Eur J Cardiothorac Surg 2002;22:833-835
© 2002 Elsevier Science NL
Synchronous left lung transplantation and right pneumonectomy for end-stage bronchiectasis through Clamshell approach. Specific problems
Jacques Jougon*,
Claire Dromer,
Tarun Mac Bride,
Jean François Velly
Service de Chirurgie Thoracique du Pr J.F. Velly, CHU de Bordeaux, Hôpital du Haut-Lévêque, Bordeaux University Hospital, Avenue de Magellan, 33604 Pessac, France
Received 10 July 2002;
accepted 4 August 2002.
* Corresponding author. Tel.: + 33-557-656-009; fax: +33-557-656-021
e-mail: jacques.jougon{at}chu-bordeaux.fr
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Abstract
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A synchronous right pneumonectomy and left lung transplantation is reported in a case of asymmetric thorax. An extreme shift of the mediastinum and over distension of the transplanted lung is shown 3 years later. Post pneumonectomy syndrome must be seeking in this alternative technique.
Key Words: Lung transplantation • Pneumonectomy • Postpneumonectomy syndrome
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1. Introduction
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Lung transplantation is an established therapeutic option for treating patients with end-stage lung disease. Double lung transplants give better results than single lung transplants in terms of lung function tests and exercise tolerance, but unilateral lung transplantation is a more economical solution to maximize use of the donor pool. However, double lung versus single lung comparisons did not show significant difference in survival benefit [1]. On the other hands, in case of septic lung disease (such as cystic fibrosis or bronchiectasis) in order to avoid recurrent infections, removal of all contaminated lung tissue requires bilateral sequential lung or heart lung transplantation [2,3]. In the case of a huge asymmetric chest, a first resection of the destroyed retracted lung and delayed single lung transplantation is an acceptable therapeutic option [4]. We present herein a case of left lung transplantation with right synchronous pneumonectomy through a Clampshell approach in a patient with bronchiectasis and an asymmetric thorax. Specific problems due to this method and occurring in the postoperative course are discussed.
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2. Case report
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A 30-year-old man was referred to us in 1996 for assess and transplantation for end stage respiratory insufficiency treated by oxygen therapy (1.5 l/mn) over night since 1986. He suffered from extensive bronchiectasis with destroyed and retracted right lung (Fig. 1)
. His past medical history consisted in a left pneumothorax treated by tube drainage 1 year before. Sputum culture revealed Pseudomonas aeruginosa and alpha haemolytic Streptococcus organisms. A perfusion scan showed absence of function of the right lung. Heart function was normal without pulmonary hypertension (mean pulmonary pression: 26 mmHg). Spirometry data and blood gas are presented in Table 1. The patient was listed for synchronous single left lung transplantation and right pneumonectomy in 1996.
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Fig. 1. CT scan and chest X-ray (in each corner) performed (A) before transplantation; and (B) 3 years after left lung transplantation and right pneumonectomy. See over distension of the left transplanted lung filling all the thoracic cavity and extreme mediastinal shift.
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On July 1999, a suitable donor was found. The left lung obtained by distal procurement from a 20-year-old female donor (170 cm height and 60 kg weight) was perfused with 2 l of Celsior® conservation solution, and transported on ice(1).
In the recipient, a single lumen tube was used during anaesthesia. The recipient chest was entered through a Clamshell approach (5th intercostal space). There were dense pleural adhesions, which were freed by electrocautery before starting cardiopulmonary bypass. The ascending aorta and right atria were cannulated for cardiopulmonary bypass without cardiac arrest but with right cavity flow discharge. After starting the cardiopulmonary bypass, the right retracted lung was first resected. Right bronchial suture was performed by staple reinforced by some interrupted stitches resorbable and buttressed by mediastinal tissues. Then, left pneumonectomy was performed. A wash of the tracheal tree was achieved with saline iodine serum after the left bronchus been clamped. Then, the left donor lung was implanted. All three anastomoses were made in a customary fashion, with wrapping of the bronchial anastomose with mediastinal tissues [5]. After reperfusion the patient was weaned from cardiopulmonary bypass without difficulty. A water sealing chest tube was left in the right cavity and two aspirating chest tubes (-20 mmHg) in the left cavity. There were no intraoperative complications. The total ischemic time was 180 min and total bypass time was 176 min.
Postoperative immunosuppressive regimen was triple-drug therapy consisting of antilymphocyte globulin, cyclosporine, and prednisolone. The first post-operative chest X-ray showed a small left pneumothorax, mediastinal shift to the right and mild lung infiltration. The right chest tube was removed on the 2nd post-operative day and the left on the 10th postoperative day. Neither rejection nor infection occurred. Inefficient mechanical ventilation led to delayed weaning from the respirator. Arterial blood gases were PO2=146 mmHg; PCO2=50 mmHg; Ph=7.46 on the 5th postoperative day under assisted ventilation with 30% of inspired oxygen fraction. Extubation was attempted but subsequently required re-intubation the following day because acidosis increased (PO2=82; PCO2=66 mmHg; Ph=7.34). A tracheotomy was then performed on the 9th postoperative day, which enabled complete weaning from the respirator 2 days later. The patient was discharged from the hospital on the 48th postoperative day. Tracheotomy was spontaneously closed 2 months later.
Since then, recovery was spectacular with normal life. Functional tests performed before transplantation and 3 years later (on the 27th of March 2002) is shown on Table 1. The chest X-ray and computed tomography (CT) scan show absence of right cavity, which is filled by a total mediastinal shift (Fig. 1).
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3. Discussion
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End-stage chronic infected pulmonary diseases such as cystic fibrosis used to be treated by bilateral sequential lung transplantation. In this case, a particular problem was the asymmetric shift of the mediastinum leaving a very small right thoracic cavity. Bilateral sequential lung transplantation would have needed major volume reduction of the right lung or right lobar lung transplant. We also thought that such a mediastinal shift would reduce diaphragmatic movement, leading to bad mucus drainage of the right transplanted lung. Other alternative could have been a two-stage approach as reported by Piotrowski et al. [4]. It consisted in first right pneumonectomy through a right thoracotomy and delayed left lung transplantation. Such a two-stage approach (with right pneumonectomy first) would have been well tolerated because the right lung was without function. It would have avoided taking the risk of bronchial stump dehiscence as well as pleural empyema in the early immunosuppressive course. However due to donor shortage we were unable to plan the transplantation. In this case waiting time before transplantation was 41 months.
Weaning from ventilation was delayed because of hypoventilation of the small lung into the single large communicated thoracic cavity. An oversize lung would have been better in this situation. Tracheotomy was the optimal option for wean from the respirator.
In our patient, we paid attention to a likely postpneumonectomy syndrome which is possible because of the over shift of the mediastinum. Postpneumonectomy syndrome which has been described more likely after right pneumonectomy, occurs mainly in young patients in whom the bronchus is softer and more compressible and the mediastinum has more elasticity [6,7]. In our patient, section of mediastinal fixations to the anterior chest wall during the Clamshell approach increased mediastinal mobility. A bilateral anterior muscle sparing thoracotomy with femoral cardiopulmonary bypass may be the technique of choice avoiding communication of the two chest cavities.
Nevertheless, this case illustrates that this is an alternative technique in such a patient.
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Footnotes
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1 Celsior®, IMTIX SangStat S.A.S. 58, avenue Debourg B.P. 7055, 69348 Lyon Cedex 07, France. 
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References
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- Charman S.C., Sharples L.D., McNeil K.D., Wallwork J. Assessment of survival benefit after lung transplantation by patient diagnosis. J Heart Lung Transplant 2002;21:226-232.[Medline]
- Forty J., Hasan A., Gould F.K., Corris P.A., Dark J.H. Single lung transplantation with simultaneous controlateral pneumonectomy for cystic fibrosis. J Heart Lung Transplant 1994;13:727-730.[Medline]
- Shennib H., Massard G., Gauthier R., Colman N., Mulder D. Single lung transplantation for cystic fibrosis: is it an option? Cystic fibrosis transplant Group. J Heart Lung Transplant 1993;12:288-293.[Medline]
- Piotrowski J.A., Splittgerber F.H., Donovan T.J., Ratjen F., Zerkowski H.R. Single-lung transplantation in a patient with cystic fibrosis and a asymmetric thorax. Ann Thorac Surg 1997;64:1456-1458.[Abstract/Free Full Text]
- Couraud L., Baudet E., Velly J.F., Dubrez J., Jougon J., Dromer C. Transplantations pulmonaires: unipulmonaires, cardiopulmonaires, bipulmonaires. In: Encycl. Méd. Chir. Techniques chirurgicales – thorax. Paris: Elsevier, 1997.
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Abstract
1. Introduction
