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The clamshell incision, which provides improved pleural space exposure as well as sufficient posterior mediastinal access. Reprinted with permission from Hayanga JW, D'Cunha J. The surgical technique of bilateral sequential lung transplantation. J Thoracic Dis. 2014;6(8):1063-9.
Source publication
Abstract: Lung transplantation is now a treatment option for many patients with end-stage lung disease.
Now 55 years since the first human lung transplant, this is a good time to reflect upon the history of lung
transplantation, to recognize major milestones in the field, and to learn from others’ unsuccessful transplant
experiences. James Hardy wa...
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We describe the intraoperative surgical management of tracheal bronchus encountered in a lung transplant recipient.
Citations
... Scrutiny, domestically as well as within the international community, has provided useful insights as to how to best predict and characterize patients who would benefit from LRT. For example, properly categorizing chronic lung allograft dysfunction (CLAD) based on phenotypic expression enables us to predict graft outcomes following LRT [1,2,4]. Much of the relevant literature comprises registry-based analyses, from which it is difficult to account for the outcomes secondary to practices and policies of individual transplant centers and regional regulations. ...
... Since the first reported lung transplant by Hardy in 1963 [4], indications for LT have broadened over time, spanning a spectrum of diseases of the airways, pulmonary parenchyma, and vasculature. LRT remains the only treatment option for the increasing number of patients who will develop CLAD [2]. ...
Provided advancements in Lung Transplantation (LT) survival, the efficacy of Lung Retransplantation (LRT) has often been debated. Decades of retrospective analyses on thousands of LRT cases provide insight enabling predictive patient criteria for retransplantation. This review used the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines. The PubMed search engine was utilized for articles relating to LRT published through August 2023, and a systematic review was performed using Covidence software version 2.0 (Veritas Health Innovation, Australia). Careful patient selection is vital for successful LRT, and the benefit leans in favor of those in optimal health following their initial transplant. However, the lack of a standardized approach remains apparent. Through an in-depth review, we will address considerations such as chronic lung allograft dysfunction, timing to LRT, surgical and perioperative complexity, and critical ethical concerns that guide the current practice as it relates to this subset of patients for whom LRT is the only therapeutic option available.
... Though small strides continue to be made to extend LTx median survival time, improvement is mostly confined to the first post-transplant year due to concentrated efforts to reduce primary graft dysfunction and acute rejection (7), with survival dropping off consistently thereafter. Thus, CLAD remains a constant threat to long-term LTx survival (8). While characteristics associated with shortterm outcomes like primary graft dysfunction and 1-year mortality are well established, less is known about factors associated with long-term outcomes. ...
... Specifically, the LAS favored transplantation of more IPF/UIP recipients than our cohort, which has drastically reduced waitlist mortality. These improvements mainly bolstered 1-year survival; while long-term survival is improving, it continues to lag significantly behind other solid organs (8). Understanding of this discrepancy is limited to the notion that immunosuppressed and nonsterile lungs yield infection, innate immune activation, and ultimately CLAD (14); however, because this phenomenon remains poorly understood, a characterization of long-term survivors remains essential novel information. ...
Background:
Lung transplantation median survival has seen improvements due to recognition of short-term survival factors but continues to trail behind other solid organs due to limited understanding of long-term survivorship. Given the creation of the United Network for Organ Sharing (UNOS) database in 1986, it was difficult to accrue data on long-term survivors until recently. This study characterizes factors impacting lung transplant survival beyond 20 years, conditional to 1-year survival.
Methods:
Lung transplant recipients listed in UNOS from 1987 to 2002 who survived to 1 post-transplant year were reviewed. Kaplan-Meier and adjusted Cox regression analyses were performed at 20 and 10 years to identify risk factors associated with long-term outcomes independent of their short-term effects.
Results:
A total of 6,172 recipients were analyzed, including 472 (7.6%) recipients who lived 20+ years. Factors associated with increased likelihood of 20-year survival were female-to-female gender match, recipient age 25-44, waitlist time >1 year, human leukocyte antigen (HLA) mismatch level 3, and donor cause of death: head trauma. Factors associated with decreased 20-year survival included recipient age ≥55, chronic obstructive pulmonary disease/emphysema (COPD/E) diagnosis, donor smoking history >20 pack-years, unilateral transplant, blood groups O&AB, recipient glomerular filtration rate (GFR) <10 mL/min, and donor GFR 20-29 mL/min.
Conclusions:
This is the first study identifying factors associated with multiple-decade survival following lung transplant in the United States. Despite its challenges, long-term survival is possible and more likely in younger females in good waitlist condition without COPD/E who receive a bilateral allograft from a non-smoking, gender-matched donor of minimal HLA mismatch. Further analysis of the molecular and immunologic implications of these conditions are warranted.
... The surgical approach to lung transplantation has benefited from numerous advances since the first successful procedure in 1963 [1]. As the field and perspectives have evolved, practices now reflect an increased understanding of the pathological processes involved and have improved graft longevity. ...
Purpose of Review
This article reviews controversial questions within the field of lung transplantation, with a focus on data generated within the last 3 years. We aim to summarize differing opinions on a selection of topics, including bridge-to-transplantation, intraoperative machine circulatory support, bronchial anastomosis, size mismatch, delayed chest closure, and ex vivo lung perfusion.
Recent Findings
With the growing rate of lung transplantations worldwide and increasing numbers of patients placed on waiting lists, the importance of determining best practices has only increased in recent years. Factors which promote successful outcomes have been identified across all the topics, with certain approaches promoted, such as ambulation in bridge-to-transplant and widespread intraoperative ECMO as machine support.
Summary
While great strides have been made in the operative procedures involved in lung transplantation, there are still key questions to be answered. The consensus which can be reached will be instrumental in further improving outcomes in recipients.
... Since it was first performed in 1963, lung transplantation has remained a multidisciplinary challenge, especially in the intraoperative setting [1]. Nevertheless, it is the only therapy for patients with end-stage lung disease for whom drug therapy fails. ...
Lung transplantation has a high risk of haemodynamic complications in a highly vulnerable patient population. The effects on the cardiovascular system of the various underlying end-stage lung diseases also contribute to this risk. Following a literature review and based on our own experience, this review article summarises the current trends and their evidence for intraoperative circulatory support in lung transplantation. Identifiable and partly modifiable risk factors are mentioned and corresponding strategies for treatment are discussed. The approach of first identifying risk factors and then developing an adjusted strategy is presented as the ERSAS (early risk stratification and strategy) concept. Typical haemodynamic complications discussed here include right ventricular failure, diastolic dysfunction caused by left ventricular deconditioning, and reperfusion injury to the transplanted lung. Pre- and intra-operatively detectable risk factors for the occurrence of haemodynamic complications are rare, and the therapeutic strategies applied differ considerably between centres. However, all the mentioned risk factors and treatment strategies can be integrated into clinical treatment algorithms and can influence patient outcome in terms of both mortality and morbidity.
... In 1963, after decades of experiments on laboratory animals, the first lung transplantation in a human being was performed at the University of Mississippi. The procedure can hardly be considered a success (the patient survived a mere 18 days), and for the next 2 decades, pulmonary transplantation led to consistently poor outcomes (1). In the 1980s, however, the introduction of cyclosporine, together with refined surgical techniques, revolutionized the field, and for the first time, some patients experienced long-term survival after pulmonary transplantation (1). ...
... The procedure can hardly be considered a success (the patient survived a mere 18 days), and for the next 2 decades, pulmonary transplantation led to consistently poor outcomes (1). In the 1980s, however, the introduction of cyclosporine, together with refined surgical techniques, revolutionized the field, and for the first time, some patients experienced long-term survival after pulmonary transplantation (1). By 1992-2001, median survival after adult lung transplant was 4.7 years, and by 2010-2017, it had risen to 6.7 years (2). ...
... The invention of Radial Probe Endobronchial Ultrasound and later Convex Probe Endobronchial Ultrasound resulted in major growth in the department secondary to the ability to stage lung cancer as well as diagnose various lung diseases (2). Despite this new technology, people still had difficulty sampling peripheral lung lesions. ...
The advent of advanced diagnostic bronchoscopy has resulted in an increased demand for anesthesiologists to administer general anesthesia in the bronchoscopy suite. One such procedure includes rigid bronchoscopy. Rigid bronchoscopy is used to treat for treatment of central airway lesions, mechanical debulking of endobronchial lesions, laser and argon plasma coagulation, electrocautery, cryotherapy, and stent deployment. Rigid bronchoscopy presents added challenges to the anesthesiologist due to the unusual nature of airway management and ventilation. Some of the challenges of providing anesthesia for rigid bronchoscopy include the need to share the airway with the proceduralist, the risk of loss of airway patency, unconventional modes of ventilation, and the need for a deep level of anesthesia with muscle relaxation. There is also a need for a quick recovery as many of these procedures are performed on an outpatient basis. Thus, knowledge of the rigid bronchoscopic procedure and excellent communication with the proceduralist is key to increasing the likelihood of a successful intervention procedure. In This manuscript we presents anesthetic considerations for rigid bronchoscopy and discusses how they may differ from other airway procedures.
... The clinical utility of bronchoscopy was first demonstrated in 1876 when Gustav Killian used a laryngoscope to remove a pork bone from a farmer's airway. 1 In 1904 Chevalier Jackson devised the forerunner of the rigid bronchoscope, and irrigation of the lung through a rigid bronchoscopy was first reported in 1927 by H Stitt. 2 However, with the development of flexible video-assisted bronchoscopy in the late 1960's, it became a key tool for research into lower respiratory tract infections, and since the late 1970s/early 1980s bronchioloalveolar lavage (BAL) has become an entrenched diagnostic procedure in respiratory medicine. 3,4 By wedging a flexible bronchoscope into a selected bronchopulmonary segment, the cellular and acellular components in the distal bronchioles and alveolar spaces can be sampled and submitted for a variety of investigations, most commonly cytology, cell differential counts and microbiology. ...
Bronchioloalveolar lavage (BAL) is a non-invasive and well-tolerated procedure that plays a key role in the diagnosis of a variety of non-neoplastic pulmonary diseases, including acute respiratory failure, infection, diffuse parenchymal lung disease (DLPD), paediatric and occupational lung disease, and in the evaluation of the lung allograft. A variety of analytic techniques are commonly performed on BAL fluid, including cytology, cell differential count, microbiology and virology, as well as a number of additional techniques in specific circumstances.
Abstract
This article reviews the current use of bronchioloalveolar lavage cytology in the diagnosis of diffuse parenchymal lung disease.
... The first lung transplant and first long-term successful human lung transplant both utilized DCD donors [2]. James Hardy performed the first human lung transplant on June 11, 1963, with a patient diagnosed with both a lung abscess and advanced lung cancer [3,4], and a few days later, George Magovern and Adolph Yates reported the second human lung transplant at the University hospital in Pittsburgh [3,5]. The combined survival of both patients was only 26 days. ...
... The first lung transplant and first long-term successful human lung transplant both utilized DCD donors [2]. James Hardy performed the first human lung transplant on June 11, 1963, with a patient diagnosed with both a lung abscess and advanced lung cancer [3,4], and a few days later, George Magovern and Adolph Yates reported the second human lung transplant at the University hospital in Pittsburgh [3,5]. The combined survival of both patients was only 26 days. ...
... The patient survived a total of 10.5 months after the procedure. During that same time period, it was recognized that death resulted from irreversible damage to the brain stem; donation after brain death (DBD) become widely accepted, and DCD was largely abandoned [3]. ...
The number of lungs available for lung transplantation is far lower than the number of patients awaiting them. Consequently, there is a significant attrition rate while awaiting transplantation. Lung procurement rates are lower than those of other solid organs. Lungs are procured from only 15–20% of donors compared with 30% of decreased donors for hearts. The reason for this low retrieval rate is related to a number of factors. Brain death is associated with neurogenic pulmonary edema. Additionally, injury to the lung itself may occur before or after brain death. Aspiration of gastric contents, pneumonia, previous thoracic trauma, ventilator-associated injury, atelectasis, and pulmonary thrombosis/embolism may all contribute to lung injury before consideration for harvest. Donation after circulatory death (DCD) is one category of nontraditional organ donation now being performed in increasing numbers as a way to increase the number of lungs available for transplantation. In some studies, estimates show that utilization of DCD lung procurement could increase the number of lungs available by up to 50%. https://rdcu.be/chVLK
... 29 The traditional formal clamshell thoracotomy does not involve an upper sternotomy. 30 However, because in our patient the sternum was split for the hemiclamshell thoracotomy, the present case is technically a bilateral hemiclamshell thoracotomy (midline sternal split), not a traditional clamshell thoracotomy (no midline sternotomy). Regardless of the nomenclature, the clamshell thoracotomy allowed simultaneous access to both chest cavities and the mediastinum. ...
The clamshell thoracotomy is often used to access both hemithoraxes and the mediastinum simultaneously for cardiothoracic pathology, but this technique is rarely used for the excision of spinal tumors. We describe the use of a clamshell thoracotomy for en bloc excision of a 3-level upper thoracic chordoma in a 20-year-old patient. The lesion involved T2, T3, and T4, and it invaded both chest cavities and indented the mediastinum. After 2 biopsies to confirm the diagnosis, the patient underwent a posterior spinal fusion followed by bilateral clamshell thoracotomy for 3-level en bloc resection with simultaneous access to both chest cavities and the mediastinum. To demonstrate how the clamshell thoracotomy was used to facilitate the tumor resection, an operative video and illustrations are provided, which show in detail how the clamshell thoracotomy can be used to access both hemithoraxes and the mediastinum.
... And some study found that the transplant candidate always had malnutrition status, such as cirrhosis awaiting liver transplantation which was at least two thirds patients (1). However, Malnutrition is frequently overlooked in LTX candidates because nutritional assessment is not routinely carried out as part of clinical practice (2). ...
Background:
Nutritional Risk Screening 2002 (NRS2002) and prognostic nutrition index (PNI) are nutritional risk screening instruments that are also used to predict the complications and morbidity after surgery. Our study aims to evaluate whether preoperative nutrition status at admission or postoperative nutrition treatment during admission for lung transplantation (LTX) was linked to clinical outcomes.
Methods:
This study is a retrospective observational cohort study of 42 patients undergoing LTX. Using PNI and NRS-2002 screening instruments, patients were tested for dietary danger upon admission. Univariate and multivariate analyzes were performed to investigate the independent nutritional risk predictive value for post-operative complications, hospital length or intensive care unit (ICU) stay, and mortality.
Results:
Age, the average calorie intake, parenteral nutrition within 7 days, furosemide, the time of postoperative mechanical ventilation (MV), postoperative extracorporeal membrane oxygenation (ECMO) between survivor and non-survivor had a significant difference. Univariate analyses of death in LTX, age [HR 1.06 (1.00-1.13), P=0.04], the average calorie intake first 3 days [HR 0.99 (0.99-1.00), P=0.02], parenteral nutrition within 7 days [HR 0.20 (0.05-0.77), P=0.02], furosemide [HR 0.08 (0.01-0.76), P=0.02] and postoperative ECMO [HR 6.40 (1.65-24.77), P=0.00] were independent predictors for increased mortality. And multivariate analyses found that only postoperative ECMO [HR 9.59 (1.07-86.13), P=0.04] was independent predictors for increased mortality, whereas PNI and NRS2002 were not.
Conclusions:
PNI and NRS2002 was not an independent predictor for post-operative mortality, and postoperative ECMO was only independent predictors for increased mortality in this study.
