- Email: [email protected]
Native Lung-sparing Lobar Transplantation for Pulmonary Emphysema
Native Lung-sparing Lobar Transplantation for Pulmonary Emphysema Masaomi Yamane, MD, Daisuke Okutani, MD, Seiichiro Sugimoto, MD, Shinichi Toyooka, MD, Motoi Aoe, MD, Megumi Okazaki, RN, Yoshifumi Sano, MD, and Hiroshi Date, MD The living-donor lobar lung transplantation procedure has been developed clinically as an alternative approach for patients considered too ill to await cadaveric transplantation. With this procedure, 2 lobes are implanted in the recipient in place of whole right and left lungs, respectively. However, the shortage of graft volume can be a problem when compared with full-sized cadaveric grafts. In an attempt to solve this problem, we have developed a native lobe–preserving lobar transplant technique using a large animal model. We report a first successful case of a patient undergoing native lobe–preserving lobar lung transplantation for severe pulmonary emphysema. J Heart Lung Transplant 2008;27:1046 –9. Copyright © 2008 by the International Society for Heart and Lung Transplantation.
After living-donor lobar lung transplantation (LDLLT), the size discrepancy between the recipient and lobar grafts occasionally causes pleural space problems and poor graft function.1 In terms of pulmonary function and pleural space problems, native lobe–preserving lobar transplantation would be be ideal as compared with conventional LDLLT, but has not been investigated. We report the first successful case of a patient in whom the native right upper lobe was preserved, and an LDLLT, namely native lung–sparing lobar transplantation (NLSLT), was performed, resulting in excellent post-operative clinical status and lung function. CASE REPORT A 55-year-old woman, never a smoker and without ␣1-anti-trypsin deficiency, was diagnosed with pulmonary emphysema, and lung volume reduction surgery (LVRS) was performed on the bottom portions of both lungs in April 2003. Although her symptoms improved in the first year after LVRS, dyspnea reappeared. She was malnourished and dependent on oxygen inhalation. In April 2006, pulmonary function tests showed a severe obstructive defect with a forced expiratory volume in 1 second (FEV1) of 470 ml. Computed tomography (CT) showed progressive hyperinflation of
From the Department of Cancer and Thoracic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmacy, Okayama, Japan. Submitted December 25, 2007; revised April 2, 2008; accepted May 21, 2008. Reprint requests: Masaomi Yamane, MD, Department of Cancer and Thoracic Surgery, Okayama University Hospital, 2-5-1 Shikata-cho, Okayama 700-8558, Japan. Telephone: ⫹81-86-235-7265. Fax: ⫹8186-235-7269. E-mail: [email protected]. Copyright © 2008 by the International Society for Heart and Lung Transplantation. 1053-2498/08/$–see front matter. doi:10.1016/ j.healun.2008.05.025
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both lungs; however, the pulmonary parenchyma of the right upper lobe remained almost normal (Figure 1A). Perfusion scintigraphy showed markedly decreased perfusion in the left lung and the lower portion of the right lung. The right lung received 93% of the total perfusion, mostly in the upper portion, whereas the left lung received only 7% (Figure 1B). Based on these findings, we decided to preserve the native right upper lobe, which was considered to have almost normal function, and perform an NLSLT. The patient’s sisters had proposed to donate their lung lobes. The operation was technically similar to conventional LDLLT.1 After induction of general anesthesia, the chest was opened via transverse sternotomy. Because of the previous LVRS, there were dense pleural adhesions between the diaphragms and bases of the lungs. To minimize blood loss, hilar dissection, pleural adhesiotomy and left pneumonectomy were performed before initiation of the systemic heparinization. The hilar structures and right interlobar vessels were dissected and exposed. After the left pneumonectomy, an arterial cannulation was established in the ascending aorta and a 2-stage venous cannula was inserted in the right atrium; subsequently, standard cardiopulmonary bypass (CPB) was initiated. The right middle and lower lobes were then removed. While the recipient was being prepared for the transplant, 2 lobar grafts were harvested from the sisters. During implantation, ventilation and pulmonary arterial flow into the native right upper lobe were maintained to prevent complete ischemia and atelectasis. CPB flow was maintained at 50% of the total flow. A conventional left lower lobe implantation was performed as previously reported.1 The right lower lobe was implanted as follows: Intermediate bronchus was incised at just proximal point of the middle lobe bronchus. Bronchial anastomosis was performed with a
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Figure 1. (A) Computed tomography scan of the chest showing that the pulmonary parenchyma of the right upper lobe remained almost normal. (B) Pulmonary perfusion scintigraphy. The right lung receives 93% of the total perfusion, mostly in the upper portion.
running 4-0 polydioxanone suture for the membranous portion and simple interrupted sutures for the cartilaginous portion (Figure 2). Because bronchial size was equivalent, end-to-end anastomosis was used. Lower pulmonary venous anastomosis was performed with a 5-0 Prolene continuous suture. Basal arterial anastomosis was performed at the peripheral part of branches of the middle lobe with a 6-0 Prolene continuous suture.
Before the chest cavity was closed, LVRS was added for part of the native lobe because of a localized evident bullous change, which would likely hamper inflation of the lobar graft. The total ischemic time was 179 minutes for the left lobar graft and 90 minutes for the right lobar graft. CPB time was 204 minutes. The post-operative course was uneventful, apart from a re-thoracotomy due to persistent intrathoracic bleed-
g
g g
g
Figure 2. An intra-operative image shows bronchial anastomosis performed with a running 4-0 polydioxanone suture for the membranous portion. The numbers indicate: (1) native intermediate bronchus; (2) native basal pulmonary artery; (3) native inferior pulmonary vein; (4) graft lower lobe bronchus; (5) graft basal pulmonary artery; and (6) graft inferior pulmonary vein.
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ing from an intercostal artery. Mechanical ventilation was discontinued on Day 4. The patient was discharged on Day 55 after completing rehabilitation, and she returned to a normal lifestyle without any limitations. At 12 months after transplantation, arterial blood gas analyses revealed the following results: pH 7.36; PaCO2 ⫽ 41.4 mm Hg; and PaO2 ⫽ 92.3 mm Hg. Forced vital capacity (FVC) was 2,740 ml and FEV1 was 2,440 ml. On the other hand, pre-operatively estimated graft FVC (measured based on the donor’s FVC and the number of segments implanted) was 1,622 ml. CT scan revealed that the emphysematous changes in the native lobe did not progress (Figure 3). DISCUSSION LDLLT has been alternative procedure because the disparity between the supply of donor organs and the demand expressed by potential recipients is extremely severe, especially in Japan. Although we previously reported that LDLLT allows for well-functioning pulmonary lobar grafts,2 the peri-operative management of respiration can sometimes be difficult, requiring longterm ventilatory support because of the relatively small grafts implanted in the recipient. These patients might be at an increased risk of pleural space problems, such as empyema, chylothorax and intrathoracic bleeding.3 Hyperinflated lobar grafts have been reported to cause pulmonary artery thrombosis and hemodynamic collapse because of heart compression and a
The Journal of Heart and Lung Transplantation September 2008
reduction in venous return.4,5 As a trial to correct these graft-size mismatch problems in LDLLT, we have developed new NLSLT techniques by using a large animal model.6 The new approach has demonstrated sufficient graft function in both short- and long-term experiments.6 In this case report, bronchoscopy revealed excellent bronchial healing without ischemic changes and stenoses. In NLSLT, because the upper lobes are spared and ventilated during the surgery, the working space is more limited, and all anastomoses are more distal compared with conventional LDLLT. In this case, however, anastomoses of the bronchi and pulmonary arteries were not as difficult as in conventional LDLLT because the middle lobe branches were removed. Conversely, regarding left NLSLT, several technical points may require elaboration to preserve the lingular branches. As shown in pulmonary emphysema patients with single lung transplantation, if the native lobe hyperinflates and compresses the transplanted lobes, then LVRS is required. We restricted the use of the LDLLT procedure to recipients with estimated graft FVC values of ⬎45% of the predicted recipient FVC.7 Hence, large adult patients are believed to be poor candidates for LDLLT; NLSLT provides an opportunity for lung transplantation in such patients. As we previously reported that overall survival in patients having LDLLT reached 93.6%,2 NLSLT is also expected to provide a survival benefit to
Figure 3. Post-operative computed tomography at 12 months after transplantation. Three well-expanded lobes occupy the whole thoracic cavity without a significant pleural space problem. Minimal emphysematous changes are observed in the native right upper lobe.
The Journal of Heart and Lung Transplantation Volume 27, Number 9
patients. In contrast, we have to carefully select candidates for NLSLT who should have relatively well-functioning lung tissues in the right and/or left upper lobes without any active infection. In conclusion, we successfully performed NLSLT for patients with pulmonary emphysema. We believe that use of this technique permits excellent postoperative pulmonary function in selected transplant candidates. REFERENCES 1. Date H, Aoe M, Nagahiro I, et al. Living-donor lobar lung transplantation for various lung diseases. J Thorac Cardiovasc Surg 2003; 126:476 – 81. 2. Yamane M, Date H, Okazaki M, Toyooka S, Aoe M, Sano Y. Long-term improvement in pulmonary function after living donor
Yamane et al.
3.
4.
5.
6.
7.
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lobar lung transplantation. J Heart Lung Transplant 2007;26: 687–92. Backhus LM, Sievers EM, Schenkel FA, et al. Pleural space problems after living lobar transplantation. J Heart Lung Transplant 2005;24:2086 –90. Baisi A, Nosotti M, Cioffi U, et al. Pulmonary artery thrombosis caused by hyperinflation of the native lung six years after single lung transplantation for emphysema. J Thorac Cardiovasc Surg 2006;131:746 –7. Haddy SM, Bremner RM, Moore-Jefferies EW, et al. Hyperinflation resulting in hemodynamic collapse following living donor lobar transplantation. Anesthesiology 2002;97:1315–7. Sugimoto S, Date H, Sugimoto R, Aoe M, Sano Y. Bilateral native lung-sparing lobar transplantation in a canine model. J Thorac Cardiovasc Surg 2006;132:1213– 8. Date H, Aoe M, Nagahiro I, et al. How to predict forced vital capacity after living donor lobar lung transplantation. J Heart Lung Transplant 2004;23:547–51.
After living-donor lobar lung transplantation (LDLLT), the size discrepancy between the recipient and lobar grafts occasionally causes pleural space problems and poor graft function.1 In terms of pulmonary function and pleural space problems, native lobe–preserving lobar transplantation would be be ideal as compared with conventional LDLLT, but has not been investigated. We report the first successful case of a patient in whom the native right upper lobe was preserved, and an LDLLT, namely native lung–sparing lobar transplantation (NLSLT), was performed, resulting in excellent post-operative clinical status and lung function. CASE REPORT A 55-year-old woman, never a smoker and without ␣1-anti-trypsin deficiency, was diagnosed with pulmonary emphysema, and lung volume reduction surgery (LVRS) was performed on the bottom portions of both lungs in April 2003. Although her symptoms improved in the first year after LVRS, dyspnea reappeared. She was malnourished and dependent on oxygen inhalation. In April 2006, pulmonary function tests showed a severe obstructive defect with a forced expiratory volume in 1 second (FEV1) of 470 ml. Computed tomography (CT) showed progressive hyperinflation of
From the Department of Cancer and Thoracic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmacy, Okayama, Japan. Submitted December 25, 2007; revised April 2, 2008; accepted May 21, 2008. Reprint requests: Masaomi Yamane, MD, Department of Cancer and Thoracic Surgery, Okayama University Hospital, 2-5-1 Shikata-cho, Okayama 700-8558, Japan. Telephone: ⫹81-86-235-7265. Fax: ⫹8186-235-7269. E-mail: [email protected]. Copyright © 2008 by the International Society for Heart and Lung Transplantation. 1053-2498/08/$–see front matter. doi:10.1016/ j.healun.2008.05.025
1046
both lungs; however, the pulmonary parenchyma of the right upper lobe remained almost normal (Figure 1A). Perfusion scintigraphy showed markedly decreased perfusion in the left lung and the lower portion of the right lung. The right lung received 93% of the total perfusion, mostly in the upper portion, whereas the left lung received only 7% (Figure 1B). Based on these findings, we decided to preserve the native right upper lobe, which was considered to have almost normal function, and perform an NLSLT. The patient’s sisters had proposed to donate their lung lobes. The operation was technically similar to conventional LDLLT.1 After induction of general anesthesia, the chest was opened via transverse sternotomy. Because of the previous LVRS, there were dense pleural adhesions between the diaphragms and bases of the lungs. To minimize blood loss, hilar dissection, pleural adhesiotomy and left pneumonectomy were performed before initiation of the systemic heparinization. The hilar structures and right interlobar vessels were dissected and exposed. After the left pneumonectomy, an arterial cannulation was established in the ascending aorta and a 2-stage venous cannula was inserted in the right atrium; subsequently, standard cardiopulmonary bypass (CPB) was initiated. The right middle and lower lobes were then removed. While the recipient was being prepared for the transplant, 2 lobar grafts were harvested from the sisters. During implantation, ventilation and pulmonary arterial flow into the native right upper lobe were maintained to prevent complete ischemia and atelectasis. CPB flow was maintained at 50% of the total flow. A conventional left lower lobe implantation was performed as previously reported.1 The right lower lobe was implanted as follows: Intermediate bronchus was incised at just proximal point of the middle lobe bronchus. Bronchial anastomosis was performed with a
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Figure 1. (A) Computed tomography scan of the chest showing that the pulmonary parenchyma of the right upper lobe remained almost normal. (B) Pulmonary perfusion scintigraphy. The right lung receives 93% of the total perfusion, mostly in the upper portion.
running 4-0 polydioxanone suture for the membranous portion and simple interrupted sutures for the cartilaginous portion (Figure 2). Because bronchial size was equivalent, end-to-end anastomosis was used. Lower pulmonary venous anastomosis was performed with a 5-0 Prolene continuous suture. Basal arterial anastomosis was performed at the peripheral part of branches of the middle lobe with a 6-0 Prolene continuous suture.
Before the chest cavity was closed, LVRS was added for part of the native lobe because of a localized evident bullous change, which would likely hamper inflation of the lobar graft. The total ischemic time was 179 minutes for the left lobar graft and 90 minutes for the right lobar graft. CPB time was 204 minutes. The post-operative course was uneventful, apart from a re-thoracotomy due to persistent intrathoracic bleed-
g
g g
g
Figure 2. An intra-operative image shows bronchial anastomosis performed with a running 4-0 polydioxanone suture for the membranous portion. The numbers indicate: (1) native intermediate bronchus; (2) native basal pulmonary artery; (3) native inferior pulmonary vein; (4) graft lower lobe bronchus; (5) graft basal pulmonary artery; and (6) graft inferior pulmonary vein.
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ing from an intercostal artery. Mechanical ventilation was discontinued on Day 4. The patient was discharged on Day 55 after completing rehabilitation, and she returned to a normal lifestyle without any limitations. At 12 months after transplantation, arterial blood gas analyses revealed the following results: pH 7.36; PaCO2 ⫽ 41.4 mm Hg; and PaO2 ⫽ 92.3 mm Hg. Forced vital capacity (FVC) was 2,740 ml and FEV1 was 2,440 ml. On the other hand, pre-operatively estimated graft FVC (measured based on the donor’s FVC and the number of segments implanted) was 1,622 ml. CT scan revealed that the emphysematous changes in the native lobe did not progress (Figure 3). DISCUSSION LDLLT has been alternative procedure because the disparity between the supply of donor organs and the demand expressed by potential recipients is extremely severe, especially in Japan. Although we previously reported that LDLLT allows for well-functioning pulmonary lobar grafts,2 the peri-operative management of respiration can sometimes be difficult, requiring longterm ventilatory support because of the relatively small grafts implanted in the recipient. These patients might be at an increased risk of pleural space problems, such as empyema, chylothorax and intrathoracic bleeding.3 Hyperinflated lobar grafts have been reported to cause pulmonary artery thrombosis and hemodynamic collapse because of heart compression and a
The Journal of Heart and Lung Transplantation September 2008
reduction in venous return.4,5 As a trial to correct these graft-size mismatch problems in LDLLT, we have developed new NLSLT techniques by using a large animal model.6 The new approach has demonstrated sufficient graft function in both short- and long-term experiments.6 In this case report, bronchoscopy revealed excellent bronchial healing without ischemic changes and stenoses. In NLSLT, because the upper lobes are spared and ventilated during the surgery, the working space is more limited, and all anastomoses are more distal compared with conventional LDLLT. In this case, however, anastomoses of the bronchi and pulmonary arteries were not as difficult as in conventional LDLLT because the middle lobe branches were removed. Conversely, regarding left NLSLT, several technical points may require elaboration to preserve the lingular branches. As shown in pulmonary emphysema patients with single lung transplantation, if the native lobe hyperinflates and compresses the transplanted lobes, then LVRS is required. We restricted the use of the LDLLT procedure to recipients with estimated graft FVC values of ⬎45% of the predicted recipient FVC.7 Hence, large adult patients are believed to be poor candidates for LDLLT; NLSLT provides an opportunity for lung transplantation in such patients. As we previously reported that overall survival in patients having LDLLT reached 93.6%,2 NLSLT is also expected to provide a survival benefit to
Figure 3. Post-operative computed tomography at 12 months after transplantation. Three well-expanded lobes occupy the whole thoracic cavity without a significant pleural space problem. Minimal emphysematous changes are observed in the native right upper lobe.
The Journal of Heart and Lung Transplantation Volume 27, Number 9
patients. In contrast, we have to carefully select candidates for NLSLT who should have relatively well-functioning lung tissues in the right and/or left upper lobes without any active infection. In conclusion, we successfully performed NLSLT for patients with pulmonary emphysema. We believe that use of this technique permits excellent postoperative pulmonary function in selected transplant candidates. REFERENCES 1. Date H, Aoe M, Nagahiro I, et al. Living-donor lobar lung transplantation for various lung diseases. J Thorac Cardiovasc Surg 2003; 126:476 – 81. 2. Yamane M, Date H, Okazaki M, Toyooka S, Aoe M, Sano Y. Long-term improvement in pulmonary function after living donor
Yamane et al.
3.
4.
5.
6.
7.
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lobar lung transplantation. J Heart Lung Transplant 2007;26: 687–92. Backhus LM, Sievers EM, Schenkel FA, et al. Pleural space problems after living lobar transplantation. J Heart Lung Transplant 2005;24:2086 –90. Baisi A, Nosotti M, Cioffi U, et al. Pulmonary artery thrombosis caused by hyperinflation of the native lung six years after single lung transplantation for emphysema. J Thorac Cardiovasc Surg 2006;131:746 –7. Haddy SM, Bremner RM, Moore-Jefferies EW, et al. Hyperinflation resulting in hemodynamic collapse following living donor lobar transplantation. Anesthesiology 2002;97:1315–7. Sugimoto S, Date H, Sugimoto R, Aoe M, Sano Y. Bilateral native lung-sparing lobar transplantation in a canine model. J Thorac Cardiovasc Surg 2006;132:1213– 8. Date H, Aoe M, Nagahiro I, et al. How to predict forced vital capacity after living donor lobar lung transplantation. J Heart Lung Transplant 2004;23:547–51.