Article :Lung Transplant Surgical Experience

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Transplantation Proceedings

Volume 35, Issue 1, February 2003,

Copyright © 2003 Elsevier Science Inc. All rights reserved.

Lung transplantation––the surgical experience

Y. C. Lee, a, b, c, Y. L. Changa, b, c, J. S. Chena, b, c, H. H. Hsua, b,

c, W. J. Koa, b, c, J. M. Leea, b, c, H. D. Wua, b, c, S. C. Changa, b, c

and S. H. Kuoa, b, c a Department of Surgery, Pathology (Y.C.L., Y.L.C.,

J.S.C., H.H.H.,

W.J.K., J.M.L.), National Taiwan University Hospital, Taipei, Taiwan

b Department of Clinical Pathology (H.D.W., S.H.K), National Taiwan

University Hospital, Taipei, Taiwanc Department of Internal Medicine

(S.C.C.), National Taiwan University

Hospital, Taipei, Taiwan

Materials and methods Result Discussion Acknowledgements References

The first 2 successful lung transplantations (LTs) in Taiwan were

performed in December 1995 in our hospital.[1] Since then, a continuous

effort has been undertaken to use LT to treat patients with benign

end-stage lung diseases. In this endemic area, a unique spectrum of

indications patterns of rejection and occurrence of complications was

noted after LT. The surgical experience is reviewed herein to analyze

factors influencing the surgical results.

Materials and methods

During the period from December 1995 to July 2001, 23 patients received

27 LTs at National Taiwan University Hospital. The category and number of

LT included single lung (20), bilateral sequential lung (2), reduced lung

(1), and retransplants (4). The spectrum of indications was (1) primary

pulmonary hypertension, seven patients; (2) end-stage sauropus

androgynus-induced bronchiolitis obliterans (SABO), seven patients; (3)

pulmonary bullous disease, four patients; (4) pneumoconiosis, two

patients; (5) bronchiolitis obliterans (BO), four patients; (6) diffuse

panbronchiolitis, one patient; (7) bronchiectasis, one patient; (8) ASD

with Eisenmenger's disease, one patient.There were 15 female and 8 male

patients of ages ranging from 4 to 64 years. All patients were oxygen

dependent with functional class III to IV. Among them, two had undergone

tracheostomy with ventilator support for periods of 3 and 6 months before

LT. Seven patients with SABO had taken raw SA extract juice for periods

ranging from 20 days to 2 months. They developed respiratory symptoms 1

to 2 months after intake and gradually became dyspneic and suffered from

respiratory failure.[2] Retransplantation was performed in four patients

in whom chronic injection with BO was noted by functional and

histological examinations. The intervals between two LTs were 18, 29, 40,

and 48 months.Lung transplantation was performed according to the

protocol and principles devised by the lung transplantation group of

Hospital at Washington University, St Louis, Mo.[3] The recipient

operations were performed via a lateral thoracotomy for single LT and

clamshell thoracotomy for bilateral sequential LT. Among the 27 LTs, 19

needed cardiopulmonary support during the operation. Extracorporeal

membranous oxygenator (ECMO) and conventional cardiopulmonary bypass were

used in 16 and 3 patients, respectively. [4] Total ischemic time ranged

from 1 hour 30 minutes to 6 hours 10 minutes. Intravenous

methylprednisolone (1 g) was infused during the early reperfusion period.

Rabbit antilymphocyte globulin (RATG) (5 mg/kg) was used during the first

five postoperative days. Cyclosporine (neoral) was used subsequently

maintaining whole-blood cyclosporine level (by the mFPIA method) at

approximately 300 ng/mL. Azathioprine (imuran) (2 mg/kg) was given daily

postoperatively, and the leukocyte count was maintained at >4000/L.

Intravenous methylprednisolone was given at 4 mg/kg/day on the first

operative day and gradually tapered to oral prednisolone 0.25 mg/kg/day.

If either donor and/or recipient was, CMV seropositive, gancyclovir was

administered intravenously (day 7 to 28, 10 mg/kg/day; day 29 to 35, 5

mg/kg once daily) for prophylaxis of CMV pneumonia. Prophylaxis of

bacterial, fungal, and pneumocytis carinii infection was used as usual.

Transbronchial lung biopsy was performed if clinical findings and image

studies were suspicious for graft rejection.

Result

Among the 27 LTs, there were 7 (25.9%) perioperative deaths. The one year

and 2 year survival rates were 66.7% and 60.0%, respectively. The causes

of early ( one month) and late mortality are summarized in Table 1. A

total of 20 transbronchial lung biopsies in the remaining 16 patients

have been performed during the follow up period to establish the

etiological diagnosis of the pulmonary lesion. Only two patients have

been diagnosed as low grade (Gr 1 to 2) acute rejection. Among the 15

patients who were followed longer than 1 year, five patients (33.3%) had

functional and histological changes of chronic rejection. Four of them

underwent retransplantation and one patient died of BO with superimposed

infection while waiting for LT. Four patients experienced stenotic

complications of the bronchial anastomosis which developed at around 1

month after transplantation. Two patients had undergone tracheostomy with

prolonged mechanical ventilation before transplantation. Among the four

patients, two were successfully managed by an internal stent, the other

two eventually died due to failure of local treatment, complicated by

pulmonary infection. One SABO patient developed a high grade

EBV-unrelated B-cell lymphoma in the transplanted lung 3 months after

transplantation. Despite antiviral agents, reduction of immunosuppression

and conventional chemotherapy, this patient eventually died of advanced

lymphoma complicated with infection 2 months later.[5] Another patient

had Herpes virus-8-associated Kaposi's sarcoma (KS) involving tongue,

oral and nasal cavities, airway and lung, but sparing the skin, 17 months

after transplantation. The KS lesions resolved spontaneously after

reduction of immunosuppression. Totally seven patients with SABO syndrome

underwent LT, there was one operative mortality, three died of bronchial

stenosis, lymphoma or pneumonia at posttransplantation 4, 5, 28 months,

respectively. The remaining three patients has been living well for 69,

63, and 27 months with improved general condition and pulmonary function.

One patient with SABO underwent retransplantation of the contralateral

lung due to chronic rejection of the pretransplanted right lung. There

were significant differences in pathological severity changes between the

right lung, which was pneumonectomized 2.5 years ago and the left native

lung excised recently. [6]

Table 1. Causes of Early and Late Mortality  (6K)

Discussion

The current report presents an early experience of LT in Taiwan. The

unique experiences of LT for patients with SABO show that LT is an

effective modality of treatment to improve pulmonary function.[2] The

irreversible and progressive course of SABO was demonstrated in a patient

receiving retransplantation in the contralateral lung. [6] In this

series, the majority of the patients (70.4%) needed cardiopulmonary

bypass (CPB), mostly by ECMO, during LT operation. Our experience shows

that the heparin-bound femoral ECMO rather than conventional CPB should

be used for LT operation unless concomitant cardiac repair is planned.

[4] The rather higher perioperative mortality was partly due to serious

conditions of the recipient and inadequacy of the experience. The

episodes of acute rejection in this series were rather few compared with

other reports, [3] partially due to less genetic difference between

donors and recipients in this endemic area. The occurrence of chronic

rejection remains as a main problem if patients survive the early

perioperative period. Although rare in the literature, we experienced

complications of KS, posttransplantation lymphoma, and hepatitis B

reactivation is this series. In general, the 1 year and 2 year survival

rates are comparable to those of other reports. The longest surviving

recipient is now 74 months after LT with a normal activity of life. With

accumulation of experience, we hope to achieve better surgical results in

the future.

Acknowledgements

This study is supported by the Lung Transplantation Foundation, Taiwan.

  Corresponding author. Address reprint requests to Dr Yung Chie Lee,

Department of Surgery, National Taiwan University Hospital, No. 7

Chung-Shan South Road, , Taipei, , Taiwan

Becki

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