Influence of Surgical Technique on the Results of Pulmonary Reimplantation

•

CLINICAL INVESTIGATIONS

Influence of Surgical Technique on the

Results of Pulmonary Reimplantation*

George E. Duvoisin, .\J.D., W. Spencer Payne, ,\J.D., F.e.c.p., and F. Henry Ellis, Jr., M.D.

The left lung was reimplanted in 94 mongrel dogs with an operative mortality rate of 36 percent. Avoidable technical factors were found to be responsible not only for the majority of operative deaths but also for the defective anastomoses in 45 of the 60 surviving animaJs. Narrowing of the vascular anastomoses was related to suture technique and accounted for the minority of complications. Bronchial necrosis and its sequelae were the predominant causes of a defective reimplanted lung and could be minimizd by maintaining a long proximal bronchial stump with an intact blood supply. The use of interrupted sutures to approximate the cartilaginous portions of the bronchus proved to be superior to a continuous suture technique.

R eimplantation of a lung provides the opportunity

venollsly pro\ided a satisfactof)' level of anesthesia for the initial steps of the proceduTt', hut supplempntary doses were

to evaluate physiologic parameters that might otherwise he obscured by rejection phenomena after homotransplantation. Despite abundant ex· perience from various institutions, pulmonary reim-

=-=---=---=-. - For-~i~rial

utilized as needed, espedally when animals were studied in the immediate postoperati"e period. All animals were intuhatt"
romment see page 94 y

Surgical Technique of Left Pulmonary Reimplantation

plantation has heen followed by a high operative mortality and persistently poor functional results. \'arious explanations for these unsatisfactory events have heen offered, but it is our opinion that these poor results can he correlated with anatomic deficiencies related to surgical technique. The purpose of this report is to describe our method of left pulmonary reimplantation and to review the rt'lation of certain featurt's of operative technique to mortality and structural intt'grity of the lung.

Tbe left chest was entered throuj(h the bed of the noore· sected fifth rib (Fig 1 ). The inferior pulmonary lij(ament was divided and the se"ered vessels were ligated. The lung was wrapped carefully in a towel to facilitate manipulation and minimizE' trauma durin~ the procedure. The left hilus was di~st"ctt>d completely, takin~ care that no bands of tissue remained bt'lween the lunj( and the mediastinum. The left main-stem hronchus was cleanly dissected onty in the area of the proposed anastomosis. Small hilar vessels were lij(ated proximally but not distally. Hilar mobilization was facilitated by opening the peri· cardium, thus allowing dissection of the entire left as well as portions of the right pulmonary artt·ry. Extensive mobilization of the left atrium by blunt and sharp dissection, as a prerequisitt, for a functionin~ ana... tolllosis for a lar~e atrial cuff. wa~ necpssary to prevent technical difficulties in suturin~ this thin friable tissue. Once the left hilus was well mobilized the lung was r('implanted by serial division and reana'itomosis.l Anticoagulation was accomplished three minutes prior to placement of vascular clamps by injecting a solution of heparin (1.5 to 3.0

~IATERIAL

i\inety-foliT adult male and female mon~Tel

do}!s ing from 11.2 to 31.4 kg underwent reimplantation of the left lung. Pentobarbital (30 mg/kg of body w"ij(bt) giveo intra-

°From the \Iayo Clinic and \Iayo Foundation: Section of Surgery, RCK.·hester, ~linnesota.

This investij(ation was supported in part by a grant from the \1innesota Heart Association.

96

97

RESULTS OF PULMONARY REIMPLANTATION

F'Gt:RE 1. Technique of left lung rt"implantation in the do~. Top, Lt·ft thorax is f'ntt'Tt'd through a It"ft fifth intercostal incision. l'sual rl'lationship of heart, ~reat yt·ssds. and left lung is shown. RighI. After individual

L,·,!.

pulmonary hilar stnlchlrt's arC' isolated ther are di,'ided and seriallv anastomosed, After adIllinistration of heparin. It'ft pulIllonary artery is occluded (not shown) and vascular clamps are applied to pulmonary v"ins and It'ft atrium. After incision of inferior and anterior wall of isolatPd portion of atrium, posterior aspect is carefully divided under direct vision, If>a\'in~ a 4-mm to .)-mm cuff on atrial side, L"ft atrial anastomosis is heJt\1n well on anterior aspect of tht' inferior anglt" as a sing-lt·-layer, running ("\"{'fling mattn'ss stitch of 6-0 nonahsorhahh.· sutUf(' material. aorta; PA pulmonary artery; PV = pulmonary ,·"in,

.\ =

mg/k,l.!;) eitht'T into a pt'riphpral n'in Of directly into the pulmonary artt'r)'. The hilar struehln's were dh'ided and serially i.lIIastoIHOS(>tl, tilt' lIlost freqlll'nt sequt'I1Ct· heing It.. ft atrium. 1l1ilmonaJ')' artery. amI left main hronchus. The pulmonilry \"('nmls anilstomosis was aCTomplished by direct approximation of a Cliff of til(> It>ft atrium. as slIgj.!psted by ~Ietra ."i.~ After anticoagulation a \'asclilar damp was placed on til(' It·ft pulmonary artery and a Satinsk~' damp "'as plal't'd over tilt' Idt atrium. in<:lmlin~ tilt' orifil't' of tilt' It·ft pul~ monar)" ,'('ins. \\'hellen'r the If:ft atrial cliff was short. \·.L';CUlar forceps ' . .·{..rt' nst'd to draw lip an 'lddihonaJ few milliFIGt."RE :2. Tpc:hnillUl' of h·ft hmg reimplantation (l'ontinued from Fi~urt· 1) showinl!; Illt'thnds of ana.o;bunosis of pulmonary arh'ry and bronchus. .-\110("('. Left pulmonary arb'r" is di,'ided h(·tWt"t"n -vascu!a'r damp.. and is T{"'approximated with do\thlf"-stay running, o\'pr-aml-on'r, single row of 6-0 nonah.. orhahle suhlr" matt··rial. Aftt'r l'ompl(·tion of "a",cIlJar anastomoses. all occlusive damps are n,·llloH·d and hlond flo\\' is rt't·,tahlislwd to It·ft lung. Belol(', [At main-stem hronchus is di,'ided with scalpel close to origin of It·ft upper-Inhe hrondl1ls. Bv a
CHEST, VOL 58. NO, 2, AUGUST 1970

=

meters of atrial tissue. a maneun'r that was ('sIX'dally Iwlpful in the region of the small ~lIperior pulmonary vein. Cart· was taken to ilvoid impingement of tlw anb-rior blade of the damp on the left corollary \'{>s.\l'ls and til(' posterior hladt· Otl the right pulmonary ,·('in...;. Once th" atrial damp wa.s optimally situated. a Satiusky damp was plat."'t·d to include all thn't' left pulmonary \'l'ins a.' tlwy leav(' the lung. After incision of the inferior atrial angle. the anterior waH was divided "dth Potts' sdssors, allo\ving d"ar ,-isualization of the posl<'rior atrial wall (Fi~ I). This latt"r structure could th"n be sewred. leaving a cuff of 4 to 5

98

DUVOISIN, PAYNE AND ELLIS

mm nn the atrial side. At this time any remaininl>: hands nf tissue conne<.·ting the hilus to the heart or media.~tinum were se\·ered. fnr the posterinr aspe<:t nf the left hilus was nnt entirely exposed. 111.. I.. ft atrial anastomosis was hel>:un wdl on the anterior aspect of th.. inf..rior anl>:l.. as a sinl>:le-Iay..r, runnin~ everting mattress suture of 6-0 Tevdek va~cular suture material (Fil>: 1). Th.. Satinsky clamps w..re r..mnved and silwr clips were placed at several points alnng the everted lips of the atrial anastomosis as an aid to later radioJ;!ntphic identi6<,·ution. After completion of the left atrial anastomosis, the left pulmnnary artery was dh;ded betw....n vascular clamps and reapproximatro in a single layer tlsin~ a double-stay nmning over-and-over suture of 6-0 Tevdek (Fi!: 2). V.. ry lin.. hites of tissue Wefe ne<.'t'Ssary to prevent subsequent narrowing of this ana:;tornosis. In addition, temporary Rauze packing was used to control any anastomotk' leaks. It Was essential to a void use of additional intemlpteu sutures to control ana.~to· motic leak.s, as these invariahly compromised the lumen at the site of anastomosis. All vascular clamps w..re then remo\·..d and hlot"rati\'e hours. Differt'ntial spironletry performed in three animals in varioliS positions within a few hours after reimplantation revealed that the usoal larger ventilatory eXl·hangl· of the dependent IUDg.·:' was prl'Senl. Furthermore, the elastk banda~e was found to have no measurable delt'lerious dreet on tidal volume or oxygen uptake in the reimplanted lung despite its somewhat constricting nature. BIu
Table

Reml/. in L .. nll Re;mplan/a/;on (94 An;mal.)

l--O,...ra/;~"

Result

_"\nirn:ll:,

60

~ur\"i\"al

""it hout stnu-f IIral dpf('(·t \\"ith sfruf'tural t1l'f('("t

E~alllation

of the Reimplanted

Postoperative evaluation was made on clinical ground'\ as well as by broncboscopy, chest roentgenography, selective pulmonary arterioj(raphy, and autopsy. Bronchoscopy was performed immediately after reimplantation and up to six times durinK the postoperative periexl, Standard roentgenograms of the thorax wer.. usually mad.. at the time of arteriography. Selective pulmonary arteriograms were obtained by inserting a size 8 Rodrigues catheter into

45

Death either jUJZular vein and advancing it to the main pulmonary artery under fluoroscopic control in 50 doJ:s on 67 occasions. From one to eight pnt'umatit' injet.. tions of l'ontra~t medium at 6.5 to 75 pounds per square iO(.'h were made on each. ()(.'Cusion, and resulted in s{"\'eral hundrt"<.1 sde<:tivt" pulmonary arlt'riograms ohservffi fluoroscopically and ret'orded on cine-mm. The de~ret> of pulmonary stenosis was determined hy takin~ paper tracings of dne-frames and calculating the deCrecL4ie in cross-sectional area'\ at the site of anastomosis. Animals with less than 50 perl"t'nt of nomlal diamett"r at the ana~tomosis were (,.'on... idered to havt' si~nificant pulmonary stenosi.....

.\Iortality

Operati~e

Of th" 94 dogs operated on. 34 (36 lll'rCent) di..d witbin six wl'l,ks of oIX'ration (Table 1). Xe"rl}" all the de"ths oc('urTl't1 within tilt' first two weeks. with the majority of deaths l)l~ing relatffi t"ither to anestheti<: difficulties or to deficiencies related to one of the three ana....tolllnses (Tahle 2). Tht.· single most common cause of death was bronchial necrosis. In fOllr animals extt'nsive bronchial necrosis resulted in erosion into the pulmonary artery or left atrium, producing a bronl'hO\"ascular 6.stula "nd massive fatal h..moptysis. In thr.... of the four animals dying with h..mothora\, a I..ak in th.. pulmonary artery was suspeckd, hut could not be proved at autopsy. Although pulmonary edema wa.'i ohserved freqllt.·ntly in a,so<"iation with various anatomk deft·t·t,\. it wa" present without apparent cause in thrt't' animaL~. Ventrkular fihrillation developed in eil(ht "nimals duriog the proc-edure. Six dogs wert' sUl'(.·(·ssfully rt.·suscitah·d, although five ulti-

Table

Dea/h. ;n L""1l Re;mplan/fI/;on (94 An;ma',)

2--O,...rat;~e

~l1mt)flr

d,·fpI" L"ft "trium

.\na~tomofi('

Thr(lml)():.;i~

u'"k

Plilmonar~'

.;

I

IRuk

2

St('no:-oi~

I

Bronchu:-,

7 aloof'

Rronl·hoVR:-iCular fil-'tnla AOf'sth(':o:i:l

()v"rdos..

()vprdi:-ofl'nc!('d lU1l1l;

Endotrnl'hpal tull{' H£'mothorux

Pulrnoll:IrY (>(Jpma P11(.. . umonia Disf('ffiJ)('r

t ·nd(·t(·rrnioed Tot,,1

6

4

~lrh'r~·

Thn)ml.o~i1'\

.:\e(·ro~is

.\let/lUds of P",s/operatire Lllng

I.;

3 4

5

I I

3 4

3 3 I I 34

CHEST, VOL. 58, NO.2, AUGUST 1970

99

RESULTS OF PULMONARY REIMPLANTATION

Flc;nu·: :3. :\. :\nh:ropo\terioT thoradc ro{'ntgC'n(J~ralll of i.l dOLl: sh months afteT reimplantation of ldt 11I1l,~. 'fltt' !lonnal ilppt'arant't· despite si1!nificant stenosis of left pullllonary artery. R, PulllIonary arteriogram (ohlique yjew) demonstrating significant anastomotic sb'llo"is (arrOlI: l. malt·!y dit·d witllin ten days. Ano\ia wa, clearly ft.':,-pollsihle for fihrillatioll ill fin' docs. hut no calise was df'tt'r1nitll'd in tilt' n'lIlaillill~ thft,l' animals. It is clt',lT that IlHht of thp

op('ratin-' deaths cmild IIf' related to technical factors.

Uc',,,l,,, of I'Il,t0l'erafirc 1':ra/ualioll of the Rcimp!tllltcd Lrllll.! Tht· fiO Upnali\l' slIni'"OT"; ITabl.· 1 I Wefe dh"itll·d illto two g;nJlIPS on the basis of the presence or ahsenct' of strllctural ddt'd!'i in thl' reimplanted 11In~. as dett·rlllint·d hy tht" tt"dmiqllc'''' dc·... (.'rilwd ahoH'. Forty.fkt" animals had one or 1II0rt' SiCllific.:illit deft'd.. ill the reimplanted lung, all of which \""eft' H·lah'd to strudural ahnormalities of one of the thrpt· Ilft)Jlchmw.;c,dar anastOlllOSl'S (Tahlt· :3 I. Clillica/ Enl/ulltion: This in general was of limitt'd ust'. :\onnally. tht' animals Wl'H' actin> and l·atin\.! on th(' day followill)! r('illlplantation. \\'}U'n dog... had Ic--tban!y or anoH'\ia tlwir ('onclitioll 1I","al1~· dd('rioratt'd, which sugge... tcd tlU' pn'senn' of a Idhal cOlliplieation. On the other hand. the ahst'Jl('(' of any clinical ... ign"i or ... ymptolll'" tlf distn,'ss did not Tabl., 3-."'·'r"",'"ral ..I"015'OIllO';C IJpjPf"f15 (S'PIIO.;.) by Sire ill Rpilllillalll.,.d Lung (4,:; ...1,,;11I01.) lA, ,\trillm -----Iii

!)lllllllllwry ,\rtt'ry

Partial

12

('llIlIpI4'1<'

21

ToTal

1~ II

CHEST, VOL. 58, NO.2, AUGUST 1970

2"2

pr('cll1d(' tilt.' po..; ihility of <.\ clt'fedin' r('implanted lung sincl' animals with {It feds limitt'd to the \·ascular anastomosis could app('ar to havt' an 1I1lt'n'ntflll Postollt'ratin' l'CHITSt". Hron<.:hial complications. on the other hand. w('rt' pr('cedecl by a sli1!ht cough usually ac:gra\'att'd hy exercise. lOne\.plaillt'd pro~n, ...... iH-' w{'i~ht loss (KTlITTed in sen'ral animals with hrtlfH.'hial complications. Thoracic

E.\'amiuafiofl: ;\ilw-hnl wen-' made in 51 dog... from (lilt' day to 17 lIumths after rl'implantation. Tt'll t'\~ :3 Band -4 dt'mollstratt> an anastomosis that wa... found to })(.' "i.l!:nificantly narrowed. BroncllO\CoPY: Immediately after reimplantation. hroncho"copic t'x"ll11ination of tht' left main-stem hrcm<.·hll" oftt'll de!llonstrakd a few lllilHlitcrs of hloody mucus but tht' bronchus was widely patent. The distal bronchial IlHll'OSa was Ilsually pink h1lt paler than tht' ti"Sllt' proximal to tht" hnmchial ana... tlHllflSis. At the ('lId of the first week the anastomu...is appeart·d slichtly £'dt'rnatous but appeared normal by tllt' rot'lltgt'no~rallls

Rocntgeuo/.!ral'hic

100

DUVOISIN, PAYNE AND ELLIS od and the hronchus was siJ,!;nific.:antly narrowed by the end of the third week. Autopsy demunstrated that the stenosis occurred in the main-stem hronchus distal to the anastomosis and, in fad, Illight ex!<'nd to involve- the orifice of the left upp(~r-lof)(· hronchus at some distan<.'e from the anastomosis itself ( FIg .5 ). The calise of the high incidence of hronchostenOSLll: appeared to 11<' related to the level at which the bronchus had been di,"ided and reanastolllosed (Table 4). The length of the hronchial stump was dt·termined hy the description at the time of opt'ration and rechecked at postoperative bronchoscopy and autopsy. There was a high incidence of bronchostenosis when division and reana.~t()mosis of the bronchus weTe perfOTIIWd close to the carina in contrast to the findings after performance of these m.aneuvers at a more distal level near til(' origin of tile left upper-Ioh,,' broncbus. Also the use of one row of interrupted sutures wa" another factor which further reduced the incidence of broncbostenoses (Table 5). DISCUSSIO:-:

FIGCRE 4. Paper tracin« of projected image of pulmonary arteriogram (Fig 3 B). Ratio of diameters squared provides an index of degrt"e of ana..;tornotic stenosis.

t"nd of tilt' St'ClUlll or third W{'('k. Unfortunately. a high inddenc{> of hronchostenosis provided numerous opportunities to document aU stages in its developlIH.'nt. During tilt' fir.;t postop('rati\'e week. animals dc."\·elopioJ,! this l'ompli<:atinn had serosanguineous secretions in all It'ft hronchial oTUk-t'S. After a'ipiration of these secretions, the hrondl1ls distal to the anastomosis was notl'd to be irregularly pale and with time hecame progressively patchy white in appearance. Fragllwnts of white cartilage on the antt'rior hronchial wall were visihlC', with nt·(.'rotic debris present in the lumen which hegan to appear diffusely nar· rowed. Friahle granulation tissue developed during this peri-

Any experimental method is characterized by a high incidence of failure in the early learning stages. Reimplantation of the lung has proved to be no exception to this observation; in fact, Juvenelle 1 reported that only one dog survived the initial 32 attempts. Subsequent in\"E'stigators confinned the fact that mortality decreased as technical experience inereased. The operative mortality rate of 36 pereent in the present study compares favorably with the rates of approximately 50 percent reported by others. H The majority of failures reported by other workers were related to suturing the thin left atrial wall and to thrombotic occlusion of this anastomosis. In the present report, bronchial necrosis and its sequelae, including bronchovascular fistula, were

FIGURE 5. Autopsy specimen. Arrow on reader's right points to site of bronchial anastomosis at carina. A. right pneumonectomy accounts for the dimple in the right main bronchus above arrow. An obstrul'ting band of scar tissue partially occludes hronchus just dbtal to the anastomosis. Arrow on left indicates site of a completdy occluded Idt uppl'f-Iobe hronchial orifice which has been opened. Brunchostt>notic complications are related to internlption of bronchial hlood supply in conjunction with 1110r(' proximal transections of hronchus. Incidence of this complication wa.Iii greatly reduced by amiding extensive surgical dissection of bronchus and bv transecting main-stem brond;us as close to origin of left uPP<'r-lohe bronchus as possible.

CHEST, VOL. 58, NO.2, AUGUST 1970

I

I I

101

RESULTS OF PULMONARY REIMPLANTATION Table 4--urf>1 01 Bronchial Ano.'onlO.i. ndolf>d 10 lVnrod. or S'flnoai. in Lun« R,.;mplantalion O"f",·t-Fr",'

To!al

u>\'"lof

:\na!'OtIJflu)~i:o;

DOl!:'

I)og"s

.\na~I.,m()~is

~f"ar

tnw}wal (·:trina

20

:l

15

~('ar

division of primary l)fIllH-tIll:-O:

l!J

II

!is

the predominant causes of failure. It is evident that the majority of operative deaths were related to technical factors. many of which could be eliminatcd with experience. Ev£'n after animals surviv£'d the immediat£' postoperatin' IJPriod. evaluation of th£' structural integritv of the r£'implant£'d lung demonstrated defects in' three fourths of 60 animals. Once again. these def£'cts could all 1)(' related directly or indirectly to the surgical techniqu£' of reimplantation. ~arrowin!!: of the vascular anastomos£'s was not as frequ£'nt as bronchial complications. Stenosis of the pulmonary arterv anastomosis was well d£'monstrated on sclectiv£' ilUlmonary art£'riograms by actual measur£'ment of the anastomotic site. Prevention of this complimtion rel!uires meticulous vascular suture kchnique and the avoidance of additional hemostatic sutures. Veith and Richards' have more recently presented evidence to suggest that e\'en anatomically nonstenotic pulmonary artery anastomoses may fail to distend in response to incr£'ased flow and may thus impose a functional ohstruction of inflow. They have suggested increasing the diameter of the pulmonary artery at the site of suture either hy spatulation of each end of the divided pulmonary arterv or hv the insertion of a diamond-shaped veno~s pat~h graft to effect a more distensible connection. Their studies clearly indicate the superiority of these methods over that employed in the present study. \lost of th(· failures of the left atrial venous anastomosis were due to ohliteration or narrowing of one vein. most commonly the small left superior pulmonary win. The superior aspect of the left atrial anastomosis was the most difficult area to

"ia'

Ann.'omo.i. R,la"d .-Vnro.i. or S'ena.i. in Lung Rp;mplon'a'ion

Tablt- 5--M"hod oj Bron..

Total ~r(lthod

HunninJ,t

of AlIll.... tomosi~ C'ontinllous ~llt\lrt'

Deft>,·t-I'rI'" .\na... t()mo~is

Do":,,

Dol!'>

c;

7

3

4:1

Sam(" in mpmhranolL" tis..'4Uf\ inh'rruptP<1 (·arti]u.~in()ll~

sutliff'S

'0

i.n

12

8

CHEST, VOL. 58, NO.2, AUGUST 1970

67

actuallv visualize and approximate, hut a properly prepar~d left atrial cuff facilitates accurate plaeement of sutures. Complications related to the bronchial anastomosis were noted more often in our animals than in other series. :\ review of previous reports indieates that \l(>arh- all investigators have noted at least occasional' problems with the bronchial anastomosis after n>implantation of the lung; 6 however. most workers have implicated the type of suture material employed although stenosis has followed the use of silk. cotton. nylon. catgut. and stainless steel. The serial bronchoscopic ohservations of the present report indicate that necrosis of th£' hronchus is simply an early phase in the series of ewnts leading to hronehostenosis. In fact. severe early necrotic changes were responsible for four bronchovaseular fistulas. In addition. disruption of suture lines. pneumonitis, and empyema have been obsern·d as sequ£'lae of hronehial necrosis. In most animals. necrosis distal to the suture line progressed to scartissue fonnation partially or completely obliterating the left main-stem bronchus hut occasionally involving only the left upper-Iohe hronchus at some distance from the suture line. The common denominator of all these bronchial complications was that the necrotic changps were isolated to the main-stem bronchi and bore a rpmarkahle resemblance to the results reported by Ellis and associates" following obliteration of the bronchial artery. Barthel and Barthel. H Otto and Trenkner,1 0 and Hughes and associates I ! have also commented on the increased incidence of bronchial necrosis with long distal stumps. In dpw of these facts it appears evident that bronchial necrosis and its sequelae were secondary to hronchial ischemia associated with long distal segments. This complication can be markedly reduced bv r£'taining a long proximal hronchial stump with an intact bronchial arterial blood supply. Thus. it was concluded from these studies that death of animals or development of persistent pulmonary dvsfunetion following left lung reimplantation can b~ correlated with the development of anatomic defects which are related to surgical technique and are therefor£' largely preventahle. It is evident that of the 94 animals in which the left lung was reimplanted. only 1,5 with structurally intact reimplanted lungs could be used in a further study for evaluating the performanee of reimplanted lungs. These studies are reported separately. REFERE:-;cES

Juve-ndle A; La. n~illlplantation du pollman apres pneumonectomit>, Poumon 7 :431, 1951

102 ~

DUVOISIN ET AL

"dras II: :Xole prt·liminaire sur la i(relfe lolal,' du chez It' ('hien. C H :\(.'ad Sci (Paris) ::nl: 1176,

POllJllU1l

(lJ.')tl

:3 :x,'phllll' \\'B. \\,.. II.. r H. Railey CP, Experim..nlal Illng tran:iplantation. J Thofae Cardio\'as(' Sur~ 26:2Tj, 19·j,3 -I (;al'nslt'T E:\.: BnH1l'hclspironll'tr~·. I. Re\'iew I)f tilt, literaIII"'.) Lah Clin \I..d 3'1,')17, 1'152 5 1I,·llll..r K, Th..ye II"\'. Fowl"r \\,5, EIf..d of I~"ilion and thoracotomy on dbtrilHitioll of air and hlo(xl to t'aeh lung dllrinJ! intermittt'nt posit i \'t-' prt>SSlITC hrt'athjn~. (Abstraet) Physiologist 4:~n. }961 6 Trlllllllll'T \1]: E:\}lt> ri Jllt'll tal transplantation of tilt' lung. Ann Thoral' Sure: 1:20:3, 196.~ '7 "t'jth FJ. Hiehards K: \It·t:hani... m and prt'Vt'ntion of fhftl high \'asl"lIlar Tesistann' in autoc:rafted and allo,-!rafted

lungs. Science 16:3:W)9. 1969 S Ellis FII Jr. Crindlay' )11. Edwards )E, Th.. l"olll·hi,,1 artt'rit''''. I. E.\pt.'riml'ntal o<,'dusioll. Stlr~('ry :30:HIO, 19.51 H B..rthd H. Bartllt'l :\: Tiert.'\lWrillwllh·llc: l'uh-r"ul'hull~t"1I uhc:r das Sp~ltt'rt" Scltil'hal hOlllolo/.! q'rpflanztt'T Lunc,,"lappt'n. Bei!r Klill Chir 194,:3').';. 19.57 10 Otto Tj. Trt>nkllt'r \1: lIolllotranspbnlatioli of the lillie in dne.... with special rdefence' to tht' circulation .. y.. te:m in tht' transplant. Thora' 21 :.56-t. IHfi6

11 IIl1clll's F..... K..J1l1t' JII. Fos )H, Hl'planlalioo and Iransplantation IIf pullllonary tisstH, in dog'S. SlITl!l'ry :30; 1101. 19'H Hl'print requests: S~·tion

chester, \Iilllwsota .~.5901.

of Puhlications, \Iayo Clinic, Ro-

Causes of Depressed Pulmonary Function Following Reimplantation of the Canine Lung* George E. Duwisin, ,\I.D.. "'ard S, Fou·/er..\1.0., F. Henry Ellis. Jr...\I.D.. and \\'. Spencer Payne..\1.0.. F.e.C.p.

FoUowilll reimplantation of the left lung of dogs. serial bronchosplrometric studies of the ventilation and ox~gen uptake of both lungs were made. The functional elfect noted was a moderate initial depres.~ion in both oxygen uptake and tidal volume in the reimplanted lung on the day of operation followed b~' a continued fall for the next two to three weeks. Tidal volume tended to be depressed less than oX~'gen uptake. After reachin!t a nadir during the first three weeks. two dilferent patterns w'ere ohsen-ed. In 14 animals without structural defects. oXlgen uptake !tradualll rose toward control valves. whereas in Ihe !troup of 28 animals with structural defects oXlgen uptake remained depressed.

pulmonary function is impaired following reimplantation of the l'anine lung. :'\eith('r the ft'sponsihll> factors nor reliable sequential chang('s ha\'<' ht'('n delineated. The purpose of this investigation was to determine the actual pattern of changes - - - - F o r edilorialrommenC seep~ie

~-----

in pulmonary function following reimplantation of the <:'anillt' lung and to attempt to idmtify the responsihle factors.

uptake W('n.' lllt·aslIrt·d hy difft'Tential hrolldHlspiroJlll'try r('corded with a Collin' dOli hit, ... pirOlndt'r usinc a \\'ril!htI..ah'cola di\-ided .Iirw,,~-,

ohtaininc: ,imu1talH'Oll" tracinl.!'" of

!loth the norlllal richt ami the rt'illlplilllh't) left lung. :\11 t'xamination... Wert' pt'rforllH'd tIIult'r j.!t'llt'ral iUlt'... tlw-sia with IWlltoharhital ,cin'll intr;ln'lIoll...ly. Tilt· ..y .• h'lII was can'flllly checked prior to lIIakinJ,! any dt'finitive rt·('ordinj.!'" to ensure eliminatioll of air leak, in tilt' "'y"i.ft'1Il and t'olllpldt' ..t·paration of right ~Ulrl left lull!.!.... Corred po... itionillj.! of tlit-' airwilY di\'idt'r did not oh,trllct till' ric:ht IIPlwr-lo!'t· hrom..lms a, dt·lIlOn ... tratt.-d hy t'\;lIl1illiltioll of the llK'atioll of tilt' divider at

~I.\TEIIIAL

A:'\D ~h:THOI)

Thl' It'ft JUlle was reimplanted in 94 do~s as descrihed in a previous rt·port. 1 Pulmonary function was t'valtlalt>fation a.. {ullc)\\": tidal \'Ohll1ll' and o-'YI!t'n -From tlit' '1;.1\"0 Clinic ilnd \1avo Foundation: Sc(.'tion of SUT/.!t'ry (DN. ·DtI\·oisin. Ellis, an~1 Payne) and of Physiology (Dr. Fow!t'r 1. Rochester. \Iinnesota. This inH.... ti~atiCln \\'i.l" slIJl(Xlrte:d in part hy Ht'st'arch Crant UE-.1';SS Irom lilt' :\al;ollal Inslihlles 01 IlPaltk Pllh\i" Health Sen·ict'. ami hy a grant frolll tlw \Iinm-'sota Heart :\.SSIK'j,\tj( In.

fllloro'l'opy and at ;lIItopsy. Spirolllt'tril' ,tllllit"

wt'rt' made

prt"lIpt'ratin·ly, ill till' illlllwdiah' postopt.'ratin· peri
lip to 17 lIlonth... afh'r reilllpialltaton of the

It'ft 11I1Ig', :\ total of 2.j,H spirollldric tracing, o!.taillt'il on 94{X",topt'f;Jtin' day .. Wert' sati·;fadory for .allaly,i... (If indi\'i(hlal tidal \'011ll1l(' ami o\yc('n lIptakt, of hotll till' normal ilnd tht' reimplanted 111 Ill-:'. Operatin' deat)l ... (.1-1 animals l ilnd the dt'\"el<){)Illt'nt l){ {)C."t
n·dlll'C.'d the 1H1I111)t'r of
CHEST, VOL. 58, NO.2, AUGUST 1970