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Ann Thorac Surg 1995;60:139-143
© 1995 The Society of Thoracic Surgeons

Lung Transplantation After Previous Thoracic Surgical Procedures

Division of Cardiothoracic Surgery, The University of North Carolina School of Medicine, Chapel Hill, North Carolina

Accepted for publication March 14, 1995.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Background. This study examined results of lung transplantation after previous thoracic surgical procedures.

Methods. Twenty percent of the 69 isolated lung transplantations performed at the University of North Carolina between January 1990 and June 1993 were in patients who had undergone a previous thoracic surgical procedure, and an additional 10% had undergone a previous chest tube placement.

Results. No statistically significant increase in morbidity or mortality was observed between those having undergone a previous procedure or chest tube placement and all other patients. Specifically, the length of intubation, length of hospital stay, hospital mortality, or the number of patients who experienced major early complications was not significantly different between these groups. A statistically significant increase in the number of blood products used was observed in the patients with previous thoracic surgical procedures but not with patients having had previous chest tube placements. However, when the data were reanalyzed with respect to the use of cardiopulmonary bypass, those patients requiring bypass had a markedly poorer outcome that reached statistical significance in all of the parameters studied: hospital death, incidence of major complications, length of intubation, hospital stay, incidence of bleeding, and number of blood products used.

Conclusions. We conclude that although increased bleeding may be encountered, lung transplantation can be performed successfully in patients who have had previous thoracic surgical procedures without increased major morbidity or mortality; however, the use of cardiopulmonary bypass has been associated with significantly increased morbidity and mortality in our patient population.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Lung transplantation has become an accepted treatment for end-stage respiratory failure. However, many transplant programs consider a previous thoracic procedure to be a relative contraindication to lung transplantation. The policy at the University of North Carolina at Chapel Hill has been not to exclude from lung transplantation patients who have had previous thoracic surgical procedures. As a result, 20% of the patients who underwent lung transplantation here had had previous thoracic surgical procedures, and an additional 10% of patients had had previous chest tube placement. This study analyzes this experience with respect to major early complications and hospital mortality.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Patients
Between January 1990 and June 1993, 65 patients underwent 69 isolated lung transplantations. Forty-six of these procedures were bilateral sequential lung transplantations and 23 were single-lung transplantations. The underlying diagnoses are depicted in Figure 1. Data were acquired by retrospective review of patient records and were 100% complete. Only complications or death occurring during the transplantation hospital stay were noted. Late complications, such as obliterative bronchiolitis, were not included.

View larger version (66K): [in this window] [in a new window]   Fig 1. . Underlying diagnoses in 65 lung transplant recipients. (CF = cystic fibrosis; COPD = chronic obstructive pulmonary disease; Infec = other infectious lung disease; IPF = idiopathic pulmonary fibrosis; PPH = primary pulmonary hypertension.)

Surgical Technique
Single-lung transplantations were performed through a lateral thoracotomy, and double-lung transplantations were performed in a bilateral sequential fashion using a bilateral thoracosternotomy (``clam shell incision'') [2, 3]. Every effort was made to avoid the use of cardiopulmonary bypass in all patients except the 4 patients who had primary pulmonary hypertension. An omental wrap was placed around the bronchial anastomoses in all except 5 patients.

Data Analysis
The lung transplant recipients were divided into three groups for purposes of analysis. Fourteen patients had undergone a previous thoracic surgical procedure (PR). This is defined as any thoracic operation or chemical pleurodesis. Patients having had a previous procedure on the side that was not transplanted were not counted. The previous procedures are as follows: open lung biopsy, 4 patients; chronic drainage of empyema, 1; talc pleurodesis, 1; surgical pleurodesis, 2; pleural stripping, 1; bullectomy and thoracoplasty, 1; lobectomy, 2; pneumonectomy, 1; and double-lung transplantation, 1 patient. Seven additional patients had a history of pneumothorax treated with one or more chest tubes but without sclerosis or further procedures (CT). In 3 patients, chest tube placement occurred within 1 month of their transplantation. The remaining patients were included in the AO (all other) group. In this group, 2 patients had a history of pneumothorax that did not require any invasive intervention, 1 patient had a history of traumatic rib fractures, 1 patient with cystic fibrosis had had a previous left upper lobe abscess, and 1 patient with a history of Hodgkin's disease had severe fibrosis of the lung from radiation therapy.

Three patients underwent early retransplantation for acute graft failure. Because these procedures were all performed less than 2 weeks after the original procedure, the second transplants were excluded from separate analysis. These 3 patients were grouped according to their status at the time of the initial transplantation. The retransplantation was counted as a major complication, and any subsequent complications were also counted.

A fourth patient underwent retransplantation for obliterative bronchiolitis 14 months after double-lung transplantation. Each of this patient's transplant procedures was analyzed separately because of the length of time between operations. At the time of her first transplantation, she was included in the AO group, and for the second transplantation she was included in the PR group.

Nonparametric statistical analyses were used because of the small size of the PR and CT groups. A Mann-Whitney U test was used for analysis of continuous data. Ordinate data were analyzed by means of the Fisher's exact test. A p value of less than 0.05 was considered significant. Multivariate analysis was not performed because of the small number of patients in some of the groups.

Definition of Terms
A hospital death was defined as any death occurring within 30 days or during the initial hospitalization. Major early complications included events during the first 3 months that led to a patient's death, prolonged the hospitalization, or required a major intervention such as another operation or dialysis. Hospital stay was defined as the number of days from the date of the transplantation to hospital discharge. For purposes of analysis, only the hospital stay of survivors was counted. Length of intubation was defined as the number of days from the transplantation until the patient was successfully extubated and remained stable for at least 24 hours. Subsequent intubations were not analyzed. Acute renal failure was defined as renal failure severe enough to require dialysis. The number of blood products used included all packed cells and other blood products given from the beginning of the transplant operation until 48 hours later.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Death, Major Complications, Length of Intubation, and Hospital Stay
The number of patients with major early complications and the hospital death rate are given in Table 1. No statistically significant differences were found for comparisons between groups. Similarly, there were no statistically significant differences between groups in the length of intubation or hospital stay, although there was a trend to shorter length of intubation in the AO group.

• PR (Previous Procedure)
  • Bleeding, graft failure, acute renal failure, multiple organ system failure, death
    
  • Bleeding, pyloroplasty, sternal infection
    
  • Mediastinal abscess
    
  • Graft failure, central nervous system injury/edema, death
    
  • Contralateral bullectomy after single-lung transplantation
    
  • Pulmonary artery stenosis
    
  • Fat embolism
    
  
  
• CT (Previous Chest Tube Placement)
  • Bleeding, graft failure, cerebrovascular accident, acute renal failure, partial airway dehiscence
    
  • Bleeding, acute renal failure, seizures
    
  
  
• AO (All Others)
  • Graft failure: 5 (with: death, 4; acute renal failure, 3; pneumonia, 2; small bowel obstruction, 1)
    
  • Airway dehiscence: 3 (with: death, 2; acute renal failure, 1; pneumonia and pulmonary embolism, 1)
    
  • Aspiration pneumonia: 1 (with: bowel perforation, acute renal failure, death)
    
  • Other: 4 (bleeding, pulmonary artery stenosis; femoral vein thrombosis; small bowel obstruction)
    
  
  

The first patient had undergone a previous pneumonectomy for hemoptysis attributable to bronchiectasis from Bruton's agammaglobulinemia. Cardiopulmonary bypass was required, and his postoperative course was complicated by bleeding and graft failure. Multiple organ system failure developed, and he died on postoperative day 11. The previous operation probably contributed significantly to the complications and death.

The next patient, who had cystic fibrosis, also experienced postoperative bleeding requiring reexploration, although cardiopulmonary bypass was not used during the transplantation. Six weeks postoperatively, a sternal wound infection developed requiring debridement. He also exhibited poor gastric emptying and underwent a pyloroplasty before hospital discharge.

The other patients experienced complications that were unrelated to the previous procedure. These included development of a small mediastinal abscess attributable to Pseudomonas cepacia; hyperexpansion of a contralateral bulla after single-lung transplantation, which ultimately required resection; severe graft failure, which caused hypoxic cerebral injury; and stenosis of a pulmonary artery anastomosis, which required revision.

In the last patient, who previously had undergone an open lung biopsy, severe sustained hypoxia (arterial oxygen tension less than 30 mm Hg for 6 hours) developed immediately after double-lung transplantation. Histologic examination of the donor right middle lobe and lingula, which had been removed for better size matching, demonstrated massive fat embolism. The donor, who had sustained multiple long bone fractures, had an arterial oxygen tension of 413 mm Hg on 100% oxygen just before organ procurement. This patient required mechanical ventilation for 1 month, but was discharged after 6 weeks with no neurologic impairment and with good exercise tolerance on room air.

Two patients who had undergone previous chest tube placement experienced complications after transplantation. One underwent a difficult double-lung transplantation requiring cardiopulmonary bypass. His postoperative course was complicated by bleeding requiring reoperation, acute renal failure, and pulmonary venous thrombosis of the left lung requiring emergent retransplantation 7 days after the initial transplantation. This was complicated by a stroke and a complete right bronchial dehiscence. His airway healed secondarily without stenosis, his renal function returned, and he made a good neurologic recovery before his discharge 2.5 months after transplantation. He continues to do well 4 years later with an forced expiratory volume in 1 second of 95% of predicted.

Another patient who had had a previous chest tube placement was found at the time of transplantation to have a right upper lobe abscess eroding into the chest wall. Cardiopulmonary bypass was required during the procedure and was associated with postoperative bleeding requiring reexploration, as well as renal failure. She recovered from these events and was discharged. In both of these patients, the complications were unrelated to their previous chest tube placements, because the bleeding occurred in the hemithorax opposite from where the chest tubes had been.

Thirty percent of the patients in the AO group experienced major complications, and these are listed in Table 2. The incidence of graft failure, airway dehiscence, or acute renal failure requiring dialysis was not significantly different from the incidence for the other two groups of patients. Seven hospital deaths occurred in this group. Three of the deaths occurred shortly after the transplantation, due to acute graft failure. A fourth patient who experienced severe graft failure was maintained on a ventilator, but died of respiratory failure 3 months after transplantation. One patient died of airway complications, and 1 died of massive aspiration that occurred 2 days after transplantation.

To assess the effect of cardiopulmonary bypass, all of our data were also analyzed with respect to the use of bypass. These results are shown in Table 3. In patients requiring cardiopulmonary bypass, statistically significant increases occurred in the length of intubation, the length of hospital stay, the number of patients with major complications, the number of hospital deaths, the number of blood products used, and the number of reoperations for bleeding.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

Further refinements in the operative technique resulted in the use of a bilateral thoracosternotomy, or clam shell incision, and the technique of bilateral sequential double-lung transplantation [10]. These refinements offered surgeons the possibility of performing double-lung transplantation without the use of cardiopulmonary bypass and offered excellent exposure to the entire chest cavity. Nevertheless, a previous thoracic surgical procedure continued to be a contraindication to isolated lung transplantation in many centers [8, 11, 12]. Because of the frequency of previous thoracic surgical procedures in patients with end-stage lung disease, such a policy excludes a large number of patients.

At the University of North Carolina, patients have not been excluded from transplantation because of a previous thoracic surgical procedure. Retrospective review of this policy demonstrates a number of interesting findings. There was no significant increase in the incidence of major complications in patients with a previous thoracic surgical procedure. Most of the complications that occurred were unrelated to the previous surgical procedure. There was also no significant difference in hospital mortality, duration of intubation, or length of hospital stay. These patients did require an increased number of blood products perioperatively.

Similarly, patients who had undergone previous chest tube placement did not have a significant difference in the incidence of major early complications, death, duration of intubation, or length of hospital stay. There was no significant difference in the number of blood products in patients who had undergone a previous chest tube placement.

The use of cardiopulmonary bypass, on the other hand, is associated with a significant increase in morbidity and mortality. This increase reached statistical significance in each parameter analyzed.

The patient population presented here is slightly different from the average transplant patient population in the United States [13]. A large number of these patients have cystic fibrosis, which is generally considered to be a group at higher risk for complications such as perioperative bleeding [9]. Generally, these patients have markedly enlarged lymph nodes with large dilated bronchial arteries, as well as many vascular pleural adhesions. The use of cardiopulmonary bypass is particularly likely to cause an increase in bleeding and other complications in this patient population.

Little published work is available relating to lung transplantation after previous surgical procedures. Madden and colleagues [14] report that 5 of 10 patients who had had previous thoracic operations died in the early postoperative period from complications including bleeding, infection, and multiorgan failure. Their patients all had cystic fibrosis and underwent heart–lung transplantation with the use of cardiopulmonary bypass.

In conclusion, our experience with isolated lung transplantation during a 3.5-year period includes many patients who have undergone previous thoracic surgical procedures. No significant increase in morbidity or mortality was seen in these patients. The duration of intubation, hospital stay, and the incidence of reoperation for bleeding were not significantly increased. However, a statistically significant increase in the use of blood products was seen. Patients who had undergone previous chest tube placement showed no increase in morbidity or mortality. However, the use of cardiopulmonary bypass was associated with a marked significant increase in morbidity and mortality, as well as an increase in length of intubation, hospital stay, use of blood products, and incidence of reoperation for bleeding. We conclude from this analysis that a previous thoracic surgical procedure should not be used as an exclusion criterion for lung transplantation. The use of cardiopulmonary bypass should be avoided when possible, because it is associated with a significant increase in morbidity and mortality, at least in our patient population.

	Acknowledgments

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
We thank Betsy L. Mann for editorial assistance in the preparation of the manuscript.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Presented at the Third International Lung Transplant Symposium, Zurich, Switzerland, June 24–25, 1993.

Address reprint requests to Dr Detterbeck, Division of Cardiothoracic Surgery, The University of North Carolina School of Medicine, 108 Burnett-Womack Building, CB 7065, Chapel Hill, NC 27599-7065.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 

1. Egan TM, Westerman JH, Lambert CJ Jr, et al. Isolated lung transplantation for end-stage lung disease: a viable therapy. Ann Thorac Surg 1992;53:590–6.[Abstract]
2. Egan TM, Cooper JD. Surgical aspects of single lung transplantation. Clin Chest Med 1990;11:195–205.[Medline]
3. Egan TM, Detterbeck FC. Technique and results of double lung transplantation. Chest Surg Clin N Am 1993;3:89–111.
4. Veith FJ, Kamholz SL, Mollenkopf FP, Montefusco CM. Lung transplantation 1983. Transplantation 1983;35:271–8.[Medline]
5. Reitz BA, Wallwork JL, Hunt SA, et al. Heart–lung transplantation: successful therapy for patients with pulmonary vascular disease. N Engl J Med 1982;306:557–64.[Abstract]
6. The Toronto Lung Transplant Group. Unilateral lung transplantation for pulmonary fibrosis. N Engl J Med 1986;314:1140–5.[Abstract]
7. Patterson GA, Cooper JD, Goldman B, et al. Technique of successful clinical double lung transplantation. Ann Thorac Surg 1988;45:626–33.[Abstract]
8. Theodore J, Lewiston N. Lung transplantation comes of age. N Engl J Med 1990;322:772–4.[Medline]
9. Egan TM, Kaiser LR, Cooper JD. Lung transplantation. Curr Probl Surg 1989;26;675–751.
10. Pasque MK, Cooper JD, Kaiser LR, et al. Improved technique for bilateral lung transplantation: rationale and initial clinical experience. Ann Thorac Surg 1990;49:785–91.[Abstract]
11. Marshall SE, Kramer MR, Lewiston NJ, Starnes VA, Theodore J. Selection and evaluation of recipients for heart–lung and lung transplantation. Chest 1990;98:1488–94.[Abstract/Free Full Text]
12. Onofrio JM, Emory WB. Selection of patients for lung transplantation. Med Clin N Am 1992;76:1207–19.[Medline]
13. Kaye MP. The Registry of the International Society for Heart and Lung Transplantation: tenth official report 1993. J Heart Lung Transplant 1993;12:541–8.[Medline]
14. Madden BP, Hodson ME, Tsang V, et al. Intermediate-term results of heart-lung transplantation for cystic fibrosis. Lancet 1992;339:1583–7.[Medline]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Frank C. Detterbeck Thomas M. Egan Michael R. Mill Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Detterbeck, F. C. Articles by Mill, M. R. Search for Related Content PubMed PubMed Citation Articles by Detterbeck, F. C. Articles by Mill, M. R.