Eur J Cardiothorac Surg 1999;15:658-662
© 1999 Elsevier Science NL
Bilateral lung transplantation via two sequential anterolateral thoracotomies1
Shahrokh Taghavia,
Tudor Bîrsana,
Arpad Pereszlenyia,
Natascha Kupilika,
Elena Deviatkoa,
Wilfried Wissera,
Heinz Steltzerb,
Walter Klepetkoa
a Division of Cardiothoracic Surgery, University of Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria
b Division of Anesthesiology, University of Vienna, Vienna, Austria
Received 22 September 1998;
received in revised form 12 January 1999;
accepted 10 February 1999.
Corresponding author. Tel.: +43-1-4040-05620; fax: +43-1-4040-05642; e-mail: walter.klepetko@akh-wien.ac.at
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Abstract
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Objective: Bilateral anterior trans-sternal thoracotomy (clam shell incision) is the standard approach used for bilateral sequential lung transplantation (BLTX). The morbidity of this large incision can be considerable. Two separate sequential anterolateral thoracotomies represent a less invasive approach. Methods: The value of this approach was investigated in a prospective series of 22 consecutive patients who received BLTX between June 1997 and July 1998. Their underlying diseases were COPD (n=16), cystic fibrosis (n=4) and other (n=2). All patients underwent BLTX through two anterolateral thoracotomies, without the use of cardiopulmonary bypass. The anterior mediastinum and the sternum with all the surrounding tissue were left completely intact. Twenty-one patients underwent spirometrical examination during the postoperative in-hospital stay. Follow-up is 7±4 months (range: 3 to 15). Results: The only intraoperative complication was severe reperfusion edema of the first transplanted lung seen in one patient at the end of the operation, which required pneumonectomy during the same session. All other operations were uneventful. The difference between the cold ischemic time of the first and second transplanted lung was 83±17 min. Median intubation duration, ICU- and in-hospital-stay were 1.5, 5 and 20 days, respectively (ranges: 1 to 96, 2 to 96 and 15 to 96, respectively). One major perioperative complication occurred and was due to gross donor/recipient size mismatch: the patient required lobectomy of the consolidated right upper lobe 11 days after transplantation. In 19 patients (86.4%), this less extensive incision allowed early postoperative mobilization, which resulted in good ventilatory performance, with VC of 53±15 and FEV1 of 60±20% of the predicted, respectively, at the first spirometry, 3 weeks after the operation. Three months survival was 100%. Conclusion: The bilateral sequential anterolateral thoracotomy represents a safe and minimal invasive approach for BLTX compared with the clam shell incision. It minimizes the operative trauma, improves postoperative functional recovery and prevents the potential spread of unilateral complications to the other pleural cavity.
Key Words: Bilateral sequential lung transplantation • Minimal invasive surgery • Clam shell incision • Anterolateral thoracotomy
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Introduction
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Bilateral sequential lung transplantation
[1] is the routine procedure for transplantation of both lungs and has largely replaced the en bloc technique
[2]. It is performed through an bilateral, trans-sternal thoracotomy, the clam shell incision, which offers excellent exposure and access to the pleural spaces from the apex to the diaphragm and to the posterior mediastinum on both sides and facilitates mobilization of the lungs and hilar structures.
However, this approach also has several disadvantages. The transverse sternotomy results in a significant restriction of chest wall mechanics in the early postoperative period. This can lead to delayed mobilization and prolonged hospitalization. In addition, in malnourished patients with extremely thin presternal subcutaneous tissue (as lung transplant candidates often present), the site of sternotomy can be affected by infection or delayed healing, eventually leading to development of pseudoarthrosis. Dissection of the anterior mediastinum is an additional factor that increases the risk for postoperative morbidity by generating a communication between the two pleural spaces. Unilateral problems like pneumothorax, pleural effusion or infection can easily affect the contralateral side too.
In an attempt to avoid these disadvantages of the clam shell incision, we have investigated the value of two separate sequential anterolateral thoracotomies as a standard approach for BLTX in a prospective series of 22 consecutive patients. It was hypothesized, that this less invasive approach should provide sufficient access for the transplant procedure without having any disadvantages, compared with the clam shell incision.
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Materials and methods
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From June 1997 to July 1998, all patients with the underlying diagnosis other than pulmonary vascular disease who underwent BLTX at our institution entered the prospective study. A total of 22 patients were operated. Their underlying diagnosis were emphysema (n=16), cystic fibrosis (n=4), and other (n=2), respectively (Table 1). Eight patients (36.4%) had a history of lung volume reduction surgery (LVRS) prior to transplantation.
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Table 1. Underlying diseases of patients who underwent BLTX through two anterolateral thoracotomies (n=22, male to female ratio=15:7)
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Patients were intubated with a double-lumen tube and prepared for operation in standard fashion. Positioning and draping of the patients were performed like for the clam shell incision, with the patients placed on the operation table in a supine position with the arms elevated. Transplantation was started on the side with the worst pulmonary function, with the table rotated towards the contralateral side. A limited anterior thoracotomy in the fourth intercostal space was performed, lungs were retrieved, and the hilus was prepared in standard fashion. Transplantation of the lung was performed in the usual way
[1] with end-to-end bronchial anastomosis, common atrial anastomosis and pulmonary artery anastomosis. After the implantation of the first lung two chest tubes were inserted and the thoracotomy was closed. Without redraping the patient, the operation table was rotated to the other side and transplantation of the left lung was then performed in an identical way. Operative times, intraoperative events and postoperative results were monitored.
Immunosuppression consisted of 1 g methylprednisolone intraoperatively, followed by 125 mg after 8, 16 and 24 h. Thereafter, prednisolone was administered at a dosage of 1 mg/kg body weight per day and tapered down to 0.25 mg/kg after 3 weeks. All patients received Rabbit-ATG (Thymoglobuline, Sero-Merieux, France) 2.5 mg/kg body weight i.v. for the first 4 p.op days. Mycophenolate Mofetil (CellCept, Hofmannn-La Roche, Basel, Switzerland) 2 g/day was given orally from the second p.op day. Cyclosporine A (Sandimmun, Novartis, Basel, Switzerland; target level 350 ng/ml FPIA) or tacrolimus (Prograf, Fujisawa, München, Germany; target level 12±3 ng/ml) was administered i.v. initially, followed by oral administration as soon as possible.
Patients underwent spirometrical examination before being discharged from hospital (usually during the 3rd postoperative week), and were afterwards routinely followed up in our outpatient department every 4 weeks.
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Results
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All patients underwent BLTX without cardiopulmonary bypass. The only intraoperative complication was severe reperfusion edema of the first transplanted lung, seen in one patient (Patient 15) at the end of the operation, which required pneumonectomy during the same session. No technical or anatomical cause for edema was found at explantation. The patient could not be weaned off the respirator and finally died, 96 days after transplantation. At autopsy, histological examination showed severe preservation damage of the transplanted lung. All other operations were uneventful. Average cold ischemic time for the first and second transplanted lung was 232±48 and 315±55 min, respectively. The difference in cold ischemic time between the first and second transplanted lung was 83±16 min (range: 65 to 120). Duration of operation was 234±40 min. Median intubation duration was 1.5 days (range: 1 to 96), and median ICU stay was 5 days (range: 2 to 96). Patients were discharged from hospital after an average of 30 days (SD: 25, median: 20). Data are summarized in Table 2.
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Table 2. Age, operation and hospitalization information of patients who underwent BLTX through two anterolateral thoracotomies
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Perioperatively, patients experienced a series of minor complications: pneumothorax (n=9), acute rejection episode (n=8), PRIND (n=1), seizures (n=1). No bronchial problem occured. There was one major perioperative complication, in a patient transplanted with a significantly larger donor lung (Patient 11). Despite resection of the lingula and middle lobe during BLTX, the patient showed severely impaired pulmonary compliance deriving from compression of the lungs. After lobectomy of the right upper lobe on postoperative day 11, the patient recovered quickly and was discharged from hospital 42 days after transplantation. The postoperative course was very prolonged in one further patient (Patient 10), who underwent bilateral retransplantation due to obliterative bronchiolitis, 4 years after BLTX for pulmonary fibrosis. Poor preoperative clinical status, infectious complications and recurrent rejection episodes made the physical rehabilitation of this patient very difficult, but she was finally discharged from hospital in a good condition 3 months after transplantation.
Nineteen patients underwent lung function tests during the 3rd postoperative week; two more patients with prolonged postoperative recovery (Patients 10 and 11) had the first spirometrical examination at 10 and 5 weeks after transplantation, respectively, and were not included into statistical analysis. Postoperative restriction was evaluated using the vital capacity as a percentage of the predicted value at this spirometry. Mean vital capacity as a percentage of the predicted value (VC%), forced exspiratory volume in one second as a percentage of the predicted value (FEV1%) and Tiffeneau-Index (FEV1/VC) at this examination were 53±15, 60±20 and 93±6, respectively (
Fig. 1 Fig. 2
).
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Fig. 1. Spirometric parameters of 19 patients, 3 weeks after BLTX through two anterolateral thoracotomies. VC%, vital capacity as a percentage of the predicted value; FEV1%, forced exspiratory volume in one second as a percentage of the predicted value; FEV1/VC, relation between the latter and the former.
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Fig. 2. Patient after minimal invasive BLTX. The separate incisions of the two anterior thoracotomies can be seen.
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Mean follow-up of the patients is 7±4 months (range 3 to 15, median 6.5). Three month survival was 100%. Two more patients, except the one already mentioned, died in the later course, both at 4 months after transplantation, due to infectious complications (sepsis with panresistant Burkholderia cepacia and Methicillin resistant Staphylococcus aureus, respectively).
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Discussion
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Patterson et al.
[2], who elaborated the lung transplant procedure, described a technique of en bloc replacement of both lungs with single tracheal, pulmonary artery and atrial anastomoses. The major disadvantage of this approach resulted from the complete interruption of the bronchial circulation at the critical region of the carina leading to a high incidence of tracheal healing problems
[3].
One approach to overcome this problem was initially developed by Couraud et al., and later also adopted by Petterson et al.
[4]
[5], who have used a technique of direct bronchial artery revascularization. Despite its success in preventing problems of bronchial healing, the technical complexity of the procedure limited its widespread application.
Pasque et al., proposed the technique of sequential bilateral lung transplantation, where two separate bronchial anastomoses replaced the tracheal anastomosis. This procedure rapidly became the standard approach for replacement of both lungs
[1]. The bilateral anterior trans-sternal thoracotomy (clam shell incision), allows to approach both pleural cavities at once and offers a superb view. This aspect is of particular importance when operating on patients with severe adhesions or patients with previous operations. Currently, most bilateral lung transplantations world wide are performed in this way
[6].
Although the clam shell incision offers undisputable advantages, it can also be associated with significant morbidity in the postoperative course. Since 1989, we have observed in a total of 104 BLTX procedures, two patients with disturbed healing of the sternum, requiring a surgical reintervention. In addition, several events of postoperative pneumothoraces after BLTX presented bilaterally, with the need for bilateral drainage therapy. Finally, early after BLTX patients have a considerable degree of restriction in spirometry due to their limitations in chest wall mechanics, thus increasing the risk for acquiring infection. For these reasons it must be questioned, whether BLTX could not be performed in a less invasive way.
It was hypothesized that BLTX could be performed via two separate anterior thoracotomies with the same operative result but reduced morbidity. In a first step this approach was offered to patients with enlarged chest cavities only (i.e. mainly patients with COPD and cystic fibrosis). Patients were operated in the same position as for the clam shell incision. They were draped in the same way and the two anterolateral thoracotomies were performed in a sequential way, only with rotating the table position. This avoided sternal split, interruption of the internal mammary arteries and dissection of the mediastinum and, therefore, kept the two pleural spaces completely separated. The two separate thoracotomies can easily be converted into a standard clam shell incision, although it was not necessary in the present series. Despite the restricted view offered by the anterolateral thoracotomy, no difficulties were encountered in performing bronchial or vascular anastomoses and all patients tolerated well the implantation of the lungs. No bronchial problems occurred in these patients during follow-up.
Although eight patients underwent previous thoracic surgery and four other patients suffered from cystic fibrosis with significant adhesions, dissection of the pleural space was always performed in a satisfying way, and no patient needed later reoperation for bleeding.
In this prospective series of 22 patients we have experienced only one intraoperative complication. However, there was no evidence for it to be related to the described method. Donor evaluation, lungs retrieval and preservation were performed in the usual way at our center. Cold ischemic time of the graft was comparable in this patient to all other patients. Intraoperatively, there was no evidence for severe pulmonary hypertension, and at pneumonectomy no technical cause for the severe reperfusion edema could be found. Finally, this patient was the only one who died before being discharged from hospital; histologic examination after autopsy established the diagnosis of graft preservation damage.
Postroperative restriction is characteristic for all patients after such an invasive thoracic surgical procedure like BLTX. Ventilatory performance early after the operation was very good in this group of patients. A vital capacity exceeding 50% of the predicted value early after transplantation accounts for a rapid functional recovery, also shortening the duration of hospitalization.
This study demonstrates that there are no major disadvantages of the suggested method, and the functional recovery of patients after BLTX is very good. From this experience, we suggest that two separate anterior thoracotomies should be the standard approach for BLTX in patients with large chest cavities.
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Footnotes
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Presented at the 12th Annual Meeting of the European Association for Cardio-thoracic Surgery, Brussels, Belgium, September 20–23, 1998. 
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References
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- Pasque M.K., Cooper J.D., Kaiser L.R., et al. Improved technique for bilateral lung transplantation: rationale and initial clinical experience. Ann Thorac Surg 1990;49:785-791.[Abstract]
- Patterson G.A., Cooper J.D., Goldman B., et al. Technique of successful clinical double lung transplantation. Ann Thorac Surg 1988;45:626-633.[Abstract]
- Patterson G.A., Todd T.R., Cooper J.D., et al. Airway complications following double lung transplantation. J Thorac Cardiovasc Surg 1990;99:14-21.[Abstract]
- Couraud L., Baudet E., Martigne C., et al. Bronchial revascularization in double-lung transplantation: a series of 8 patients. Ann Thorac Surg 1992;53:88-94.[Abstract]
- Petterson G., Arendrup H., Mortensen S.A., et al. Early experience of double-lung transplantation with bronchial artery revascularization using mammary artery. Eur J Cardio-thorac Surg 1994;8:520-524.[Abstract]
- Patterson GA, Isolated lung transplantation. In: Kapoor AS, Laks H, Schroeder JS, Yacoub MH, editors. Cardiomyopathies and heart-lung transplantation, New York: McGraw-Hill, 1991.
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Abstract
Introduction
