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a Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
b Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
c Department of Pulmonary, Allergy, and Critical Care Medicine, Cleveland Clinic, Cleveland, Ohio
Accepted for publication October 30, 2007.
* Address correspondence to Dr Mason, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Avenue/Desk F24, Cleveland, OH 44195 (Email: masond2{at}ccf.org).
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Abstract |
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Methods: From February 1990 to December 2006, 553 patients underwent lung transplantation; postoperative decortications were performed 27 times in 24 patients (4.3%).
Results: Indications for decortication included presumed empyema (15), loculated effusion (7), hemothorax (3), and fibrothorax (2). Decortication was performed at a median of 81 days after transplantation (range, 12 days to 7.8 years). Complete lung reexpansion was achieved after 19 of 27 decortications (70%). Infection was cleared from the pleural space in 9 of 15 empyema patients (64%). Survivals at 1, 3, 6, and 12 months after decortication were 85%, 73%, 65%, and 60%, respectively. Operative mortality (30-day or in-hospital) was 23%, and median length of stay was 19 days.
Conclusions: Decortication may alleviate the compromise of a transplanted lung by restrictive or infectious pleural-space disease, but operative risk is substantial.
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Introduction |
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TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Patients and Methods |
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TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Yearly follow-ups were obtained for all patients, most of whom received all postoperative care at Cleveland Clinic. Mean follow-up of patient survival after decortication was 1.4 ± 1.5 years; 35 patient-years of data were available for analyses.
Endpoints
Primary endpoint was all-cause mortality. Procedures considered in mortality tabulations included 24 primary decortications as well as two reoperative decortications of contralateral lungs. Reoperation for refractory empyema during the same admission was not included in mortality calculations. Secondary endpoints were lung expansion and clearance of infection. Lung expansion was determined by the surgeon at the time of operation and confirmed by chest radiography. Clearance of infection was judged by clinical evaluation and freedom from reoperation.
Data Analysis
Survival curves were estimated by the Kaplan-Meier method; resulting curves were compared using the log-rank test. A p value less than 0.05 was considered statistically significant.
Decortication
Surgical approaches to the pleural space were through posterolateral thoracotomy (22), video-assisted thoracic surgery (VATS; 3), redo clamshell (1), or sternotomy (1). One patient underwent Clagett window at the time of decortication through a posterolateral thoracotomy [6]. Technical goals of the procedure were clearance of all fluid and debris and expansion of the allograft. An open approach was performed when the surgeon believed a minimally invasive technique could not achieve these goals. Indications for surgery included pleural thickening with signs of lung entrapment documented by computed tomographic (CT) scan and loculations not considered amenable to percutaneous drainage or tube thoracostomy. The most common approach was posterolateral thoracotomy, commencing through the fifth interspace with the creation of an extrapleural dissection. The lung was freed up in its entirety: medially to the mediastinum, superiorly to the apex, inferiorly to the diaphragm, and posteriorly to the hilum. Careful parietal and visceral decortication was continued using a combination of sharp and blunt techniques until the lung was maximally reexpanded (Fig 1). No further attempts were made to obliterate the residual pleural space (such as pleural tenting) in patients whose lungs failed to reexpand in the operating room.
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Results |
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Timing of Operation
The interval between lung transplantation and decortication ranged from 12 days to 7.8 years (median 81 days). Median interval between transplant and VATS decortication was 25 days, while the interval between transplant and open decortication was 82 days. During this latter interval, more conservative attempts were made to manage the pleural space: thoracentesis (10), tube thoracostomy (7), and fibrinolysis (3).
Lung Reexpansion
Decortication resulted in complete reexpansion of the transplanted lung in 19 of 27 procedures (70%; Table 1). Complete lung reexpansion was more likely in patients undergoing decortication in the early postoperative period. Complete lung reexpansion was observed in 78% (11 of 14) of patients undergoing decortication within 90 days of transplant, compared with 58% (7 of 12) of patients decorticated beyond 90 days.
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Complications
Median length of stay was 19 days (range, 3 to 102 days). Operative mortality (30-day or in-hospital) for 26 primary decortications (one patient had the same lung decorticated twice) was 23% (6 of 26). Causes of death included sepsis in three patients and multisystem organ failure, brain abscess, and respiratory failure in one patient each. Morbidities included renal failure in 15 patients and new-onset atrial fibrillation in four patients.
Survival
Survivals at 1, 3, 6, and 12 months after decortication were 85%, 73%, 65%, and 60%, respectively. Survival at 3 years was 56% (Fig 2A). Patients undergoing decortication within 90 days of lung transplant had significantly better long-term survival than patients whose interval was greater than 90 days (p = 0.03, log-rank test; Fig 2B).
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Comment |
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TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Principal Findings
Indications for decortication
Empyema was the most common indication for decortication in this series. Management options become more invasive as the empyema becomes more organized, ranging from thoracentesis, tube thoracostomy, and fibrinolytics, to VATS and open decortication [7–9]. Patients in this series represent fibrinopurulent and chronic organizing phases typically refractory to nonoperative interventions [10]. Earlier detection of pleural space infections, closer to the time of lung transplant, may reduce the magnitude of secondary procedures as well as the sobering mortality (29% to 36%) [11].
Although VATS has been used to manage loculated effusions and other complex pleural space diseases, only three of our patients were successfully managed with this technique [12]. Pleural symphysis, dense loculations, and fusion of the cortex to the underlying lung precluded a less invasive approach in the current series. Perhaps surgical intervention earlier in the time course would allow more patients to be managed by VATS.
Fibrothorax was the least common indication for decortication. Surgery was performed for two patients whose restrictive scarring was possibly a manifestation of prior episodes of rejection or subclinical infection [13, 14].
Timing of operation
The interval between lung transplant and decortication was highly variable, with many procedures taking place beyond what we would consider the "initial" postoperative period. Delayed presentation of pleural disease is likely multifactorial. Pleural effusions have been shown to present in a delayed fashion after cardiac surgery, particularly coronary artery bypass grafting (CABG), most likely a result of perioperative inflammatory conditions [15]. In one series, pleural surgery was necessary a median of 132 days after CABG [16]. Similar operative conditions may contribute to postoperative pleural effusions after lung transplantation. In addition, allograft infection or rejection at any time after transplant may induce parapneumonic effusion that can rapidly become organized if not adequately addressed.
Lung reexpansion
Decortication has been used to reexpand entrapped lungs in a variety of clinical settings [17]. We found decortication after lung transplantation successfully achieved complete lung reexpansion in the majority of patients. While the small study population precluded identifying predictors of lung reexpansion, two observations relating to chronicity were made. First, patients who underwent decortication within three months of transplant were more likely to achieve lung reexpansion than patients whose transplant to decortication interval exceeded three months. Second, fibrothorax, a process thought to represent the endpoint of a chronic inflammatory process, was not amenable to decortication in this series. The duration of lung entrapment generally leads to more mature pleural fibrosis and tissue ingrowth into the underlying lung parenchyma [18]. As postoperative visits become less frequent, a pleural process may go unchecked, leading to lung entrapment. Early intervention prior to maturation might prevent the need for decortication.
Clearance of infection
Pleural space infection was controlled in most patients, with redo decortication required only once. Mortality, however, was high in this subset of patients, highlighting the importance of intervention prior to the organization of pleural space infections.
Survival
Even though decortication carried high operative mortality and extended length of hospital stay, short- and long-term survivals were reasonable.
Limitations
This represents a small, retrospective study from a single center of heterogeneous pleural space processes selected for decortication. Choice and timing of intervention was surgeon dependent, subjective, and individually made. It is our hope, however, that our experience with decortication after lung transplantation can help guide other surgeons faced with this difficult problem.
Conclusions
Decortication after lung transplantation, albeit technically demanding, is feasible and largely effective. Patients must be carefully selected and potential benefits weighed against high operative mortality.
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This article has been cited by other articles:
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  D. P. Mason, L. H. Batizy, J. Wu, E. R. Nowicki, S. C. Murthy, A. M. McNeill, M. M. Budev, A. C. Mehta, G. B. Pettersson, and E. H. Blackstone Matching donor to recipient in lung transplantation: How much does size matter? J. Thorac. Cardiovasc. Surg., May 1, 2009; 137(5): 1234 - 40.e1. [Abstract] [Full Text] [PDF]
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