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Ann Thorac Surg 1996;61:1286-1287
© 1996 The Society of Thoracic Surgeons

Update

Contralateral Pneumonectomy After Single-Lung Transplantation for Emphysema

As Originally Published in 1991:

Updated in 1996 by Richard J. Novick, MD, Kenneth E. Gehman, MD, Alan H. Menkis, MD, and F. Neil McKenzie, MD

Division of Cardiovascular-Thoracic Surgery and the Multi-Organ Transplant Service, University Hospital, London, Ontario, Canada

We continue to follow up this exceptional patient who remains well 65 months after a right single-lung transplantation for {alpha}1-antitrypsin deficiency emphysema and a subsequent contralateral pneumonectomy. Since publication of our case report in December 1991 [1], she has had no cardiorespiratory difficulties. An emergency Hartman's procedure was performed in May 1991 for perforated sigmoid diverticulitis, but the patient underwent an uneventful colonic reanastomosis in February 1993. At that time significant hyperglycemia was noted, which was managed by reduction of the prednisone dose and the institution of glyburide therapy. In February 1995 left lower quadrant abdominal pain again developed; abdominal and pelvic ultrasonography and computed tomographic scanning revealed a complex 5 x 4 x 6-cm cystic mass associated with the left ovary. At exploratory laparotomy the mass consisted of an amalgamation of small bowel and omentum adherent to her previous Hartman's reconstruction. The patient made an uneventful recovery from this surgical procedure, with complete resolution of her left lower quadrant discomfort.

At present the patient is able to walk for several blocks and climb two flights of stairs before exertional dyspnea develops. She has experienced no cough or sputum production since recovering from her transplantation and contralateral pneumonectomy. On physical examination she is mildly Cushingoid, but not hypertensive. Exercise testing revealed that oxygen desaturation does not develop with moderate exertion. Her blood sugar is well-controlled on glyburide 5 mg/day orally, and her renal function is normal (blood urea nitrogen level, 7.4 mmol/L; creatinine level, 101 µmol/L). Her immunosuppressive medications consist of cyclosporine, 100 mg orally twice per day (trough whole blood level, 150 to 175 ng/mL), azathioprine, 75 mg/day orally, and prednisone, 2.5 mg/day orally. Pulmonary function testing 5 years postoperatively (Table 1Go) confirmed that the patient's spirometric, lung volume, and diffusion capacity measurements were similar to, or exceeded, published values in a cohort of patients undergoing single-lung transplantation for emphysema [2]. Echocardiography 5 years postoperatively demonstrated mild dilatation of the right atrium and right ventricle, with mild tricuspid regurgitation. The right ventricular systolic pressure was 40 to 45 mm Hg, slightly lower than in 1991. Right and left ventricular contractility were normal. As a result of her uncomplicated cardiorespiratory status and consistently satisfactory pulmonary function, no biopsy of the patient's right lung graft has ever been performed.


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  		Table 1. . Pulmonary Function Test Results 5 Years Postoperatively
 
These observations have confirmed that good quality, long-term survival is possible after single-lung transplantation and bilateral sequential pneumonectomies. Since our case report, other authors have published articles on surgical intervention for infection [3] and recurrent pneumothorax [4] of the contralateral native lung after single-lung transplantation. A further report of a child who underwent bilateral lung transplantation for cystic fibrosis, followed by removal of the left lung graft for infarction on postoperative day 10, confirmed a satisfactory clinical outcome after 6 months of follow-up [5]. Moreover, the Newcastle group has recently reported on a patient who was progressing well 18 months after a right single-lung transplantation and a contralateral pneumonectomy for cystic fibrosis [6].

In view of the favorable long-term results demonstrated in our patient, we believe that surgical procedures on the contralateral lung should be considered in patients with intractable native lung pathology after single-lung transplantation. Given the relatively poor survival after pulmonary retransplantation for graft failure or an airway complication [7, 8], we also believe that unilateral graft pneumonectomy, without retransplantation, may be applicable to select patients in whom one lung is affected by pulmonary vascular thrombosis or airway necrosis after bilateral lung transplantation.

Footnotes

Address reprint requests to Dr Novick, Division of Cardiovascular-Thoracic Surgery, University Hospital, PO Box 5339, London ON N6A 5A5, Canada.

References

  1. Novick RJ, Menkis AH, Sandler D, et al. Contralateral pneumonectomy after single-lung transplantation for emphysema. Ann Thorac Surg 1991;52:1317–9.
  2. Brunsting LA, Lupinetti FM, Cascade PN, et al. Pulmonary function in single lung transplantation for chronic obstructive pulmonary disease. J Thorac Cardiovasc Surg 1994;107: 1337–45.[Abstract/Free Full Text]
  3. Colquhoun IW, Gascoigne AD, Gould K, Corris PA, Dark JH. Native pulmonary sepsis after single-lung transplantation. Transplantation 1991;52:931–3.[Medline]
  4. Venuta F, Rendina EA, De Giacomo T, Ciriaco PP, Della Rocca G, Ricci C. Thoracoscopic treatment of recurrent contralateral pneumothorax after single lung transplantation. J Heart Lung Transplant 1994;13:555–7.[Medline]
  5. Shennib H, Massard G, Gauthier R, Colman N, Mulder D, Cystic Fibrosis Transplant Study Group. Single lung transplantation for cystic fibrosis: is it an option? J Heart Lung Transplant 1993;12:288–93.[Medline]
  6. Forty J, Hasan A, Gould FK, Corris PA, Dark JH. Single lung transplantation with simultaneous contralateral pneumonectomy for cystic fibrosis. J Heart Lung Transplant 1994;13: 727–30.[Medline]
  7. Novick RJ, Kaye M, Patterson G, et al. Redo lung transplantation: a North American-European experience. J Heart Lung Transplant 1993;12:5–16.[Medline]
  8. Novick RJ, Schäfers HJ, Stitt L, et al. Recurrence of obliterative bronchiolitis and determinants of outcome in 139 pulmonary retransplant recipients. J Thorac Cardiovasc Surg 1995;110:1402–14.[Abstract/Free Full Text]



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Pulmonary resection following lung transplantation
Ann. Thorac. Surg., November 1, 2003; 76(5): 1680 - 1686.
[Abstract] [Full Text] [PDF]

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