Video-assisted minimally invasive approach in clinical bilateral lung transplantation

Impact of minimally invasive lung transplantation on early outcomes and analgesia use: A matched cohort study

BACKGROUND

Minimally invasive (MI) approaches to lung transplantation (LTx) offer the prospect of faster recovery compared to traditional incisions, however, little data exist describing the impact of surgical technique on early outcomes and analgesia use.

METHODS

A prospectively maintained institutional registry identified 170 patients who underwent LTx between January, 2017 and June, 2022. Post-COVID acute respiratory distress syndrome, repeat, and multiorgan transplants were excluded (n = 27) leaving 37 MILTx and 106 traditional LTx patients. Propensity score matching by age, sex, body mass index, diagnosis, lung allocation score, double vs. single lung, hypertension, diabetes, and hospitalization status created 37 pairs.

RESULTS

Before matching, MILTx patients were more often male (70% vs 43%) and more likely to receive grafts from younger (31 vs 42 years), circulatory death donors (19% vs 6%) compared with traditional LTx patients (all p < 0.05). After matching, there were no differences in graft warm ischemia or operative duration (both p > 0.05). Postoperatively, MILTx experienced shorter intensive care unit (ICU) (4.3 [IQR 3.1-5.5] vs 8.2 [IQR 3.7-10.8] days) and hospital lengths of stay (LOS) (13 [IQR 11-15] vs 17 [IQR 12-25] days) (both p < 0.05). Among patients surviving to discharge, MILTx patients required fewer opioid prescriptions at discharge (38% vs 66%, p = 0.008) and had improved pulmonary function at 3 months (Forced expiratory volume in 1 second 82 [IQR 72-102] vs 77 [IQR 52-88]% predicted; forced vital capacity 78 [IQR 65-92] vs 70 [IQR 62-80]% predicted] (both p < 0.05).

CONCLUSION

Minimally invasive LTx techniques demonstrate potential advantages over traditional approaches, including reduced ICU and hospital LOS, lower opioid use on discharge, and improved early pulmonary function.

Robotic-assisted lung transplantation: First in man

Lung transplantation remains the best option for patients with end-stage lung disease. However, this operation has historically carried significant potential morbidity. To improve near-term patient outcomes, attempts have been made to decrease invasiveness, but this is limited by the complex nature of the operation and the anatomy of the chest. To facilitate further reduction in incision size and augment our existing minimally invasive approach, we developed a novel technique utilizing the Da Vinci robotic system to implant a right lung in a 69-year-old recipient.

Advances in robotic lung transplantation: development and validation of a new surgical technique in animal models

The objective of this study was to describe a novel minimally invasive robotic video-assisted approach for lung transplantation, utilizing a minimally invasive technique with a subxiphoid incision, in an animal experimentation model. Two left robotic-assisted single lung transplants were performed in sheep using a robotic surgical system. A subxiphoid incision was made, and robotic ports were inserted into the thoracic cavity for dissection and anastomoses of the bronchus, artery, and pulmonary veins. The integrity of anastomoses was evaluated, and procedural details were recorded. Both animals survived the procedure, with a mean duration of 255 min and a mean console time of 201 min. Anastomoses were performed without complications, and the closed-chest approach with a subxiphoid incision proved successful in preventing gas leakage. The novel approach demonstrated improved exposure and workflow compared to existing techniques. The minimally invasive robotic video-assisted approach for lung transplantation utilizing a closed-chest technique with a subxiphoid incision appears safe and feasible in an animal experimentation model. Further studies in the clinical setting are warranted to establish its feasibility and safety in human lung transplantation. This approach has the potential to offer benefits over the traditional Clamshell incision in lung transplantation procedures.

Lung Transplantation for Pulmonary Artery Hypertension

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.

Anesthetic management of lung transplantation: Results from a multicenter, cross-sectional survey by the society for advancement of transplant anesthesia

BACKGROUND

Current protocols for the perioperative care of lung transplant (LTX) recipients lack rigorous evidence and are often empiric, based upon institutional preferences. We surveyed LTX anesthesiologists to determine the most common practices.

METHODS

We developed a survey of 40 questions regarding perioperative care of LTX recipients using Qualtrics software. The survey was sent out to members of the Society of Cardiovascular Anesthesiologists performing LTX at geographically diverse sites to facilitate data collection for as many practices as possible.

RESULTS

The responses were center-weighed (127 responses, 85% from academic settings). The clamshell approach was commonly used (70%). Cardiopulmonary bypass was preferred by 56%, ex vivo lung perfusion utilized by 43%, and 49.4% indicated they use lungs from donation after circulatory determination of death. Most (69%) used oximetric pulmonary artery catheters, 60% used tissue oximetry, and 89.3% utilized transesophageal echocardiography. Inhaled nitric oxide was preferred by 48%, restrictive fluid management by 48%, and systemic analgesia advocated by 49% of participants. Inspired oxygen concentration <30% was applied to the new lung on reperfusion by 28% of the respondents.

CONCLUSION

Variations in healthcare delivery and utilization for LTX recipients indicate gaps in knowledge and potential opportunities to improve the quality of care.

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.

Moving Back to the Future: Use of Organ Care System Lung for Lobectomy Before Lobar Lung Transplantation

BACKGROUND Lung transplantation remains the gold standard treatment for patients with end-stage lung disease. Lobar lung transplantation allows for transplantation of size-mismatch donor lungs in small recipients; however, donor lung volume reduction represents a challenging surgical technique. In this paper we present our initial experience with bilateral lobectomy in donor lungs before lobar lung transplantation using normothermic perfusion on the Organ Care System (OCS) Lung. MATERIAL AND METHODS Specifics of the surgical technique for donor lung instrumentation on the OCS, lobar dissection on the OCS, and right and left donor lobectomies are presented in detail. RESULTS Potential advantages of the use of the OCS for lobectomy for lobar lung transplantation are described in this section. Donor lung volume reduction utilizing OCS appeared to be easier and safer compared to the conventional cold storage technique, due to continuous perfusion of the lungs with blood and well-distended vessels that offer the feel of live lobectomy. Moreover, the OCS represents a platform for donor organ assessment and optimization of its function before transplantation. CONCLUSIONS Donor lung volume reduction was safe and feasible utilizing the OCS, which could be a useful tool for volume reduction in cases of size mismatch. Further research is needed to evaluate early and long-term results after lobar lung transplantation using the OCS in clinical studies.

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.

Paclitaxel-coated balloons in refractory nonanastomostic airway stenosis following lung transplantation

Airway stenosis represents the commonest airway complication following lung transplantation, affecting between 7% and 18% of patients. Existing treatment options offer limited efficacy and can cause additional patient morbidity. Paclitaxel-coated balloons (PCB) have proved effective in managing postinterventional coronary artery re-stenosis. In a first-in-man study, we evaluated similar PCBs in refractory nonanastomotic airway stenosis in 12 patients. Following a single application, luminal patency was maintained in 50% at 270 days. No significant peri-interventional or early postinterventional complications occurred. Given these encouraging initial findings, further studies appear warranted.

Sternal-sparing approach for reoperative bilateral lung transplantation

OBJECTIVES

A sternal-sparing approach for bilateral lung transplantation was recently applied to reoperative lung transplant cases and is compared with the traditional clamshell approach.

METHODS

A retrospective analysis of 15 consecutive reoperative bilateral lung transplants performed from January 2008 to April 2011 was conducted. Outcomes were compared between the first 11 patients who underwent the traditional clamshell and the most recent 4 patients who underwent the sternal-sparing approach.

RESULTS

The indication for retransplantation was obliterative bronchiolitis in all patients. Both groups were similar with regard to age, allograft ischaemic time and operative time. Cardiopulmonary bypass was more frequent in the sternal-sparing group although required for a shorter period of time. The need for postoperative extracorporeal membrane oxygenation for primary graft dysfunction was similar in both groups. The length of ICU care and total hospitalization length of stay were similar for the sternal-sparing group compared with the traditional clamshell approach. Operative mortality and overall survival also did not differ.

CONCLUSIONS

Reoperative bilateral lung transplantation with a sternal-sparing approach is feasible and may yield outcomes similar to those in the traditional clamshell approach. Further analysis with larger numbers of patients is warranted to delineate the benefits of this approach for patients requiring reoperative lung transplantation.

Update on lung transplantation

Lung transplantation is a suitable treatment to improve the quality of life and the prognosis of patients with various end-stage pulmonary diseases. There is a shortage of organs and the number of patients on waiting list is exceeding the number of transplants per year approximately two-fold in most countries. Strategies to increase the donor pool are therefore crucial. The long-term prognosis after lung transplantation is not yet as good as for other transplantation procedures and special complications should be taken into account. Aside from infections chronic organ dysfunction is the main cause of death and the most important prognosis limiting factor. Other typical problems are rejection, bronchus complications, and primary transplant dysfunction. However, the results of large centers show promising improvements in recent years.

Effects of exogenous surfactant instillation in clinical lung transplantation: a prospective, randomized trial

OBJECTIVE

Despite the introduction of low potassium-based preservation strategies for clinical lung transplantation, relevant early graft dysfunction occurs in up to 20% of cases after lung transplantation. This was found to be frequently associated with postreperfusion surfactant dysfunction. We performed a randomized, prospective study investigating the effect of exogenous surfactant instillation into human donor lungs on posttransplant surfactant function and on clinical outcome.

METHODS

Exogenous surfactant was instilled into 15 donor lungs before retrieval via bronchoscopy. Bronchoalveolar lavage fluids were taken before instillation as well as 24 hours after transplantation. Surfactant function, phospholipids, and protein content in bronchoalveolar lavage fluids were assessed and clinical data prospectively recorded. Pulmonary function testing was performed 4 weeks after lung transplantation. Additionally, the best forced expiratory volume in 1 second was determined within the first year after lung transplantation. The control group consisted of 14 patients receiving donor lungs without surfactant instillation in randomized order. Pulmonary function test results were further compared with those of 154 consecutive recipients of bilateral lung transplants, which were not involved in the study (historical control).

RESULTS

No deaths occurred during the first year after lung transplantation. Surfactant function in donor lungs was within normal ranges before harvest. In the control group, surfactant function was markedly impaired after reperfusion. This was significantly improved by surfactant substitution. Protein content of the bronchoalveolar lavage fluid in the surfactant group was significantly lower, indicating less leakage through the alveolocapillary membrane. Forced expiratory volume in 1 second after 4 weeks was significantly higher in the surfactant group than in either control group (P = .034 and .01, respectively). Interestingly, the best forced expiratory volume in 1 second during the first year after lung transplantation was significantly higher in both control groups compared with forced expiratory volume measured in examinations 4 weeks after lung transplantation (P = .01). The best forced expiratory volumes in 1 second of control patients were comparable with those in surfactant lungs 4 weeks after transplant.

CONCLUSIONS

This study indicates a protective effect of exogenous surfactant instillation to donor lungs before retrieval on post-lung transplantation surfactant function and on early clinical outcome. This approach may help to improve the outcome after lung transplantation in the future.

[Surgical aspects of (cardio) pulmonary transplantation]

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.

Technical considerations in lung transplantation

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