Step 1
Surgical Anatomy
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Solid working knowledge of the anatomy of the chest, in particular the hilar relationships of the left and right lung, is crucial. Other important structures whose anatomic relationships must be studied include the following:
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Phrenic nerves
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Pericardium and its reflections
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Recurrent laryngeal nerve on the left side
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Because lung transplantation may require cardiopulmonary bypass (CPB) established either through the chest or the femoral vessels, it is key to understand anatomy relevant to CPB and to have a plan in mind if this is required, regardless of one’s approach to the chest for the transplant ( Fig. 24-1 ).
Figure 24-1
Step 2
Preoperative Considerations
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Lung transplantation is performed for end-stage lung disease. The decision for single or bilateral transplant is multifactorial but essentially depends on the disease and the patient’s age. In general, suppurative lung disease (i.e., cystic fibrosis) requires bilateral transplant to prevent contamination of the other lung. Younger patients are generally considered for bilateral transplant because of modestly improved long-term survival.
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Candidacy for transplantation is decided by a multidisciplinary transplant committee after a protocol-driven evaluation. The full scope of this decision process is beyond the limits of this chapter; however, here follows a list of fairly standard inclusion criteria and contraindications. Realize that these are center specific.
1
Inclusion Criteria
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High likelihood of death from lung disease within 2 to 3 years
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New York Heart Association functional class III or IV
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Acceptable psychosocial profile
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Normal metabolic profile
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Adequate nutritional status (body mass index [BMI] between 16 and 35)
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Ability to live within 4 to 6 hours of transplant center while awaiting transplant
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Ability to comply with a long-term disciplined medical regimen
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Normal heart assessment, including catheterization or appropriate stress monitoring
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No contraindication for immunosuppressive therapy
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Potential for rehabilitation
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Failure of maximum appropriate medical management
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Not amenable to other proven surgical treatment options
2
Absolute Contraindications
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Active malignancy
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Active extrapulmonary infection, including HIV and AIDS, hepatitis B, and hepatitis C
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Active pulmonary infection in patient considered for single-lung transplantation
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Significant acute or chronic cardiac insufficiency
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Significant hepatic or gastrointestinal disease
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Chronic renal disease (creatinine clearance <50 mL/min)
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Persistent colonization with Burkholderia cepacia
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Active fungal infection
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Known active substance abuse or history of substance abuse with failure to comply with rehabilitation
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Obesity (BMI >35)—refractory to weight-control programs
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Cachexia—not amenable to nutritional rehabilitation
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Acute illness that will adversely affect the outcome of transplantation
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Current use of mechanical ventilation for more than a very brief period
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Cigarette smoking within the past 6 months
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Insulin-dependent diabetes mellitus with evidence of end-organ damage, including the following:
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Diabetic vasculopathy
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Diabetic nephropathy
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3
Relative Contraindications
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Older than 55 years for bilateral lung transplantation
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Steroid use greater than 10 mg/day; prednisone that cannot be weaned
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Previous cardiothoracic surgery or other bases for pleural adhesions
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Insulin-dependent diabetes mellitus with evidence of end-organ damage, including the following:
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Diabetic retinopathy
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Diabetic peripheral neuropathy
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History of noncompliance or psychiatric disorder likely to interfere significantly with a disciplined medical regimen
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Persistent colonization with pan-resistant Pseudomonas aeruginosa
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Ventilator dependency (if patient is already listed he or she will still be considered for lung transplant)
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Severe osteoporosis
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Systemic hypertension refractory to medical management
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4
Donor Assessment
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By the time of operation, sidedness or bilaterality will already have been determined. You must determine the following:
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ABO compatibility
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Size matching (dimensions measured from apex to dome, across at the level of the aortic knob, and dome of diaphragm). Remember, with some diseases (e.g., chronic obstructive pulmonary disease) patients have hyperexpanded lungs, whereas patients with other diseases (e.g., idiopathic pulmonary fibrosis, pulmonary hypertension) tend to have normal to small lungs.
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Review donor history, arterial blood gases and trend, bronchoscopy, Gram stain, and chest radiograph.
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5
Recipient-specific Considerations
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Location to hospital and transportation time
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Health at time of notification—any immediate new contraindications (i.e., fever)
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Previous thoracic operations or virgin chest
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Pulmonary artery (PA) pressures, hemodynamic stability, and risk of requiring CPB
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Patent foramen ovale
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Single or bilateral
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Drugs: induction protocol of the institution
Step 3
Operative Steps
1
Procurement
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View all radiographs and laboratory tests, confirm ABO blood type. Perform a bronchoscopy to ensure that anatomy is normal and all segments are clear of secretions. If mild to moderate amounts of purulent secretions are present, lavage with saline. If the secretions clear easily and do not reaccumulate, the lungs are generally still acceptable. This decision requires experience and is program specific.
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Exposure is made via median sternotomy in conjunction with abdominal teams. Widely open the pericardium in cruciform fashion and widely open each pleura, and take down the inferior pulmonary ligaments. Fully inspect both lungs for nodules, atelectasis, significant contusion or trauma, and other contraindications to transplant. Isolate superior vena cava (SVC) and encircle with umbilical tape, using care to avoid the azygos vein and right pulmonary artery (RPA). Isolate the aorta from the PA laterally and the RPA posteriorly and encircle with umbilical tape. Place pulmoplegia stitch in the main pulmonary artery (MPA) about 1 cm from bifurcation; we use a 4-0 Prolene U -stitch, a diamond purse string also works well. Systemically heparinize (coordinate with visceral team) ( Fig. 24-2 ).
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Before cross-clamping, give 500 µg of prostaglandin E (PGE) into the MPA ( Fig. 24-3 ) and wait for a systemic response drop in mean arterial pressure (MAP). Cross-clamp the aorta and amputate the left atrial appendage and divide 50% of the IVC for venting. Administer pulmoplegia (Perfadex at our institution) 3 L at 30 cm H 2 O, and apply topical crushed ice. Use adequate suction so that the lungs are not bathed in the warm blood. Tie the SVC with the umbilical tape.
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