doi:10.1510/mmcts.2004.000976
Bilateral living-donor lobar lung transplantation Hiroshi Date*, Motoi Aoe, Yoshifumi Sano, Keiji Goto, Masaaki Kawada, Nobuyoshi Shimizu Department of Cancer and Thoracic Surgery II, Okayama University Graduate School of Medicine and Dentistry, 2-5-1 Shikata-Cho, Okayama 700-8558, Japan Bilateral living-donor lobar lung transplantation is a procedure for patients considered too ill to await cadaveric transplantation. In this relatively new procedure, right and left lower lobes from two healthy donors are implanted in the recipient in place of the whole right and left lungs, respectively. The surgical aspects of the right and left donor lobectomy, the donor lobe back-table preservation technique, and the recipient bilateral pneumonectomy and bilateral lobar implantation under cardiopulmonary bypass are shown. Keywords: Living-donor; Lung transplantation; Primary pulmonary hypertension Introduction Bilateral living-donor lobar lung transplantation (LDLLT) was introduced by Starnes and his colleagues for patients who were thought to be too critical to wait for cadaveric lung transplantation w1–3x. In this relatively new procedure, right and left lower lobes from two healthy donors are implanted in the recipient in place of the whole right and left lungs, respectively (Schematic 1). Because only two lobes are transplanted, it seems to be best suited for children and small adults, and has been applied most exclusively to cystic fibrosis w4x. We began to apply the procedure to a wide range of pathophysiology both for pediatric and adult patients since 1998 w5,6x. Because of the possible serious morbidity associated with donor lobectomy, our policy has been to limit LDLLT to critically ill patients who are unable to wait for cadaveric lungs w7,8x. Here, the techniques of bilateral LDLLT for patients with primary pulmonary hypertension are shown.
Surgical technique 1. In the donor Epidural catheters for postoperative analgesia are placed routinely the day before surgery to avoid com* Corresponding author: Tel.: q81-86-235 7265; fax: q81-86-235 7269. E-mail: [email protected] 䉷 2005 European Association for Cardio-thoracic Surgery
plications related to heparinization during the donor lobectomies. After induction of general anesthesia, donors are intubated with a left-sided double lumen endotracheal tube. The donors are placed in the lateral decubitus position and a posterolateral thoracotomy is performed through the 5th intercostal space. Fissures are developed using linear stapling devices. Dissection in the fissure is carried out to isolate the pulmonary artery to the lower lobe, and to define the anatomy of the pulmonary arteries to the middle lobe. The pericardium surrounding the inferior pulmonary vein is opened circumferentially (Video 1). Intravenous prostaglandin E1 is administered to decrease the systolic blood pressure by 10 to 20 mmHg. Ten thousand units of heparin and 500 mg of methylprednisolone are administered intravenously. After placing the vascular clamps in the appropriate positions, the division of the pulmonary artery, the pulmonary vein and the bronchus is carried out in this order. The right lower lobe is extracted (Video 2). Vascular stumps are oversewn with a 5-0 Prolene continuous suture. The bronchial stump is closed with 3-0 Prolene interrupted sutures. Then, each bronchial closure is covered with a pedicled pericardial fat tissue. Heparinization is reversed by administering protamine. In the left side donor, pulmonary artery to the lingular segment is carefully identified. The pulmonary artery is divided in an oblique fashion (Video 3). 1
H. Date et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000976
Video 3. Left lower lobectomy of the donor. Pulmonary artery to the lingular segment is carefully identified. The pulmonary artery is divided in an oblique fashion. If the branches of the lingular artery are small, they are ligated and divided.
Schematic 1. Bilateral living-donor lobar lung transplantation. Right and left lower lobes from two healthy donors are implanted in the recipient in place of whole right and left lungs, respectively. Video 4. Back table preparation. The extracted lobes are flushed with 1 l of Euro-Collins solution both antegradely and retrogradely from a bag approximately 50 cm above the table. Lobes are gently ventilated with room air during the flush.
Video 1. Right lower lobectomy of the donor. A posterolateral thoracotomy is performed through the 5th intercostal space. Fissures are developed using linear stapling devices. Dissection in the fissure is carried out to isolate the pulmonary artery to the lower lobe, and to define the anatomy of the pulmonary arteries to the middle lobe. The pericardium surrounding the inferior pulmonary vein is opened circumferentially.
Video 5. Recipient operation. With the spine position, the ‘‘clamshell’’ incision is used and the sternum is transsected. The sternum is notched at the level of transsection by aiming the sternal saw at a 45 degrees angle and cutting toward the midpoint to facilitate postoperative sternal adaptation.
gradely from a bag approximately 50 cm above the table. The lobes are gently ventilated with room air during the flush (Video 4).
Video 2. Extraction of the right lower lobe. After placing vascular clamps in appropriate positions, the division of the pulmonary artery, the pulmonary vein and the bronchus is carried out in this order. The right lower lobe is extracted. If the branches of the middle lobe artery are small, they are ligated and divided.
Back table preparation On the back table, the lobes are flushed with 1 l of Euro-Collins solution both antegradely and retro2
2. In the recipient with primary pulmonary hypertention The patient is a 43-year-old female with primary pulmonary hypertension. The patient is anesthetized and intubated with a left-sided double lumen endotracheal tube. We perform a bilateral intercostal transsternal incision through the 4th intercostal space. The sternum is notched at the level of transsection by aiming the sternal saw at a 45 degrees angle and cutting toward the midpoint to facilitate postoperative sternal adaptation (Video 5).
H. Date et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000976
Video 6. Bilateral hilar dissection. Before heparinization, bilateral hilar dissection is carried out. Branches of the pulmonary artery and the veins are taped outside of the pericardium.
Video 7. Cardiopulmonary bypass. The pericardium is opened. The ascending aorta and the right atrium are cannulated after heparinization and the patient is placed on standard cardiopulmonary bypass.
Video 8. Right pneumonectomy 1. Pulmonary vein branches are divided between the silk ties. The right main pulmonary artery is stapled distal to the first branch, and then divided.
Video 10. Hilar preparation 1. A stay stitch is placed on the bronchial stump. Meticulous hemostasis in the posterior mediastinum is achieved at this point because it is extremely difficult to reach this portion after implantation of the donor lobe.
Video 11. Hilar preparation 2. The upper pulmonary vein stump is grasped and retracted laterally. The pericardium is opened circumferentially around the upper pulmonary vein. Interatrial groove is developed to permit proximal placement of a vascular clamp. The right pulmonary artery is separated from the surrounding tissue behind the superior vena cava.
Video 12. Left pneumonectomy and chest irrigation. Left pneumonectomy is performed. The chest is irrigated with warm saline containing antibiotics. The upper airway is also irrigated by an anesthesiologist.
bypass (Video 7). Right pneumonectomy is performed (Videos 8 and 9). Hilar preparation is performed to facilitate subsequent implantation (Videos 10 and 11). Left pneumonectomy is performed in the same manner. The chest is irrigated with warm saline containing antibiotics (Video 12). Video 9. Right pneumonectomy 2. The bronchial stapler is fired as distal as possible. Then, the main stem bronchus is divided and the right lung is excised.
Pleural and hilar dissection is carried out before heparinization to reduce blood loss (Video 6). The pericardium is opened. The ascending aorta and the right atrium are cannulated after heparinization and the patients are placed on standard cardiopulmonary
The right main bronchus is transected and the donor’s right lower lobe is placed in the right chest cavity (Videos 13 and 14). The sequence of the recipient anastomosis is the bronchus (Videos 15 and 16), the vein (Video 17) and the artery (Videos 18–21). The first implanted right graft is packed in iced saline and slush while the left graft is implanted (Video 22). 3
H. Date et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000976
Video 13. Transection of the right main bronchus. A stay stitch is placed on the right main stem bronchus near the carina. The right main bronchus is transected just proximal to the upper bronchial take-off.
Video 17. Pulmonary venous anastomosis. The right pulmonary venous anastomosis is performed by connecting the donor lower pulmonary vein to the recipient upper pulmonary vein. A vascular clamp is placed on the recipient’s left atrium intrapericardially. The back wall of the venous anastomosis is performed with a running 6-0 Prolene suture. It is important to assure intima-to-intima approximation. The anterior wall of the venous anastomosis is performed in the same fashion and the sutures are kept untied.
Video 14. Placing the right graft in the right chest cavity. A moist cold sponge is placed in the right chest cavity and the right lower lobe of the donor rests on this during implantation. Additional ice slush is placed over the graft to slow the warming process. Video 18. Pulmonary artery anastomosis 1. In patients with primary pulmonary hypertension, the pulmonary artery is markedly dilated. A vascular clamp is placed behind the superior vena cava. The right pulmonary artery is transected proximal to the first branch. Leaving a long pulmonary artery might increase the risk of arterial kinking after reperfusion. Note the huge size discrepancy between the recipient main pulmonary artery and the donor lobar pulmonary artery. Video 15. Bronchial anastomosis – membranous portion. The bronchial anastomosis begins with a running 4-0 polydioxanone suture for membranous portion.
Video 16. Bronchial anastomosis – cartilaginous portion. The cartilaginous rings of the donor and recipient are jointed with simple interrupted 4-0 polydioxanone sutures. No attempt is made to intentionally intussuscept of the donor lower bronchus to the recipient main bronchus. The bronchial wrapping is not employed except for the patients who are on a high dose of steroid therapy.
The left graft is implanted in the same manner as for the right graft (Video 23). Just before completing the bilateral implantations, 500 mg to 1 g of methylprednisolone is given intra4
Video 19. Pulmonary artery anastomosis 2. To compensate for the huge size discrepancy, tack stitches are placed on the recipient’s pulmonary artery. In this case, four tack stitches were placed.
venously and nitric oxide inhalation is initiated at 20 ppm. After both lungs are reperfused and ventilated, cardiopulmonary bypass is gradually weaned and then removed (Videos 24 and 25). All blood accumulated in the chest cavity during the operation is discarded to avoid infection. After placing two chest tubes in each chest cavity and a pericardial drainage tube in the pericardium, the chest is closed in the standard fashion (Video 26).
H. Date et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000976
Video 20. Pulmonary artery anastomosis 3. The back wall of the pulmonary artery anastomosis is performed with a running 6-0 Prolene suture.
Video 21. Pulmonary artery anastomosis 4. The anterior wall of the pulmonary arterial anastomosis is performed in the same fashion. At completion of the anterior wall anastomosis, saline solution is injected into the pulmonary artery to remove residual air.
Video 24. Re-ventilation and reperfusion of the right graft. Both implanted lungs are re-ventilated gradually. The right graft is first reperfused by loosening the pulmonary artery clamp momentarily. The anterior wall of the venous anastomosis is kept open to allow de-airing of the right graft with the atrial clamp still in place. The venous sutures are then secured and the clamps are removed.
Video 25. Reperfusion of the left graft and weaning from the bypass. Left graft is reperfused in the same fashion. We ventilate both lungs manually and confirm full re-expansion of the grafts. Cardiopulmonary bypass is gradually weaned and then removed. Fibrin glue is applied to both hilum to obtain complete hemostasis.
Video 22. Placing the left graft in the left chest cavity. The first implanted right graft is packed in iced saline and slush while the left graft is implanted. The donor left lower lobe is placed into the left chest cavity and kept cold with iced saline and slush. Video 26. Closure of the chest. Two chest tubes are placed in each chest cavity and a pericardial drainage tube is placed in the pericardium. The resultant cut ends of the sternum fit nicely together at the time of closure with three sternal wires.
Video 23. Left graft implantation. The sequence of the left graft anastomosis is the bronchus, vein and artery.
Results Dramatic improvement of pulmonary hemodynamics is confirmed by chest X-ray (Photo 1) and echocardiogram (Video 27). In this particular case, pulmonary
Photo 1. Chest X-rays before (A) and after (B) receiving LDLLT. (A) Before operation. Marked cardiomegaly was present. (B) Three months after receiving LDLLT. Well-expanded lobes filled the chest cavity, leaving no detectable dead space without cardiomegaly.
5
H. Date et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000976 lator at the time of transplantation for as long as 7 weeks. Bilateral LDLLT was performed in 29 patients and right single LDLLT was performed in 2 patients. Among the 64 living-donors, 7 were non-blood related donors (patients’ spouses) and others were blood-related donors within the second degree. Video 27. Echocardiographic images before and after LDLLT. Left: Pre-operation. A dilated hypokinetic right ventricle and a Dshaped left ventricle are demonstrated. Right: Three days after LDLLT. Note marked decrease in RV diameter and a round LV. Table 1. Diagnoses of living-donor lobar lung transplantation Diagnoses
Number
Primary pulmonary hypertension Idiopathic interstitial pneumonia Bronchiolitis obliterans Bronchiectatis Lymphangioleiomyomatosis Cystic fibrosis Eisenmenger’s syndrome Total
10 10 6 3 2 1 1 33
The most frequent complication was lung edema, which occurred in 6 patients (18%). Tracheostomy was required in 15 patients (50%), re-intubation in 8 (24%), re-thoracotomy in 5 (15%), continuous hemodiafiltration in 5 (15%), and extracorporeal membrane oxygenation in 3 (9%). The duration of mechanical ventilation required was 15.4"2.8 days; ICU stay was 23.5"2.9 days. In spite of complicated postoperative course, 31 patients (94%) were discharged without oxygen inhalation after the average hospital stay of 64.7"4.2 days. Two patients (6%) died of acute rejection and Aspergillus infection, respectively. Over the course of this study, 5 patients (17% of 3month survivors) developed unilateral bronchiolitis obliterans syndrome (BOS) after LDLLT. Contralateral graft was unaffected in these 5 patients and their FEV1 decline stopped within 9 months. At the time of final data analysis in April 2005, there has been no late mortality during the observation period (Graph 1).
References
Graph 1. Survival after living-donor lobar lung transplantation. After receiving a living-donor lobar lung transplantation, 31 of 33 recipients (94%) are currently alive for as long as 77 months at Okayama University.
artery pressure decreased from 107/47 (72) mmHg to 19/6 (11) mmHg. Sixteen months postoperatively, the patient is in excellent physical condition with a forced vital capacity of 2,400 ml (88.6% of predicted), forced expiratory volume in one second of 2,260 ml (92.2% of predicted). We have applied LDLLT in 33 patients from October 1998 through December 2004. There were 27 females and 6 males with ages ranging from 6 to 55 years (average 30.9 years). Seven of the patients were children and 26 were adults. Recipient’s diagnoses were listed (Table 1). Five patients (15%) were on a venti6
w1x Starnes VA, Barr ML, Cohen RG. Lobar transplantation: indications, technique, and outcome. J Thorac Cardiovasc Surg 1994;108: 403–411. w2x Cohen RG, Schenkel FA, DeMeester TR, Wells WJ, Starnes VA. Living-related donor lobectomy for bilateral lobar transplantation in patients with cystic fibrosis. Ann Thorac Surg 1994;57:1423– 1427. w3x Starnes VA, Barr ML, Cohen RG, Hagen JA, Wells WJ, Horn MV, Schenkel FA. Living-donor lobar lung transplantation experience: intermediate results. J Thorac Cardiovasc Surg 1996;112: 1284–1290. w4x Starnes VA, Bowdish ME, Woo MS, Barbers RG, Schenkel FA, Horn MV, Pessotto R, Sievers EM, Baker CJ, Cohen RG, Bremner RM, Wells WJ, Barr ML. A decade of living lobar lung transplantation. Recipient outcomes. J Thorac Cardiovasc Surg 2004;127:114–122. w5x Date H, Aoe M, Nagahiro I, Sano Y, Andou A,
H. Date et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000976 Matsubara H, Goto K, Tedoriya T, Shimizu N. Living-donor lobar lung transplantation for various lung diseases. J Thorac Cardiovasc Surg 2003;126:476–481. w6x Date H, Aoe M, Sano Y, Nagahiro I, Miyaji K, Goto K, Kawada M, Sano S, Shimizu N. Improved survival after living-donor lobar lung transplantation. J Thorac Cardiovasc Surg 2004; 128:933–940.
w7x Battafarano RJ, Anderson RC, Meyers BF, Guthrie TJ, Schuller D, Cooper JD, Patterson GA. Perioperative complications after living donor lobectomy. J Thorac Cardiovasc Surg 2000;120: 909–915. w8x Bowdish ME, Barr ML, Schenkel FA, Woo MS, Bremner RM, Horn MV, Baker CJ, Barbers RG, Wells WJ, Starnes VA. Am J Transplant 2004; 4:1283–1288.
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Bilateral living-donor lobar lung transplantation Hiroshi Date*, Motoi Aoe, Yoshifumi Sano, Keiji Goto, Masaaki Kawada, Nobuyoshi Shimizu Department of Cancer and Thoracic Surgery II, Okayama University Graduate School of Medicine and Dentistry, 2-5-1 Shikata-Cho, Okayama 700-8558, Japan Bilateral living-donor lobar lung transplantation is a procedure for patients considered too ill to await cadaveric transplantation. In this relatively new procedure, right and left lower lobes from two healthy donors are implanted in the recipient in place of the whole right and left lungs, respectively. The surgical aspects of the right and left donor lobectomy, the donor lobe back-table preservation technique, and the recipient bilateral pneumonectomy and bilateral lobar implantation under cardiopulmonary bypass are shown. Keywords: Living-donor; Lung transplantation; Primary pulmonary hypertension Introduction Bilateral living-donor lobar lung transplantation (LDLLT) was introduced by Starnes and his colleagues for patients who were thought to be too critical to wait for cadaveric lung transplantation w1–3x. In this relatively new procedure, right and left lower lobes from two healthy donors are implanted in the recipient in place of the whole right and left lungs, respectively (Schematic 1). Because only two lobes are transplanted, it seems to be best suited for children and small adults, and has been applied most exclusively to cystic fibrosis w4x. We began to apply the procedure to a wide range of pathophysiology both for pediatric and adult patients since 1998 w5,6x. Because of the possible serious morbidity associated with donor lobectomy, our policy has been to limit LDLLT to critically ill patients who are unable to wait for cadaveric lungs w7,8x. Here, the techniques of bilateral LDLLT for patients with primary pulmonary hypertension are shown.
Surgical technique 1. In the donor Epidural catheters for postoperative analgesia are placed routinely the day before surgery to avoid com* Corresponding author: Tel.: q81-86-235 7265; fax: q81-86-235 7269. E-mail: [email protected] 䉷 2005 European Association for Cardio-thoracic Surgery
plications related to heparinization during the donor lobectomies. After induction of general anesthesia, donors are intubated with a left-sided double lumen endotracheal tube. The donors are placed in the lateral decubitus position and a posterolateral thoracotomy is performed through the 5th intercostal space. Fissures are developed using linear stapling devices. Dissection in the fissure is carried out to isolate the pulmonary artery to the lower lobe, and to define the anatomy of the pulmonary arteries to the middle lobe. The pericardium surrounding the inferior pulmonary vein is opened circumferentially (Video 1). Intravenous prostaglandin E1 is administered to decrease the systolic blood pressure by 10 to 20 mmHg. Ten thousand units of heparin and 500 mg of methylprednisolone are administered intravenously. After placing the vascular clamps in the appropriate positions, the division of the pulmonary artery, the pulmonary vein and the bronchus is carried out in this order. The right lower lobe is extracted (Video 2). Vascular stumps are oversewn with a 5-0 Prolene continuous suture. The bronchial stump is closed with 3-0 Prolene interrupted sutures. Then, each bronchial closure is covered with a pedicled pericardial fat tissue. Heparinization is reversed by administering protamine. In the left side donor, pulmonary artery to the lingular segment is carefully identified. The pulmonary artery is divided in an oblique fashion (Video 3). 1
H. Date et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000976
Video 3. Left lower lobectomy of the donor. Pulmonary artery to the lingular segment is carefully identified. The pulmonary artery is divided in an oblique fashion. If the branches of the lingular artery are small, they are ligated and divided.
Schematic 1. Bilateral living-donor lobar lung transplantation. Right and left lower lobes from two healthy donors are implanted in the recipient in place of whole right and left lungs, respectively. Video 4. Back table preparation. The extracted lobes are flushed with 1 l of Euro-Collins solution both antegradely and retrogradely from a bag approximately 50 cm above the table. Lobes are gently ventilated with room air during the flush.
Video 1. Right lower lobectomy of the donor. A posterolateral thoracotomy is performed through the 5th intercostal space. Fissures are developed using linear stapling devices. Dissection in the fissure is carried out to isolate the pulmonary artery to the lower lobe, and to define the anatomy of the pulmonary arteries to the middle lobe. The pericardium surrounding the inferior pulmonary vein is opened circumferentially.
Video 5. Recipient operation. With the spine position, the ‘‘clamshell’’ incision is used and the sternum is transsected. The sternum is notched at the level of transsection by aiming the sternal saw at a 45 degrees angle and cutting toward the midpoint to facilitate postoperative sternal adaptation.
gradely from a bag approximately 50 cm above the table. The lobes are gently ventilated with room air during the flush (Video 4).
Video 2. Extraction of the right lower lobe. After placing vascular clamps in appropriate positions, the division of the pulmonary artery, the pulmonary vein and the bronchus is carried out in this order. The right lower lobe is extracted. If the branches of the middle lobe artery are small, they are ligated and divided.
Back table preparation On the back table, the lobes are flushed with 1 l of Euro-Collins solution both antegradely and retro2
2. In the recipient with primary pulmonary hypertention The patient is a 43-year-old female with primary pulmonary hypertension. The patient is anesthetized and intubated with a left-sided double lumen endotracheal tube. We perform a bilateral intercostal transsternal incision through the 4th intercostal space. The sternum is notched at the level of transsection by aiming the sternal saw at a 45 degrees angle and cutting toward the midpoint to facilitate postoperative sternal adaptation (Video 5).
H. Date et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000976
Video 6. Bilateral hilar dissection. Before heparinization, bilateral hilar dissection is carried out. Branches of the pulmonary artery and the veins are taped outside of the pericardium.
Video 7. Cardiopulmonary bypass. The pericardium is opened. The ascending aorta and the right atrium are cannulated after heparinization and the patient is placed on standard cardiopulmonary bypass.
Video 8. Right pneumonectomy 1. Pulmonary vein branches are divided between the silk ties. The right main pulmonary artery is stapled distal to the first branch, and then divided.
Video 10. Hilar preparation 1. A stay stitch is placed on the bronchial stump. Meticulous hemostasis in the posterior mediastinum is achieved at this point because it is extremely difficult to reach this portion after implantation of the donor lobe.
Video 11. Hilar preparation 2. The upper pulmonary vein stump is grasped and retracted laterally. The pericardium is opened circumferentially around the upper pulmonary vein. Interatrial groove is developed to permit proximal placement of a vascular clamp. The right pulmonary artery is separated from the surrounding tissue behind the superior vena cava.
Video 12. Left pneumonectomy and chest irrigation. Left pneumonectomy is performed. The chest is irrigated with warm saline containing antibiotics. The upper airway is also irrigated by an anesthesiologist.
bypass (Video 7). Right pneumonectomy is performed (Videos 8 and 9). Hilar preparation is performed to facilitate subsequent implantation (Videos 10 and 11). Left pneumonectomy is performed in the same manner. The chest is irrigated with warm saline containing antibiotics (Video 12). Video 9. Right pneumonectomy 2. The bronchial stapler is fired as distal as possible. Then, the main stem bronchus is divided and the right lung is excised.
Pleural and hilar dissection is carried out before heparinization to reduce blood loss (Video 6). The pericardium is opened. The ascending aorta and the right atrium are cannulated after heparinization and the patients are placed on standard cardiopulmonary
The right main bronchus is transected and the donor’s right lower lobe is placed in the right chest cavity (Videos 13 and 14). The sequence of the recipient anastomosis is the bronchus (Videos 15 and 16), the vein (Video 17) and the artery (Videos 18–21). The first implanted right graft is packed in iced saline and slush while the left graft is implanted (Video 22). 3
H. Date et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000976
Video 13. Transection of the right main bronchus. A stay stitch is placed on the right main stem bronchus near the carina. The right main bronchus is transected just proximal to the upper bronchial take-off.
Video 17. Pulmonary venous anastomosis. The right pulmonary venous anastomosis is performed by connecting the donor lower pulmonary vein to the recipient upper pulmonary vein. A vascular clamp is placed on the recipient’s left atrium intrapericardially. The back wall of the venous anastomosis is performed with a running 6-0 Prolene suture. It is important to assure intima-to-intima approximation. The anterior wall of the venous anastomosis is performed in the same fashion and the sutures are kept untied.
Video 14. Placing the right graft in the right chest cavity. A moist cold sponge is placed in the right chest cavity and the right lower lobe of the donor rests on this during implantation. Additional ice slush is placed over the graft to slow the warming process. Video 18. Pulmonary artery anastomosis 1. In patients with primary pulmonary hypertension, the pulmonary artery is markedly dilated. A vascular clamp is placed behind the superior vena cava. The right pulmonary artery is transected proximal to the first branch. Leaving a long pulmonary artery might increase the risk of arterial kinking after reperfusion. Note the huge size discrepancy between the recipient main pulmonary artery and the donor lobar pulmonary artery. Video 15. Bronchial anastomosis – membranous portion. The bronchial anastomosis begins with a running 4-0 polydioxanone suture for membranous portion.
Video 16. Bronchial anastomosis – cartilaginous portion. The cartilaginous rings of the donor and recipient are jointed with simple interrupted 4-0 polydioxanone sutures. No attempt is made to intentionally intussuscept of the donor lower bronchus to the recipient main bronchus. The bronchial wrapping is not employed except for the patients who are on a high dose of steroid therapy.
The left graft is implanted in the same manner as for the right graft (Video 23). Just before completing the bilateral implantations, 500 mg to 1 g of methylprednisolone is given intra4
Video 19. Pulmonary artery anastomosis 2. To compensate for the huge size discrepancy, tack stitches are placed on the recipient’s pulmonary artery. In this case, four tack stitches were placed.
venously and nitric oxide inhalation is initiated at 20 ppm. After both lungs are reperfused and ventilated, cardiopulmonary bypass is gradually weaned and then removed (Videos 24 and 25). All blood accumulated in the chest cavity during the operation is discarded to avoid infection. After placing two chest tubes in each chest cavity and a pericardial drainage tube in the pericardium, the chest is closed in the standard fashion (Video 26).
H. Date et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000976
Video 20. Pulmonary artery anastomosis 3. The back wall of the pulmonary artery anastomosis is performed with a running 6-0 Prolene suture.
Video 21. Pulmonary artery anastomosis 4. The anterior wall of the pulmonary arterial anastomosis is performed in the same fashion. At completion of the anterior wall anastomosis, saline solution is injected into the pulmonary artery to remove residual air.
Video 24. Re-ventilation and reperfusion of the right graft. Both implanted lungs are re-ventilated gradually. The right graft is first reperfused by loosening the pulmonary artery clamp momentarily. The anterior wall of the venous anastomosis is kept open to allow de-airing of the right graft with the atrial clamp still in place. The venous sutures are then secured and the clamps are removed.
Video 25. Reperfusion of the left graft and weaning from the bypass. Left graft is reperfused in the same fashion. We ventilate both lungs manually and confirm full re-expansion of the grafts. Cardiopulmonary bypass is gradually weaned and then removed. Fibrin glue is applied to both hilum to obtain complete hemostasis.
Video 22. Placing the left graft in the left chest cavity. The first implanted right graft is packed in iced saline and slush while the left graft is implanted. The donor left lower lobe is placed into the left chest cavity and kept cold with iced saline and slush. Video 26. Closure of the chest. Two chest tubes are placed in each chest cavity and a pericardial drainage tube is placed in the pericardium. The resultant cut ends of the sternum fit nicely together at the time of closure with three sternal wires.
Video 23. Left graft implantation. The sequence of the left graft anastomosis is the bronchus, vein and artery.
Results Dramatic improvement of pulmonary hemodynamics is confirmed by chest X-ray (Photo 1) and echocardiogram (Video 27). In this particular case, pulmonary
Photo 1. Chest X-rays before (A) and after (B) receiving LDLLT. (A) Before operation. Marked cardiomegaly was present. (B) Three months after receiving LDLLT. Well-expanded lobes filled the chest cavity, leaving no detectable dead space without cardiomegaly.
5
H. Date et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000976 lator at the time of transplantation for as long as 7 weeks. Bilateral LDLLT was performed in 29 patients and right single LDLLT was performed in 2 patients. Among the 64 living-donors, 7 were non-blood related donors (patients’ spouses) and others were blood-related donors within the second degree. Video 27. Echocardiographic images before and after LDLLT. Left: Pre-operation. A dilated hypokinetic right ventricle and a Dshaped left ventricle are demonstrated. Right: Three days after LDLLT. Note marked decrease in RV diameter and a round LV. Table 1. Diagnoses of living-donor lobar lung transplantation Diagnoses
Number
Primary pulmonary hypertension Idiopathic interstitial pneumonia Bronchiolitis obliterans Bronchiectatis Lymphangioleiomyomatosis Cystic fibrosis Eisenmenger’s syndrome Total
10 10 6 3 2 1 1 33
The most frequent complication was lung edema, which occurred in 6 patients (18%). Tracheostomy was required in 15 patients (50%), re-intubation in 8 (24%), re-thoracotomy in 5 (15%), continuous hemodiafiltration in 5 (15%), and extracorporeal membrane oxygenation in 3 (9%). The duration of mechanical ventilation required was 15.4"2.8 days; ICU stay was 23.5"2.9 days. In spite of complicated postoperative course, 31 patients (94%) were discharged without oxygen inhalation after the average hospital stay of 64.7"4.2 days. Two patients (6%) died of acute rejection and Aspergillus infection, respectively. Over the course of this study, 5 patients (17% of 3month survivors) developed unilateral bronchiolitis obliterans syndrome (BOS) after LDLLT. Contralateral graft was unaffected in these 5 patients and their FEV1 decline stopped within 9 months. At the time of final data analysis in April 2005, there has been no late mortality during the observation period (Graph 1).
References
Graph 1. Survival after living-donor lobar lung transplantation. After receiving a living-donor lobar lung transplantation, 31 of 33 recipients (94%) are currently alive for as long as 77 months at Okayama University.
artery pressure decreased from 107/47 (72) mmHg to 19/6 (11) mmHg. Sixteen months postoperatively, the patient is in excellent physical condition with a forced vital capacity of 2,400 ml (88.6% of predicted), forced expiratory volume in one second of 2,260 ml (92.2% of predicted). We have applied LDLLT in 33 patients from October 1998 through December 2004. There were 27 females and 6 males with ages ranging from 6 to 55 years (average 30.9 years). Seven of the patients were children and 26 were adults. Recipient’s diagnoses were listed (Table 1). Five patients (15%) were on a venti6
w1x Starnes VA, Barr ML, Cohen RG. Lobar transplantation: indications, technique, and outcome. J Thorac Cardiovasc Surg 1994;108: 403–411. w2x Cohen RG, Schenkel FA, DeMeester TR, Wells WJ, Starnes VA. Living-related donor lobectomy for bilateral lobar transplantation in patients with cystic fibrosis. Ann Thorac Surg 1994;57:1423– 1427. w3x Starnes VA, Barr ML, Cohen RG, Hagen JA, Wells WJ, Horn MV, Schenkel FA. Living-donor lobar lung transplantation experience: intermediate results. J Thorac Cardiovasc Surg 1996;112: 1284–1290. w4x Starnes VA, Bowdish ME, Woo MS, Barbers RG, Schenkel FA, Horn MV, Pessotto R, Sievers EM, Baker CJ, Cohen RG, Bremner RM, Wells WJ, Barr ML. A decade of living lobar lung transplantation. Recipient outcomes. J Thorac Cardiovasc Surg 2004;127:114–122. w5x Date H, Aoe M, Nagahiro I, Sano Y, Andou A,
H. Date et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000976 Matsubara H, Goto K, Tedoriya T, Shimizu N. Living-donor lobar lung transplantation for various lung diseases. J Thorac Cardiovasc Surg 2003;126:476–481. w6x Date H, Aoe M, Sano Y, Nagahiro I, Miyaji K, Goto K, Kawada M, Sano S, Shimizu N. Improved survival after living-donor lobar lung transplantation. J Thorac Cardiovasc Surg 2004; 128:933–940.
w7x Battafarano RJ, Anderson RC, Meyers BF, Guthrie TJ, Schuller D, Cooper JD, Patterson GA. Perioperative complications after living donor lobectomy. J Thorac Cardiovasc Surg 2000;120: 909–915. w8x Bowdish ME, Barr ML, Schenkel FA, Woo MS, Bremner RM, Horn MV, Baker CJ, Barbers RG, Wells WJ, Starnes VA. Am J Transplant 2004; 4:1283–1288.
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