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Ann Thorac Surg 1999;67:1440-1443
© 1999 The Society of Thoracic Surgeons
a Divisions of Cardiothoracic Surgery, University of Vienna, Vienna General Hospital, Vienna, Austria
b Cardiothoracic Anesthesiology, University of Vienna, Vienna General Hospital, Vienna, Austria
Accepted for publication November 3, 1998.
Address correspondence to Dr Klepetko, Division of Cardiothoracic Surgery, University of Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria
e-mail: walter.klepetko{at}akh-wien.ac.at
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Abstract |
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Methods. The value of this approach was investigated in a prospective series of 13 consecutive patients with the underlying diagnosis of COPD or cystic fibrosis (group A). Results were compared to 8 consecutive patients with similar indications who had undergone BLTX via clamshell incision during the last year prior to this new technique (group B).
Results. No intraoperative complications occurred in either group. The difference between the cold ischemic time of the 1st and 2nd transplanted lung was comparable between the 2 groups (81 min±17 min in group A vs 79 min ±14 min in group B, p = 0.783). Postoperative restriction was significantly less in the group operated through 2 separate thoracotomies, as proven by the vital capacity in the first spirometry performed during the 3rd postoperative week (VC group A 55%±16% predicted vs 41%±11 % predicted in group B; p= 0.043).
Conclusion. The bilateral sequential anterolateral thoracotomy represents a safe and less invasive approach for BLTX in patients with large chest volumes. It minimizes the operative trauma, improves postoperative functional recovery and prevents the potential spread of unilateral complications to the other pleural cavity.
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Introduction |
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However, the clamshell incision also owns several disadvantages. The transverse sternotomy results in a significant restriction of chest wall mechanics in the early postoperative period. This can lead to delayed mobilization and prolonged hospitalization. In addition, in malnourished patients with extremely thin presternal subcutaneous tissue (as lung transplant candidates often present), the site of sternotomy can be affected by infection or delayed healing, eventually leading to development of pseudoarthrosis. Dissection of the anterior mediastinum is an additional factor that increases the risk for postoperative morbidity by generating a communication between the two pleural spaces. Unilateral problems like pneumothorax, pleural effusion or infection can easily affect the contralateral side too.
In an attempt to avoid these disadvantages of the clamshell incision, we have investigated the value of two separate sequential anterolateral thoracotomies as a standard approach for BLTX in a prospective series of 13 patients. It was hypothesized that this limited approach should provide sufficient access for the transplant procedure, at least in patients with large chest cavities.
From June to December 1997, all patients with large chest volumes, ie patients with the underlying diagnosis of COPD or cystic fibrosis who underwent BLTX at our institution entered the prospective study. A total of 13 patients were operated (group A). Their underlying diagnoses were emphysema (n = 9) and cystic fibrosis (n = 4), respectively. Four patients (30.8%) had a history of lung volume reduction surgery (LVRS) prior to transplantation.
Patients were intubated with a double lumen tube and prepared for operation in standard fashion. Positioning and draping of the patients were performed like for the clamshell incision, with the patients placed on the operation table in a supine position with the arms elevated. Transplantation was started on the right side, with the table rotated toward the contralateral side. A limited anterolateral thoracotomy in the 4th intercostal space was performed, lungs were retrieved, and the hilus was prepared in standard fashion. Transplantation of the lung was performed in the usual way [1] with end to end bronchial anastomosis, common atrial anastomosis and pulmonary artery anastomosis. After the implantation of the first lung, two chest tubes were inserted and the thoracotomy was closed. Without redraping the patient, the operation table was rotated to the other side and transplantation of the left lung was then performed in an identical way. Operative times, intraoperative events and postoperative results were monitored.
Results of this group of patients were compared retrospectively to the results of 8 patients with the same diagnoses (emphysema, n = 4; cystic fibrosis, n = 3; Kartagener’s syndrome, n = 1), who had received a BLTX via clamshell incision during the last year prior to the new approach (group B). In this group, 1 patient had undergone LVRS prior to transplantation. Demographic data of the 2 groups are summarized in Table 1.
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Results |
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Perioperatively, patients from both groups experienced a series of minor complications: pneumothorax (n = 6), acute rejection episode (n = 3), prolonged reversible ischemic neurologic deficit (PRIND) (n = 1), seizures (n = 1). No bronchial problem occurred in either group. In group B, 2 bilateral pneumothoraces occurred due to a unilateral prolonged air leak from a parenchymal fistula. Both patients were treated with bilateral drainage and 1 of them was reoperated on the 19th day after transplantation and a tiny parenchymal leak was oversewn.
There was only one major perioperative complication in group A, where a patient was transplanted with a significantly larger donor lung. Despite resection of the lingula and middle lobe during BLTX, the patient showed severely impaired pulmonary compliance deriving from compression of the lungs. After lobectomy of the consolidated right upper lobe on postoperative day 11, the patient recovered quickly and was discharged from hospital 42 days after transplantation.
Two major perioperative complications occurred in group B: In 1 patient, initially localized wound infection with methicillin resistant Staphylococcus aureus, observed at postoperative day 5, spread from the subcutaneous level to both pleural spaces, leading to sepsis and subsequent death of the patient at day 18. Another patient died from sepsis and multiorgan failure at day 34. Thus, 3-month survival for group B was 75%, vs 100% for group A.
All patients discharged from the ICU underwent lung function tests during the 3rd postoperative week. Postoperative restriction was evaluated using the vital capacity as percent of the predicted value (VC%) at this spirometry. There was a significant difference between the 2 groups: group A: 55% ± 16%; group B: 41% ± 11%; p = 0.043; (Fig 1 ) , providing evidence for the better functional recovery of patients from Group A.
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Comment |
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In another attempt to overcome bronchial healing problems, it was suggested to perform two separate bronchial anastomoses. Pasque and colleagues proposed the technique of sequential bilateral lung transplantation, which rapidly became the standard approach for replacement of both lungs [1]. With this technique, two single lung transplantations are performed in a sequential way. Cardiopulmonary bypass is not necessary and the procedure is performed in one stage. The bilateral transsternal thoracotomy (clamshell incision) allows approach to both pleural cavities at once and offers a superb view. This is of particular importance for treatment of patients with severe adhesions or patients with previous operations. Currently, most bilateral lung transplantations worldwide are performed in this way [6].
Although this technique is well established, it must be questioned whether BLTX could be performed in a less invasive way. The clamshell incision can be associated with significant morbidity in the postoperative course. In the past, we have observed in a total of 104 BLTX procedures, 2 patients with disturbed healing of the sternum, making a surgical reintervention necessary. In addition, several events of postoperative pneumothoraces after BLTX presented bilaterally, with the need for bilateral drainage therapy. Finally, early after BLTX patients have a considerable degree of restriction in spirometry due to their limitations in chest wall mechanics, thus increasing the risk for acquiring infection. In view of the general trend in thoracic surgery toward less invasive procedures, we have tried to minimize the operative approach in BLTX as well.
It was hypothesized that BLTX could be performed via 2 separate anterolateral thoracotomies with the same operative result but reduced morbidity. In a 1st step this approach was offered to patients with enlarged chest cavities only (ie patients with COPD or cystic fibrosis). Patients were operated in the same position as for the clamshell incision. They were draped in the same way and the two anterolateral thoracotomies were performed in a sequential way, only with rotating the table position. This avoided sternal split, interruption of the internal mammary arteries and dissection of the mediastinum and therefore kept the two pleural spaces completely separated. The two separate thoracotomies can easily be converted into a standard clamshell incision if needed, although it was not necessary in the present series.
In this prospective series of 13 patients we have experienced no intraoperative problems. Despite the fact that 4 patients had undergone previous thoracic surgery and 4 other patients suffered from cystic fibrosis with significant adhesions, dissection of the pleural space was always performed in a satisfying way, and no patient needed later reoperation for bleeding. There was no occurrence of bronchial problems and there was 100% 3 month survival. When compared with a retrospective control group, no significant difference in cold ischemic time between the 1st and 2nd graft could be seen. Furthermore, overall operation time was even shorter in the group with two separate thoracotomies and postoperative ICU stay was reduced.
One major drawback of the study is the lack of a prospective randomization. One could argue that this retrospective comparison is biased by the gain in experience during the study period. However, we have performed more than 100 BLTX at our institution since 1989 and therefore, it is unlikely that the increase in overall experience within the last year contributed to the better results in the anterolateral thoracotomy group to such a degree.
This study demonstrates that there are no major disadvantages to the suggested method, and the functional recovery of patients after BLTX is significantly improved. From this experience, we suggest that two separate anterolateral thoracotomies should be the standard approach for BLTX in patients with large chest cavities. (Fig 2)
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F. Venuta, E. A. Rendina, T. De Giacomo, A. M. Ciccone, M. Moretti, E. Mercadante, M. Anile, and G. F. Coloni Bilateral sequential lung transplantation without sternal division Eur J Cardiothorac Surg, June 1, 2003; 23(6): 894 - 897. [Abstract] [Full Text] [PDF]
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