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Ann Thorac Surg 1996;62:363-368
© 1996 The Society of Thoracic Surgeons

Original Articles: General Thoracic

Unilateral Volume Reduction After Single-Lung Transplantation for Emphysema

Timothy J. Kroshus, MD, R. Morton Bolman, III, MD, Vibhu R. Kshettry, MD

Division of Cardiovascular and Thoracic Surgery, University of Minnesota, Minneapolis, Minnesota

Accepted for publication April 1, 1996.


   Abstract
Top
 Footnotes
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
Background. Single-lung transplantation has become accepted therapy for patients with end-stage emphysema. Hyperinflation of the native lung can occur after single-lung transplantation with mediastinal shifting and compression of the transplanted lung. A volume reduction operation (pneumonectomy) may relieve symptoms of dyspnea and improve exercise tolerance.

Methods. Three of 66 patients who underwent single-lung transplantation for emphysema had development of native lung hyperexpansion and mediastinal shifting causing compression of the transplanted contralateral lung at 12, 17, and 42 months after transplantation. There were 2 men and 1 woman. Unilateral volume reduction was performed without complication in all 3 patients.

Results. All patients were noted to have marked improvement in chest radiographs after volume reduction, substantial relief of dyspnea, and improvement in exercise tolerance. An improvement in pulmonary function test results was noted in 1 patient, but tests were not done for the other 2 patients.

Conclusions. Patients with chronic obstructive pulmonary disease who undergo single-lung transplantation may have symptomatic hyperexpansion of the native lung requiring volume reduction months to years after transplantation. Unilateral volume reduction can be safely performed in the posttransplantation period.


   Introduction
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 Footnotes
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 References
 
Lung transplantation has become accepted therapy for patients with end-stage pulmonary disease caused by chronic obstructive pulmonary disease (COPD) [1]. Initial transplant procedures for COPD were primarily double-lung or bilateral single-lung transplantation because of the concern that hyperinflation of the native lung would cause compression of the transplanted lung if single-lung transplantation were undertaken [2, 3]. Subsequent reports [4, 5] have demonstrated successful single-lung transplant procedures for COPD. Hyperinflation of the native lung can lead to mediastinal shifting with compression and impaired ventilation of the transplanted lung [2, 6]. The transplanted lung often appears to be reduced in volume as the native lung increases in size [7]. A recent report [8] measured lung volumes of native and transplanted lungs after single-lung transplantation for COPD and demonstrated smaller than predicted transplanted lung volumes and increasing lung volumes of the native lung up to 6 months after transplantation, findings suggesting some restriction of the transplanted lung. However, the transplanted single lung was not constrained by hyperinflation of the contralateral native lung in another report [9].

Volume reduction surgery (pneumonectomy) has recently resurfaced as treatment of patients with end-stage COPD to relieve symptoms of dyspnea and to improve exercise tolerance [10, 11] and has been suggested as an alternative to lung transplantation [12]. Exercise tolerance may be improved and symptoms of dyspnea, lessened after excision, plication, or decompression of space-occupying bullae in patients with COPD [10, 13]. Bilateral lung hyperexpansion can occur in patients with COPD, and hyperexpansion of the contralateral native lung can also occur after single-lung transplantation. The present report describes the development of unilateral native lung hyperexpansion with symptomatic compression of the transplanted lung in 3 patients who underwent single-lung transplantation for COPD. These patients were treated with unilateral native lung volume reduction and demonstrated substantial improvement in respiratory function and symptoms.


   Material and Methods
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 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
Between August 26, 1989, and September 21, 1995, a total of 66 patients (28 deficient in {alpha}-1-antitrypsin and 38 with COPD) underwent single-lung transplantation for emphysema. The technique of single-lung transplantation used has been previously described by our group [14]. In 3 patients, progressive dyspnea that was not attributable to infection or rejection developed after transplantation. Two were men 34 and 55 years old, and 1 was a woman 50 years old. Chest radiographs demonstrated marked hyperexpansion of the native lung with mediastinal shifting and compression of the contralateral transplanted lung. One patient was ventilator dependent.

Immunosuppression after transplantation consisted of steroids (500 mg of intravenous methylprednisolone intraoperatively, followed by a taper and maintenance at 0.1 to 0.5 mg•kg-1•day-1), cyclosporin A (to maintain serum levels of 200 to 300 ng/dL by high-pressure liquid chromatography, whole-blood method), and azathioprine (2.5 mg•kg-1•day-1, adjusted to maintain a white blood cell count of greater than 3.5 x 109/L). At regular intervals after transplantation and as indicated clinically, recipients underwent pulmonary function testing, quantitation ventilation/perfusion scans, and bronchoscopy with bronchoalveolar lavage and transbronchial biopsy to monitor for rejection and infection.

Patients selected for unilateral volume reduction were intubated with a double-lumen endotracheal tube to allow deflation of the native lung with one-lung ventilation. A standard median sternotomy incision was made, and the pleura was incised longitudinally, with care taken to avoid injury to the phrenic nerve. The native lung was then deflated, and multiple wedge resections with bovine pericardium-reinforced staplers were taken from those portions of the native lung that remained inflated or demonstrated bullous disease, primarily from the lung apices. The overall lung volume resected was estimated to be 25% to 30% in each patient. The native lung was reinflated and assessed for air leaks and adequacy of the resection. Chest and mediastinal thoracostomy tubes were placed, and the sternum was closed with sternal wires. Two of the 3 patients were extubated immediately after the procedure. All were transported to the intensive care unit for monitoring.


   Results
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 Abstract
 Introduction
 Material and Methods
 Results
Comment
 References
 
The 3 patients selected for unilateral volume reduction had undergone single-lung transplantation for emphysema 12, 17, and 42 months before unilateral native lung volume reduction. There were 2 men and 1 woman. Their individual case reports follow.

Patient 1
A 50-year-old woman underwent right single-lung transplantation for {alpha}-1-antitrypsin deficiency in April 1994. The posttransplantation course was unremarkable for 8 months, followed by a 4-month deterioration in pulmonary function test results. Chest radiographs demonstrated progressive hyperinflation with herniation of the native left lung across the midline, which caused compression of the transplanted right lung (Fig 1Go). Chest computed tomographic scan demonstrated similar findings with marked mediastinal shifting.



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  		Fig 1. . (Patient 1.) Chest radiographs made (A) before and (B) after volume reduction. Arrows indicate changes in end-inspiratory lung volume of the native left lung before and after unilateral volume reduction.

 
Left lung volume reduction was performed with about 25% resection of the left lung apex by multiple wedge excisions. After sternotomy, the hyperexpanded left lung herniated out of the chest (Fig 2AGo) in a similar manner as in the other 2 patients. The bullous disease changes after native lung deflation and selective right-lung ventilation are shown in Figure 2BGo. In addition, an open lung biopsy was performed on the transplanted right lung. The patient did well after volume reduction with improvement noted in pulmonary function test results (Fig 3Go) and exercise tolerance and normalization of the chest radiograph (see Fig 1Go).



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  		Fig 2. . (Patient 1.) (A) Herniation of the hyperexpanded native left lung out of the chest after median sternotomy. (B) Appearance of the native left lung after deflation and selective right-lung ventilation. Bullous disease and persistent inflation of peripheral portions of the lung are evident.

 


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  		Fig 3. . (Patient 1.) Pulmonary function test results. (FEV1 = forced expiratory volume in 1 second; FVC = forced vital capacity; * = pulmonary function tests done after unilateral volume reduction.)

 
Patient 2
A 55-year-old man underwent left single-lung transplantation for COPD in October 1993. The posttransplantation course was complicated by episodes of sepsis, malnutrition, and respiratory failure. The condition of the patient gradually improved, and he remained well until 5 months after transplantation when a symptomatic airway anastomotic stenosis developed. A Gianturco stent was placed to treat the stenosis, with major improvement noted in pulmonary function test results. The patient was seen again with pulmonary sepsis 12 months after transplantation and became ventilator dependent, necessitating a tracheostomy. After stabilization of numerous medical problems, several attempts to wean the patient from the ventilator failed. Chest radiographs showed hyperinflation of the native right lung with mediastinal shifting and compression of the transplanted left lung (Fig 4Go). Rapid hyperexpansion of the native lung developed and necessitated periodic bronchoscopic decompression. Eventually selective single-lung ventilation with a dual-lumen endotracheal tube was necessary to keep the native lung from further hyperexpansion. This situation worsened whenever the patient was switched to a standard endotracheal tube or shortly after extubation.



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  		Fig 4. . (Patient 2.) Chest radiographs made (A) before and (B) after volume reduction. Arrows indicate changes in end-inspiratory lung volume of the native right lung before and after unilateral volume reduction.

 
Because of persistent progressive hyperinflation and failure to wean from selective lung ventilation, volume reduction of the native right lung was performed. Preoperative and postoperative volume reduction chest radiographs are shown in Figure 4Go; they demonstrate a marked reduction in the volume and herniation of the native lung. After volume reduction, the patient was extubated within a week and remained off a ventilator for 2 months. However, respiratory failure and sepsis secondary to fungal pneumonia subsequently developed, and the patient died 6 months after volume reduction. The request for a postmortem examination was denied.

Patient 3
A 34-year-old man underwent left single-lung transplantation in September 1991 for {alpha}-1-antitrypsin deficiency. The posttransplantation course was unremarkable for 42 months, at which time progressive dyspnea not attributable to infection or rejection developed. Chest radiographs demonstrated hyperinflation and herniation of the native right lung into the left chest with mediastinal shifting and compression of the transplanted left lung (Fig 5Go). Unilateral volume reduction of the native right lung was performed and led to radiographic improvement with reduction in herniation of the native lung (see Fig 5Go). After volume reduction, the patient noted an improvement in exercise tolerance. Several months after the procedure, disseminated fungal sepsis developed, and the patient died 6 months after volume reduction. A postmortem examination was not performed.



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  		Fig 5. . (Patient 3.) Chest radiographs made (A) before and (B) after volume reduction. Arrows indicate changes in end-inspiratory lung volume of the native right lung before and after unilateral volume reduction.

 

   Comment
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
Single-lung transplantation has become an acceptable therapeutic option for patients with end-stage emphysematous pulmonary disease [1]. Survival in this patient population has been markedly increased with single-lung transplantation compared with medical management alone. Initial concerns regarding the use of single-lung transplantation for end-stage COPD versus bilateral sequential lung transplantation regarding hyperexpansion of the native lung causing compression of the transplanted lung have been shown to be of little consequence. Several investigators have reported acceptable results after single-lung transplantation for COPD. Patients receiving single-lung transplantation for COPD had nearly identical levels of allograft-specific function at 6 months after transplantation as patients with pulmonary fibrosis [9]. Short-term morbidity and mortality rates were not worse with the use of single versus bilateral lung transplantation for COPD in another report [15]. These results support the use of single-lung transplantation for COPD. Because of the profound shortage of organs and the largest need of lung allografts in the emphysema patient population, use of single-lung transplantation will increase the number of potential recipients receiving a transplanted lung.

Volume reduction surgery, or pneumonectomy, was reported in the literature several decades ago for the treatment of bullous emphysema. The pathophysiology of bullous emphysematous changes in the lung parenchyma has been attributed to compression of normal underlying lung tissue by the bullous lesions [13]. Functional improvement was noted after the removal of such bullae because of the restoration of functional lung tissue [16]. Brantigan and Mueller [17] suggested that distended emphysematous lungs caused by COPD lead to a loss of the normal outward circumferential pull on the bronchioles, thereby resulting in their collapse during expiration. The reduction in overall lung volume was thought to restore the outward elastic pull on the small airways and reduce expiratory pressure.

Cooper and associates [12] suggested that certain principles suggested by Brantigan might apply to patients with COPD with restoration of outward elastic forces on collapsible bronchioles by multiple wedge resections of peripheral lung tissue. A significant improvement in exercise tolerance, oxygen requirements, and spirometric and lung volume measurements was demonstrated in patients with COPD who underwent bilateral pneumonectomy [12]. In addition, these authors indicated that use of this procedure in properly selected patients might serve as a possible alternative to lung transplantation or as a bridge to transplantation. Unlike patients in other series, our patients had undergone previous single-lung transplantation and demonstrated hyperexpansion and herniation of the native emphysematous lung into the contralateral chest with compression of the transplanted lung months to years after transplantation. These patients benefited from resection of bullous emphysematous lung tissue with improvement in the function of the nondiseased transplanted lung.

Patients were selected for unilateral volume reduction after workup failed to identify other causes of progressive respiratory insufficiency. The workup included screening for infectious causes of progressive dyspnea, including cytomegalovirus, bacterial or fungal pneumonia, acute or chronic rejection, congestive heart failure, and bronchiolitis obliterans syndrome. Patients with unilateral hyperinflation were readily identified by chest radiographs demonstrating hyperexpansion of the native lung and mediastinal shifting causing compression of the transplanted lung. We have seen this problem only in patients who had single-lung transplantation for emphysema and not after transplantation for restrictive or septic lung disease or after bilateral sequential lung or heart-lung transplantation. In these selected patients, progressive dyspnea was attributed to compression of normal pulmonary parenchyma in the transplanted lung by the hyperinflated native lung. On the basis of our findings, we think patients with substantial bullous lung disease can benefit from bilateral sequential lung transplantation. However, the realities of donor availability preclude offering bilateral lung transplantation to patients with bullous lung disease, as a greater number of patients benefit from single-lung transplantation.

The 3 patients undergoing unilateral volume reduction of the native lung were noted to have substantial clinical improvement with an increase in exercise tolerance in 2 patients and resolution of ventilator dependence in the other. In 1 patient, obliterative bronchiolitis had not been previously diagnosed in an open lung biopsy specimen from the transplanted lung at the time of volume reduction. Despite the diagnosis of obliterative bronchiolitis, this patient demonstrated substantial improvement in pulmonary function test results after volume reduction and remained in stable condition over the next 12 months. The other 2 patients with symptomatic improvement in pulmonary symptoms subsequently had development of infectious complications that were unrelated to the pneumonectomy procedure and died several months later.

A median sternotomy approach was used in these patients to gain access to both lungs. This approach has been reported to result in excellent exposure of both lungs for the resection of emphysematous bullae [12]. In each patient described in the present series, the hyperinflated native lung herniated out of the chest after sternotomy. Selective one-lung ventilation was used with deflation of the native lung in each instance and was well tolerated. Resection of hyperexpanded pulmonary tissue was performed preponderantly in the apex of the native lung, with resection directed at those areas of the lung that did not deflate, a finding indicating air trapping and nonfunctional lung tissue. All patients were receiving steroids as part of the posttransplantation immunosuppression protocol, which potentially left them at increased risk for air leaks after pulmonary resection. Resection was performed in each patient with bovine pericardium-lined stapling devices to reduce the risk of air leak. The study of Cooper and colleagues [12] demonstrated complete elimination of air leak complications from suture lines and reduced morbidity and length of hospital stay, findings suggesting that the use of pericardial strips is of considerable benefit. No patient in the present study had a persistent air leak, defined as an air leak for greater than 7 days after volume reduction.

An objective assessment of results of unilateral pneumonectomy can be made on the basis of the improvement seen on chest radiographs with a return of the mediastinum to the midline and the absence of native lung herniation into the contralateral chest. A subjective assessment was provided by symptomatic improvement, increased exercise tolerance, or decreased ventilatory assistance. All patients showed some improvement in respiratory mechanics. No other indices of overall lung function were performed in the 2 patients who eventually died of other causes. Improvement in pulmonary mechanics continues for at least 3 months after volume reduction for COPD [12]. These patients need to be followed long term to fully evaluate the efficacy of this treatment.

In summary, unilateral volume reduction can be successfully performed after single-lung transplantation in properly selected patients with emphysema in whom marked hyperexpansion of the native lung develops. The pathophysiology of this disorder is caused by compression of viable transplanted pulmonary tissue by the contralateral hyperexpanded native lung. Unilateral volume reduction, when indicated, appears to alleviate this problem. Unilateral volume reduction in properly selected patients with emphysema can be considered at the time of single-lung transplantation to avoid this problem in the later posttransplantation period.


   Footnotes
Top
 Footnotes
Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 
Address reprint requests to Dr Kshettry, Box 207 UMHC, 420 Delaware St SE, Minneapolis, MN 55455.


   References
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

  1. Kaiser LR, Cooper JD, Trulock EP, Pasque MK, Triantafillou A, Haydock D. The evolution of single lung transplantation for emphysema. J Thorac Cardiovasc Surg 1991;102:333–41.[Abstract]
  2. Stevens PM, Johnson PC, Bell RL, Beall AC, Jenkins DE. Regional ventilation after lung transplantation in patients with emphysema. N Engl J Med 1970;282:245–9.
  3. The Toronto Lung Transplant Group. Experience with single lung transplantation for pulmonary fibrosis. JAMA 1988;259:2258–62.[Abstract/Free Full Text]
  4. Trulock EP, Egan TM, Kouchoukos NT, et al. Single lung transplantation for severe chronic obstructive pulmonary disease. Chest 1989;96:738–42.[Abstract/Free Full Text]
  5. Marinelli WA, Hertz MI, Shumway SJ, et al. Single lung transplantation for severe emphysema. J Heart Lung Transplant 1992;11:577–83.[Medline]
  6. Vanderhoeft RJ, Roqman SP, Nemry C. Left lung transplantation in a patient with emphysema. Arch Surg 1971;178:463–76.
  7. Patterson GA, Maurer JR, Williams TJ, Cardoso PG, Scavuzzo M, Todd TR. Comparison of outcomes of double and single lung transplantation for obstructive lung disease. J Thorac Cardiovasc Surg 1991;101:623–32.[Abstract]
  8. Cheriyan AF, Garrity ER, Pifarre R, Fahey PJ, Walsh JM. Reduced transplant lung volumes after single lung trans-plantation for chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1995;151:851–3.[Abstract]
  9. 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]
  10. Delarue NC, Woolf CR, Sanders DE, et al. Surgical treatment for pulmonary emphysema. Can J Surg 1977;20:222–30.[Medline]
  11. Knudson RJ, Gaensler EA. Surgery for emphysema. Ann Thorac Surg 1965;1:332–62.
  12. Cooper JD, Trulock EP, Triantafillou AN, et al. Bilateral pneumectomy (volume reduction) for chronic obstructive pulmonary disease. J Thorac Cardiovasc Surg 1995;109:106–19.[Abstract/Free Full Text]
  13. Billig DM. Surgery for bullous emphysema. Chest 1976;70:572–3.
  14. Kshettry VR, Shumway SJ, Gauthier RL, Bolman RM III. Technique of single-lung transplantation. Ann Thorac Surg 1993;55:1019–21.[Abstract]
  15. Low DE, Trulock EP, Kaiser LR, et al. Morbidity, mortality, and early results of single versus bilateral lung transplantation for emphysema. J Thorac Cardiovasc Surg 1992;103:1119–26.[Abstract]
  16. Benfield JR, Cree EM, Pellet JR, Barbee R, Mendenhall JT, Hickey RC. Current approach to the management of emphysema. Arch Surg 1966;93:59–70.[Abstract/Free Full Text]
  17. Brantigan OC, Mueller E. Surgical treatment of pulmonary emphysema. Am J Surg 1957;23:789–804.



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