristics did not differ. Primary graft dysfunction (PGD) at 72 hours was comparable in both groups (P = .75). The median duration of postoperative mechanical ventilation (1 [range, 0-84] vs 1 [range, 0-410] day, P = .35), the hospital length of stay (31 days [20-84] vs 32 days [12-435], P = .36) did not differ between the two groups. No statistically significant difference was found in 1-year and 5-year survival between the HG (83% and 78%) and the CG (86% and 75%), P = .85.

CONCLUSION

We believe that hanging donors should be considered as conventional donors with particular caution in the final evaluation of the graft and in perioperative management.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Transplant arteriosclerosis in humanized mice reflects chronic lung allograft dysfunction and is controlled by regulatory T cells

OBJECTIVE

Chronic lung allograft dysfunction (CLAD) is a severe complication of lung transplantation limiting long-term survival. We studied correlations between CLAD after clinical lung transplantation and leukocyte-mediated development of transplant arteriosclerosis (TA) in a humanized mouse model. The pericardiophrenic artery was procured from surplus tissue of donor lungs (n = 22) transplanted in our clinical program and was implanted into the abdominal aorta of immune-deficient mice.

METHODS

Allogeneic human peripheral blood mononuclear cells (PBMCs) had been procured 1 day after lung transplantation from the respective recipients with or without enriching for CD4⁺CD25^high T cells were used. TA was assessed in mice 28 days later by histology. The respective clinical lung recipients were later divided into 2 groups. Eight patients (36.3%) had developed CLAD 23 ± 5 months after lung transplantation, whereas the remaining 14 (63.6%) did not develop CLAD within 25 ± 5 months.

RESULTS

In the PBMC CLAD+ group of mouse experiments, TA was significantly more severe than in the PBMC CLAD- group (39.9% ± 13% vs 14.9% ± 4% intimal thickening; P = .0081). Then, intimal thickening was significantly inhibited in the PBMC+ regulatory T cells CLAD+ group compared with the PBMC CLAD+ group (0.4% ± 4% vs 39.9% ± 13%; P = .003). In the experiments using PBMCs from lung recipients without CLAD, enriching regulatory T cells also suppressed the development of TA (0.9% ± 3% PBMC CLAD- vs 14.9% ± 4% PBMC+ regulatory T cells CLAD-; P = .001).

CONCLUSIONS

Lung transplant recipients who later develop CLAD have peripheral leukocytes already at the time of transplant that transfer proinflammatory properties leading to TA in a humanized mouse model. TA remains sensitive to inhibition by autologous regulatory T cells, suggesting a cell therapy-based approach for the prevention of CLAD after lung transplantation.

Landscape of Living Multiorgan Donation in the United States: A Registry-Based Cohort Study

BACKGROUND

The donation of multiple allografts from a single living donor is a rare practice, and the patient characteristics and outcomes associated with these procedures are not well described.

METHODS

Using the Scientific Registry of Transplant Recipients, we identified 101 living multiorgan donors and their 133 recipients.

RESULTS

The 49 sequential (donations during separate procedures) multiorgan donors provided grafts to 81 recipients: 21 kidney-then-liver, 15 liver-then-kidney, 5 lung-then-kidney, 3 liver-then-intestine, 3 kidney-then-pancreas, 1 lung-then-liver, and 1 pancreas-then-kidney. Of these donors, 38% donated 2 grafts to the same recipient and 15% donated 2 grafts as non-directed donors. Compared to recipients from first-time, single organ living donors, recipients from second-time living donors had similar graft and patient survival. The 52 simultaneous (multiple donations during one procedure) multiorgan donors provided 2 grafts to 1 recipient each: 48 kidney-pancreas and 4 liver-intestine. Donors had median of 13.4 years (interquartile range, 8.3-18.5 years) of follow-up. There was one reported death of a sequential donor (2.5 years after second donation). Few postdonation complications were reported over a median of 116 days (interquartile range, 0-295 days) of follow-up; however, routine living donor follow-up data were sparse. Recipients of kidneys from second-time living donors had similar graft (P = 0.2) and patient survival (P = 0.4) when compared with recipients from first-time living donors. Similarly, recipients of livers from second-time living donors had similar graft survival (P = 0.9) and patient survival (P = 0.7) when compared with recipients from first-time living donors.

CONCLUSIONS

Careful documentation of outcomes is needed to ensure ethical practices in selection, informed consent, and postdonation care of this unique donor community.

Native upper lobe-sparing living-donor lobar lung transplantation maximizes respiratory function of the donor graft

BACKGROUND

We have developed a novel method for native upper lobe-sparing living-donor lobar lung transplantation (LDLLT) to overcome a small-for-size graft in standard LDLLT with acceptable results. We hypothesized that grafts implanted with this procedure might work more efficiently than those in standard lobe transplantation.

METHODS

Bilateral LDLLT was performed in 31 patients with a functional graft matching of less than 60% at our institution between August 2008 and December 2015. Of these, 22 patients were available for evaluation of pulmonary function more than 1 year later: 15 undergoing standard LDLLT with less than 60% functional matching and 7 undergoing native upper lobe-sparing LDLLT.

RESULTS

Overall survival at 2 years was 87.5% in the lobe-sparing LDLLT patients and 79.0% in the standard LDLLT patients (p = 0.401). The median forced vital capacity size-matching levels were 50.7% ± 1.6% in the standard LDLLT and 45.2% ± 2.3% in the sparing LDLLT group (p = 0.074). The 1-year and 2-year post-operative volume ratios of inspiration to expiration were significantly different between the 2 groups, at 1.76 and 1.45 after standard LDLLT (p = 0.019) vs 2.41 and 2.23 after lobe-sparing LDLLT (p = 0.015).

CONCLUSIONS

The grafts in lobe-sparing LDLLT functioned more effectively than those in standard LDLLT. This advantage was associated with the improvement of pulmonary functions.

Living-donor lung transplantation after surgical repair of transposition of the great arteries

Pediatric pulmonary hypertension after surgery for congenital heart disease is a significant complication. We present a case of living-donor lung transplantation for a 12-year-old girl with pulmonary hypertension after surgical repair of transposition of great arteries. Despite repairing the transposition of great arteries, her growth was severely restricted because of progressive pulmonary hypertension; thus, lung transplantation was discussed. Standard bilateral lobar transplantation seemed unfeasible due to oversized grafts, so we performed a single lobar transplantation. Unexpectedly, she developed complications and died 3 months postoperatively despite another emergent lobar transplantation. We discussed the challenges and potential solutions regarding lobar size mismatching.

Clinical significance of radiological pleuroparenchymal fibroelastosis pattern in interstitial lung disease patients registered for lung transplantation: a retrospective cohort study

BACKGROUND

Radiological pleuroparenchymal fibroelastosis (PPFE) lesion is characterized by pleural thickening with associated signs of subpleural fibrosis on high-resolution computed tomography (HRCT). This study evaluated the clinical significance of radiological PPFE as an isolated finding or associated with other interstitial lung diseases (ILDs) in patients having fibrotic ILDs and registered for cadaveric lung transplantation (LT).

METHODS

This retrospective study included 118 fibrotic ILD patients registered for LT. Radiological PPFE on HRCT was assessed. The impact of radiological PPFE on clinical features and transplantation-censored survival were evaluated.

RESULTS

Radiological PPFE was observed in 30/118 cases (25%): definite PPFE (PPFE concentrated in the upper lobes, with involvement of lower lobes being less marked) in 12 (10%) and consistent PPFE (PPFE not concentrated in the upper lobes, or PPFE with features of coexistent disease present elsewhere) in 18 (15%). Of these, 12 had late-onset non-infectious pulmonary complications after hematopoietic stem-cell transplantation and/or chemotherapy (LONIPCs), 9 idiopathic PPFE, and 9 other fibrotic ILDs (idiopathic pulmonary fibrosis, IPF; other idiopathic interstitial pneumonias, other IIPs; connective tissue disease-associated ILD, CTD-ILD, and hypersensitivity pneumonia, HP). Radiological PPFE was associated with previous history of pneumothorax, lower body mass index, lower percentage of predicted forced vital capacity (%FVC), higher percentage of predicted diffusion capacity of carbon monoxide, less desaturation on six-minute walk test, and hypercapnia. The median survival time of all study cases was 449 days. Thirty-seven (28%) received LTs: cadaveric in 31 and living-donor lobar in six. Of 93 patients who did not receive LT, 66 (71%) died. Radiological PPFE was marginally associated with better survival after adjustment for age, sex, %FVC, and six-minute walk distance < 250 m (hazard ratio 0.51 [0.25-1.05], p = 0.07). After adjustment for covariates, idiopathic PPFE and LONIPC with radiological PPFE was associated with better survival than fibrotic ILDs without radiological PPFE (hazard ratio 0.38 [0.16-0.90], p = 0.03), and marginally better survival than other fibrotic ILDs with radiological PPFE (hazard ratio, 0.20 [0.04-1.11], p = 0.07).

CONCLUSIONS

idiopathic PPFE and LONIPC with radiological PPFE has better survival on the wait list for LT than fibrotic ILDs without radiological PPFE, after adjustment for age, sex, %FVC, and six-minute walk distance.

Gastrointestinal complications after lung transplantation in Japanese patients

PURPOSE

Gastrointestinal complications after lung transplantation (LTx) are an important postoperative morbidity associated with malnutrition and the malabsorption of drugs. We reviewed our experience of managing gastrointestinal complications after LTx.

METHODS

Between June, 2008 and April, 2017, 160 lung transplants were performed at our institution, as living-donor lobar lung transplants in 77 patients, and as deceased-donor lung transplants in 83. We reviewed, retrospectively, the incidence, type and management of gastrointestinal complications.

RESULTS

Among the 160 LTx recipients, 58 (36.3%) suffered a collective 70 gastrointestinal complications, the most frequent being gastroparesis, followed by gastroesophageal reflux disease. Two complications were managed surgically, by Nissen fundoplication for gastroesophageal reflux disease in one recipient and Hartmann's operation for sigmoid colon perforation in one. The other 68 complications were managed medically. Two patients died of complications: one, of aspiration pneumonia caused by gastroparesis; and one, of panperitonitis caused by a gastric ulcer. There were no significant differences in overall survival or chronic lung allograft dysfunction-free survival between the patients with and those without gastrointestinal complications.

CONCLUSIONS

Gastrointestinal complications are not uncommon in LTx recipients and may be serious; therefore, early detection and appropriate treatment are imperative. Surgical management is required for some complications, but most can be managed medically.

Living-related lung transplantation

Living-donor lobar lung transplantation (LDLLT) was developed to deal with the severe shortage of brain dead door for patients who would not survive the long waiting period. In standard LDLLT, right and left lower lobes removed from two healthy donors are implanted into a recipient after right and left pneumonectomies using cardiopulmonary bypass (CPB). The number of LDLLT has decreased in the USA due to the recent change in allocation system for cadaveric donor lungs. For the past several years, most of the reports on LDLLT have been from Japan, where the average waiting time for a cadaveric lung is exceeding 800 days. LDLLT has been performed both for adult and pediatric patients suffering from various end-stage lung diseases including restrictive, obstructive, vascular and infectious lung diseases. Since only two lobes are implanted, size matching is a very important issue. Functional size matching by measuring donor pulmonary function and anatomical size matching by three-dimensional computed tomography (3D-CT) volumetry are very useful. For oversize graft, we have employed several techniques, including single lobe transplantation, delayed chest closure, downsizing the graft, and middle lobe transplantation. In cases of undersize mismatch, native upper lobe sparing transplant or right-left inverted transplant was performed. The 5-, 10- and 15-year survivals were 80.8%, 72.6% and 61.7%, respectively. There was no difference in survival between standard LDLLT and non-standard LDLLT such as single, sparing and inverted transplant. All donors have been discharged without any restrictions. LDLLT is a viable option for very ill patients who would not survive a long waiting time for cadaveric lungs. We have successfully developed various surgical techniques to overcome size mismatching with favorable outcome.