Ann Thorac Surg 2007;83:1891-1893
© 2007 The Society of Thoracic Surgeons
Case Reports
Graft Pneumonectomy and Delayed Contralateral Lung Transplantation
David Gómez de Antonio, MD*,
Pablo Gámez, MD, PhD,
Mar Córdoba, MD,
Javier Moradiellos, MD,
Andres Varela, MD, PhD
Division of Thoracic Surgery, Hospital Universitario Puerta de Hierro, Madrid, Spain
Accepted for publication November 13, 2006.
* Address correspondence to Dr Gómez de Antonio, c/o Lino 11, 3°F, Madrid, 28020 Spain (Email: dgavm{at}yahoo.es).
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Abstract
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We believe that contralateral single lung transplantation after graft pneumonectomy has not been reported yet in the literature. We present the case of an emphysematous patient who received a unilateral left lung transplant and had severe stenosis in bronchial anastomosis and bronchiectasis develop. Four years after transplantation we decided to perform a left pneumonectomy and a delayed right lung transplantation. Nine months after the procedure the patient is ambulatory and is not dependent on oxygen support.
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Introduction
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Airway anastomotic complications after lung transplantation remain a source of morbimortality, with an incidence of 12% to 15%, and an associated mortality of 2% to 3% [1]. Most of these can be managed endoscopically (ie, debridement, dilation, and stent placement), whereas surgery is seldom indicated and redo transplant is reserved for highly selected cases [2].
We report the case of a patient with severe bronchial stenosis and progressive ipsilateral bronchiectasis after a left lung transplantation who finally underwent graft pneumonectomy and delayed contralateral lung transplantation with excellent outcome.
Left lung transplantation was performed on a 46 year-old man because of advanced emphysema at another institution in April 2001. One month later he had a bronchial anastomotic stenosis develop. Conservative management was indicated at that time. Further bronchoscopic and imaging examinations revealed an associated malacia in the left main bronchus and bronchiectasis in the left lower lobe (Fig 1). The patient began having frequent hospital admissions due to pulmonary infections and finally, in 2002, a silicon stent was placed under rigid bronchoscopy. Several months later the stent was removed with apparently good results, but in 2004 the stenosis recurred and septic complications became a main concern again. At this point the patient was admitted to our hospital. His pulmonary function tests showed a severe obstructive defect with a forced expiratory volume in 1 second of 15.8%, a forced vital capacity of 28.5%, and forced expiratory volume in 1 second/forced vital capacity ratio of 45.4. Fiberscopic exploration revealed a lumen of 8 mm at the level of a malacic bronchial suture and severe left bronchial distortion. Lung perfusion scintigraphy showed 10% of total lung perfusion to the left lung. The development of diffuse bronchiectasis and persistent septic complications precluded more stenting attempts.
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Fig 1. Severe stenosis at the level of the left bronchial anastomosis, architectural distortion of the left hilum, and loss of volume of the left hemithorax.
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In August 2005 we performed a left posterolateral thoracotomy and graft pneumonectomy. Intense adherences and a distortional anatomy made the procedure extremely challenging, with two accidental tears of the left atrium that were finally able to be sutured. The bronchial stump was stapled and covered with a previously harvested intercostal muscle pedicle. The postoperative course was complicated by pneumonia, atrial fibrillation, and impossible weaning from mechanical ventilation through a tracheostomy (Fig 2).
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Fig 2. Postoperative chest X-ray showing a tracheostomy cannula and complete filling of the left hemithorax.
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After 6 weeks of physical rehabilitation and mechanical ventilation the patient was added to our waiting list for a right lung transplantation.
In November 2005, we performed a right lung transplantation with cardiopulmonary bypass. Ischemic time was 3 hours 30 minutes and cardiopulmonary bypass time was 2 hours 30 minutes. The patient had primary graft dysfunction (PaO2, 43 mm Hg) develop that solved with nitric oxide, diuretics, and positive end-expiratory pressure. Weaning from mechanical respiratory assistance was difficult, but was finally achieved after 10 days of continuous positive airway pressure ventilation.
Nine months after transplantation the patient is ambulatory with good exercise tolerance. He is not dependent on oxygen support and has improved his respiratory function measurements (forced expiratory volume in 1 second of 60% and forced vital capacity of 52%) (Fig 3).
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Comment
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Airway anastomotic complications represent a challenge in the management of lung transplant patients. Many factors may impair bronchial healing, such as immunosuppressive agents, absence of bronchial vascularization, and long ischemic times. When the lumen is severely reduced or symptoms are present, endoscopic treatment is initially indicated. Surgery is rarely performed and re-transplantation is reserved for selected cases [1].
In our case, stent placement finally failed to improve bronchial healing and a definite treatment was mandatory to prevent septic complications in an immunodeficient patient. Several surgical options were considered (ie, graft pneumonectomy and re-transplantation, graft pneumonectomy and sequential contralateral transplantation, and graft pneumonectomy with or without a delayed contralateral transplantation). The first option was considered unfeasible because of the architectural distortion of the hilum and the deficient bronchial tissue. A sequential contralateral transplantation was feasible, but a technically hazardous graft pneumonectomy could preclude a right lung transplantation with acceptable ischemic times. A graft pneumonectomy without transplantation would definitely lead to a situation of respiratory insufficiency with an impossible weaning from ventilatory support. Thereby, the best option was to have the patient undergo an elective graft pneumonectomy with a delayed contralateral lung transplantation with cardiopulmonary bypass.
Graft pneumonectomy is a very rare indication in those selected candidates for re-transplantation. We believe that there are two published cases in the literature that describe elective graft pneumonectomy several years after single lung transplantation, with partial reversal of the primary lung disease and acceptable long-term results in idiopathic pulmonary hypertension [3] and extrinsic allergic alveolitis [4]. However, so far there is no description in the literature of a graft pneumonectomy in a patient with severe emphysema and delayed contralateral lung transplantation.
We believe that graft pneumonectomy and delayed contralateral lung transplantation is a reasonable and feasible option in severely compromised respiratory patients who have septic allograft complications develop.
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References
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- Mulligan MS. Endoscopic management of airway complications after lung transplantation Chest Surg Clin North Am 2001;11:907-915.[Medline]
- Strueber M, Fischer S, Gottlieb J, et al. Long term outcome after pulmonary retransplantation J Thorac Cardiovasc Surg 2006;132:407-412.[Abstract/Free Full Text]
- Deb S, Yun J, Burton N, Omron E, Thurber J, Nathan SD. Reversal of idiopathic pulmonary arterial hypertension and allograft pneumonectomy after single lung transplantation Chest 2006;130:214-217.[Medline]
- Onyeaka P, Alexion C, Rocco G, et al. Elective transplant pneumonectomy in a 38-year-old man J Heart Lung Transplant 2005;24:1140-1142.[Medline]
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Abstract
Introduction
