- Email: [email protected]
Right-to-left inverted living-donor lobar lung transplantation combined with sparing of native right upper lobe
Author’s Accepted Manuscript Right to left inverted living-donor lobar lung transplantation combined with sparing native right upper lobe Yasufumi Goda, Hideki Motoyama, Akihiro Aoyama, Masatsugu Hamaji, Kyoko Hijiya, Toyofumi F. Chen-Yoshikawa, Hiroshi Date http://www.jhltonline.org
PII: DOI: Reference:
S1053-2498(16)30444-2 http://dx.doi.org/10.1016/j.healun.2016.12.003 HEALUN6412
To appear in: Journal of Heart and Lung Transplantation Cite this article as: Yasufumi Goda, Hideki Motoyama, Akihiro Aoyama, Masatsugu Hamaji, Kyoko Hijiya, Toyofumi F. Chen-Yoshikawa and Hiroshi Date, Right to left inverted living-donor lobar lung transplantation combined with sparing native right upper lobe, Journal of Heart and Lung Transplantation, http://dx.doi.org/10.1016/j.healun.2016.12.003 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Right to left inverted living-donor lobar lung transplantation combined with sparing native
right upper lobe
Yasufumi Goda, MD; Hideki Motoyama, MD; Akihiro Aoyama, MD; Masatsugu Hamaji, MD;
Kyoko Hijiya, MD; Toyofumi F. Chen-Yoshikawa, MD; Hiroshi Date, MD
Department of Thoracic Surgery, Kyoto University, Kyoto, Japan
Correspondence and requests for reprints should be addressed to:
Hiroshi Date, MD, PhD
Department of Thoracic Surgery, Kyoto University
54 Shogoin,Kawaharacho, Sakyo-ku, Kyoto 606-8507, Japan
E-mail: [email protected]; Phone: +81-75-751-4975; Fax: +81-75-751-4974
1
Keywords: living-donor lung transplantation, under-sized graft, native lung spared, inverted lung
transplantation
In Japan, living-donor lobar lung transplantation (LDLLT) plays an important role because of the
critical shortage of deceased-donor organs. The size of the grafts is one of the most critical issues, and
adult recipients frequently withdraw from LDLLT because of the small size of donor grafts.
To deal with this problem, we already developed two novel surgical techniques: sparing native upper
lobe1,2 and right to left inverted lobar lung transplantation.3 Herein, we report the first two cases of a
successful bilateral LDLLT using these two novel surgical techniques simultaneously in order to
overcome more severely undersized grafts, that would not be dealt with using one of these techniques
(Figure 1).
Case 1
A 63-year-old man with end-stage idiopathic interstitial pneumonia was referred to our hospital as a
possible candidate for lung transplantation. His daughter and sister were eligible donors for LDLLT.
According to Date’s previously reported formula, the estimated forced vital capacity (FVC) of the
graft should be >45%–50% of the recipient’s predicted FVC.4 The right lower lobe (RLL) from his
daughter and left lower lobe (LLL) from his sister were estimated to provide only 41.7% of the
2
recipient’s predicted FVC, and RLLs from the two donors were estimated to provide 46.1%. This
meant that the grafts could only be borderline-sized even if we performed bilateral LDLLT using right
to left inverted lobar lung transplantation. The recipient’s preoperative chest computed tomography
and perfusion scintigraphy showed a less diseased and well perfused right upper lobe (Figure 2A, B).
Therefore, sparing his right upper lobe and inverted LDLLT was simultaneously performed for this
patient.
The patient’s postoperative course was uneventful. He left the intensive care unit on postoperative
day (POD) 7 and was discharged on POD 58 without oxygen supplementation. The postoperative
3-dimensional CT scan showed no kinks or stenoses at anastomoses (Figure 3).
The perfusion of his spared RUL was maintained after 2 and 6 months in the postoperative
perfusion scintigraphy (Figure 4). Ten months after LDLLT, he is doing well without oxygen
supplementation.
Case 2
A 44-year-old man with end-stage idiopathic interstitial pneumonia was referred for lung
transplantation. His two donors were his sister and brother. If we used a right and left lower lobe of
donors as our standard LDLLT, the FVC ratio was 41.4%. If we performed right to left inverted
3
LDLLT, the ratio was better at 47.2%；however, the donor grafts were still on the borderline size in
terms of size matching as with case 1. His right upper lobe was well perfused and less diseased.
(Figure 2C, D). Because of these reasons, we performed right to left inverted LDLLT in addition to
sparing his right upper lobe (Figure 5).
He left the intensive care unit on 16 POD and was discharged home on 63 POD. He is doing well
without oxygen supplementation four months after the transplantation.
Discussion
In standard LDLLT, two donors are needed, and we transplant a right lower lobe from one donor and a
left lower lobe from the other donor into a recipient. However, it is difficult to find two donors with
an ideal-sized graft.
The under-sized grafts are one of the highest risk factors of primary graft dysfunction (PGD) in
lung transplantation.5 In the short term, the more the grafts have a large vascular bed, the less the
recipients are at risk of postoperative complications of PGD.1,2 RLLs are 120% larger than LLLs;
larger grafts can be transplanted using the right to left inverted technique, which leads to an increased
vascular bed in the recipients after LDLLT. Moreover, the spared upper lobes also work as a reservoir
of blood flow, particularly in the short term. In fact, none of the inverted group patients (eight cases)
4
and the sparing group patients (eight cases), including two combined cases in this study, required
postoperative extracorporeal membrane oxygenation (ECMO) support for severe PGD despite the
under-sized grafts. The preserved native RUL will deteriorate gradually in function as a reservoir,
however, provide adequate lung volume and reduce the intrathoracic dead space1.
The indication of this technique is limited to patients with not infected, less diseased, and
well-perfused upper lobes. Idiopathic pulmonary fibrosis, rather than upper lobe-predominant
emphysema and cystic fibrosis, would be an ideal indication for this technique.
In conclusion, we report the first two cases of a successful bilateral LDLLT using two novel
surgical techniques simultaneously: right to left inverted lobar lung transplantation combined with
sparing native upper lobe. This novel strategy appears to be feasible in LDLLTs using undersized
grafts.
Conflict of Interest and Funding Sources: None.
5
References
1. Aoyama A, Chen A, Minakata K, et al. Sparing Native Upper Lobes in Living-Donor Lobar
Lung Transplantation: Five Cases From a Single Center. Am J Transplant 2015;15:3202-7.
2. Fujinaga T, Bando T, Nakajima D, et al. Living-donor lobar lung transplantation with sparing
of bilateral native upper lobes: A novel strategy. J Heart Lung Transplant 2011;30:351-3.
3. Chen F, Miyamoto E, Takemoto M, et al. Right and Left inverted Lobar Lung Transplantation.
Am J Transplant 15:1716-21.
4. 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.
5. Eberlein M, Arnaoutakis GJ, Yarmus L, et al. The effect of lung size mismatch on complications and resource utilization after bilateral lung transplantation. J Heart Lung
Transplant 2012;31:492-500.
6
Figure Legends
Figure 1 Illustration of right to right and right to left LDLLT combined with sparing native right upper lobe. We spared recipient’s native right upper lobe (RUL) and transplanted donor 1’s right lower lobe
(RLL) graft into the right thorax and transplanted donor 2’s inverted RLL graft into the left thorax.
Figure 2 Preoperative chest computed tomography and lung perfusion scintigraphy.
Preoperative lung perfusion scintigraphy of the two recipients showed that their right upper lobes
(RULs) were well perfused, and the preoperative chest CT also showed that their RULs were less
diseased. (A, B: case 1; C, D: case 2)
Figure 3
Postoperative three-dimensional (3D) computed tomography (CT).
It does not show any kinks or stenoses at anastomoses. Anastomotic problems have not yet occurred.
Figure 4
Postoperative perfusion scintigraphy (2 and 6 months after transplantation).
7
The recipient’s postoperative perfusion scintigraphy showed that his spared right upper lobe still had
much the same perfusion at 2 and 6 months, which suggested that it worked as a reservoir not only in
the short term but also in the medium term.
Figure 5
The recipient’s (case 2) intraoperative photo.
Spared native upper lobe and transplanted right lower lobe are in the right thorax, and inverted and
transplanted right lower lobe is in the left thorax.
8
9
10
11
12
13
PII: DOI: Reference:
S1053-2498(16)30444-2 http://dx.doi.org/10.1016/j.healun.2016.12.003 HEALUN6412
To appear in: Journal of Heart and Lung Transplantation Cite this article as: Yasufumi Goda, Hideki Motoyama, Akihiro Aoyama, Masatsugu Hamaji, Kyoko Hijiya, Toyofumi F. Chen-Yoshikawa and Hiroshi Date, Right to left inverted living-donor lobar lung transplantation combined with sparing native right upper lobe, Journal of Heart and Lung Transplantation, http://dx.doi.org/10.1016/j.healun.2016.12.003 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Right to left inverted living-donor lobar lung transplantation combined with sparing native
right upper lobe
Yasufumi Goda, MD; Hideki Motoyama, MD; Akihiro Aoyama, MD; Masatsugu Hamaji, MD;
Kyoko Hijiya, MD; Toyofumi F. Chen-Yoshikawa, MD; Hiroshi Date, MD
Department of Thoracic Surgery, Kyoto University, Kyoto, Japan
Correspondence and requests for reprints should be addressed to:
Hiroshi Date, MD, PhD
Department of Thoracic Surgery, Kyoto University
54 Shogoin,Kawaharacho, Sakyo-ku, Kyoto 606-8507, Japan
E-mail: [email protected]; Phone: +81-75-751-4975; Fax: +81-75-751-4974
1
Keywords: living-donor lung transplantation, under-sized graft, native lung spared, inverted lung
transplantation
In Japan, living-donor lobar lung transplantation (LDLLT) plays an important role because of the
critical shortage of deceased-donor organs. The size of the grafts is one of the most critical issues, and
adult recipients frequently withdraw from LDLLT because of the small size of donor grafts.
To deal with this problem, we already developed two novel surgical techniques: sparing native upper
lobe1,2 and right to left inverted lobar lung transplantation.3 Herein, we report the first two cases of a
successful bilateral LDLLT using these two novel surgical techniques simultaneously in order to
overcome more severely undersized grafts, that would not be dealt with using one of these techniques
(Figure 1).
Case 1
A 63-year-old man with end-stage idiopathic interstitial pneumonia was referred to our hospital as a
possible candidate for lung transplantation. His daughter and sister were eligible donors for LDLLT.
According to Date’s previously reported formula, the estimated forced vital capacity (FVC) of the
graft should be >45%–50% of the recipient’s predicted FVC.4 The right lower lobe (RLL) from his
daughter and left lower lobe (LLL) from his sister were estimated to provide only 41.7% of the
2
recipient’s predicted FVC, and RLLs from the two donors were estimated to provide 46.1%. This
meant that the grafts could only be borderline-sized even if we performed bilateral LDLLT using right
to left inverted lobar lung transplantation. The recipient’s preoperative chest computed tomography
and perfusion scintigraphy showed a less diseased and well perfused right upper lobe (Figure 2A, B).
Therefore, sparing his right upper lobe and inverted LDLLT was simultaneously performed for this
patient.
The patient’s postoperative course was uneventful. He left the intensive care unit on postoperative
day (POD) 7 and was discharged on POD 58 without oxygen supplementation. The postoperative
3-dimensional CT scan showed no kinks or stenoses at anastomoses (Figure 3).
The perfusion of his spared RUL was maintained after 2 and 6 months in the postoperative
perfusion scintigraphy (Figure 4). Ten months after LDLLT, he is doing well without oxygen
supplementation.
Case 2
A 44-year-old man with end-stage idiopathic interstitial pneumonia was referred for lung
transplantation. His two donors were his sister and brother. If we used a right and left lower lobe of
donors as our standard LDLLT, the FVC ratio was 41.4%. If we performed right to left inverted
3
LDLLT, the ratio was better at 47.2%；however, the donor grafts were still on the borderline size in
terms of size matching as with case 1. His right upper lobe was well perfused and less diseased.
(Figure 2C, D). Because of these reasons, we performed right to left inverted LDLLT in addition to
sparing his right upper lobe (Figure 5).
He left the intensive care unit on 16 POD and was discharged home on 63 POD. He is doing well
without oxygen supplementation four months after the transplantation.
Discussion
In standard LDLLT, two donors are needed, and we transplant a right lower lobe from one donor and a
left lower lobe from the other donor into a recipient. However, it is difficult to find two donors with
an ideal-sized graft.
The under-sized grafts are one of the highest risk factors of primary graft dysfunction (PGD) in
lung transplantation.5 In the short term, the more the grafts have a large vascular bed, the less the
recipients are at risk of postoperative complications of PGD.1,2 RLLs are 120% larger than LLLs;
larger grafts can be transplanted using the right to left inverted technique, which leads to an increased
vascular bed in the recipients after LDLLT. Moreover, the spared upper lobes also work as a reservoir
of blood flow, particularly in the short term. In fact, none of the inverted group patients (eight cases)
4
and the sparing group patients (eight cases), including two combined cases in this study, required
postoperative extracorporeal membrane oxygenation (ECMO) support for severe PGD despite the
under-sized grafts. The preserved native RUL will deteriorate gradually in function as a reservoir,
however, provide adequate lung volume and reduce the intrathoracic dead space1.
The indication of this technique is limited to patients with not infected, less diseased, and
well-perfused upper lobes. Idiopathic pulmonary fibrosis, rather than upper lobe-predominant
emphysema and cystic fibrosis, would be an ideal indication for this technique.
In conclusion, we report the first two cases of a successful bilateral LDLLT using two novel
surgical techniques simultaneously: right to left inverted lobar lung transplantation combined with
sparing native upper lobe. This novel strategy appears to be feasible in LDLLTs using undersized
grafts.
Conflict of Interest and Funding Sources: None.
5
References
1. Aoyama A, Chen A, Minakata K, et al. Sparing Native Upper Lobes in Living-Donor Lobar
Lung Transplantation: Five Cases From a Single Center. Am J Transplant 2015;15:3202-7.
2. Fujinaga T, Bando T, Nakajima D, et al. Living-donor lobar lung transplantation with sparing
of bilateral native upper lobes: A novel strategy. J Heart Lung Transplant 2011;30:351-3.
3. Chen F, Miyamoto E, Takemoto M, et al. Right and Left inverted Lobar Lung Transplantation.
Am J Transplant 15:1716-21.
4. 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.
5. Eberlein M, Arnaoutakis GJ, Yarmus L, et al. The effect of lung size mismatch on complications and resource utilization after bilateral lung transplantation. J Heart Lung
Transplant 2012;31:492-500.
6
Figure Legends
Figure 1 Illustration of right to right and right to left LDLLT combined with sparing native right upper lobe. We spared recipient’s native right upper lobe (RUL) and transplanted donor 1’s right lower lobe
(RLL) graft into the right thorax and transplanted donor 2’s inverted RLL graft into the left thorax.
Figure 2 Preoperative chest computed tomography and lung perfusion scintigraphy.
Preoperative lung perfusion scintigraphy of the two recipients showed that their right upper lobes
(RULs) were well perfused, and the preoperative chest CT also showed that their RULs were less
diseased. (A, B: case 1; C, D: case 2)
Figure 3
Postoperative three-dimensional (3D) computed tomography (CT).
It does not show any kinks or stenoses at anastomoses. Anastomotic problems have not yet occurred.
Figure 4
Postoperative perfusion scintigraphy (2 and 6 months after transplantation).
7
The recipient’s postoperative perfusion scintigraphy showed that his spared right upper lobe still had
much the same perfusion at 2 and 6 months, which suggested that it worked as a reservoir not only in
the short term but also in the medium term.
Figure 5
The recipient’s (case 2) intraoperative photo.
Spared native upper lobe and transplanted right lower lobe are in the right thorax, and inverted and
transplanted right lower lobe is in the left thorax.
8
9
10
11
12
13