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Ann Thorac Surg 2003;76:1680-1686
© 2003 The Society of Thoracic Surgeons
a The Johns Hopkins Medical Institution, Baltimore, MD, USA
b Baltimore, Maryland, USA
Accepted for publication May 28, 2003.
* Address reprint requests to Dr Conte, Johns Hopkins Cardiac Surgery, Blalock 615, 600 Wolfe Street, Baltimore, MD 21287, USA.
e-mail: jconte{at}csurg.jhmi.jhu.edu
Presented at the Forty-ninth Annual Meeting of the Southern Thoracic Surgical Association, Miami Beach, FL, Nov 7–9, 2002.
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Abstract |
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METHODS: A retrospective review of the lung transplant database was performed. Data are presented as mean ± standard error (median).
RESULTS: A total of 136 lung transplants (80 single lung transplants [SLT], 55 bilateral lung transplants [BLT], and 3 heart-lung transplants [HLT]) were performed from August 1995 to February 2002. Twelve pulmonary resections, 7 lobectomies, and 5 wedge resections were performed on 11 patients. The indication for lobectomy was infection in 5 of 7 lobectomies (3 fungal, 2 bacterial), mass in 1 of 7, and infarction in 1 of 7. The indication for wedge resection was native lung hyperinflation in 4 of 5 wedge resections and mass in 1 of 5. The native lung was resected in 3 of 7 lobectomies and 4 of 5 wedge resections. An allograft lobectomy was performed following 1 SLT and 3 BLT and a wedge resection was performed after 1 SLT. The mean time to pulmonary resection was 12.4 ± 3.9 (9.1) months. Survival postresection was 17.2 ± 5.8 (8.3) months and 5 of 11 patients are still alive. There were no bronchial stump leaks following lobectomy.
CONCLUSIONS: Major pulmonary resections can safely be performed following lung transplant. We recommend early intervention to optimize outcomes.
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Introduction |
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Indications for pulmonary resection postlung transplant include native lung hyperinflation, infection, hemorrhage, infarction, bronchiolitis obliterans organizing pneumonia (BOOP), and malignancy [3–19]. No center has published their overall institutional experience regarding postlung transplant pulmonary resections performed for all indications.
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Material and methods |
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Review of our lung transplant database identified 11 patients who had undergone posttransplant pulmonary resections. Pulmonary resections were divided into lobar or wedge resections involving either the allograft or native lung. Lobar resections included standard lobectomy and bilobectomy procedures. Wedge resections included lung reduction and diagnostic wedge resections. All resections were performed with standard, commercially available, surgical staplers. All bronchial stumps were reinforced with intercostal muscle.
A literature review was conducted using the keywords pneumonectomy, lobectomy, bullectomy, volume reduction, wedge resection, and lung transplant. Previous reports of posttransplant pulmonary resections are summarized in Table 1.
Descriptive statistics were calculated and compared, using 
2 and analysis of variance (ANOVA), and are reported as mean ± standard error (median). Time to pulmonary resection by indication and survival postresection for either lobectomy or wedge resection was calculated using Kaplan-Meier analysis and compared, using log-rank analysis, with overall survival of all lung transplant recipients.
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Results |
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Five patients underwent pulmonary resection for infectious complications: 3 patients with cavitary fungal abscesses (2 Aspergilloma and 1 Histoplasmosis); and 2 patients with refractory lobar pneumonias (Pseudomonas). The initial indication for lung transplantation differed between each patient requiring resection for infection. Mean time from transplantation to resection for fungal infection was 7.8 ± 1.6 [9] months and for bacterial infection was 1.4 ± 0.2 (1.4) months. The fungal abscesses occurred at 5, 9, and 10 months posttransplant, involving the allograft in 2 patients and the native lung in 1 patient. The lobectomies for bacterial infection, performed at 1 and 1.6 months posttransplant, involved the allograft in 1 patient and the native lung in the other. Two patients, both with Aspergilloma, remain alive at 31.2 and 59.4 months postresection. Two patients, both with Pseudomonas, died at 3.1 and 38.3 months postresection, 1 patient from postprocedural sepsis and the other from BOOP. Since the conclusion of the study, 1 patient resected for cavitary Histoplasmosis, died acutely after stent placement for bronchial stenosis. This was unrelated to the pulmonary resection.
Two patients underwent pulmonary resection for a suspicious mass after bronchoscopy and computer tomographic (CT) guided biopsies were nondiagnostic. One patient, who developed a mass in the native lung, had previously undergone a successful thoracoscopic LVR on the same lung. The second patient developed a mass in the allograft and underwent a wedge resection. In both patients final histopathologic analysis revealed BOOP without any evidence of carcinoma. Both patients in our series undergoing mass resection died, at 0.4 and 0.6 months, from acute respiratory distress syndrome and organ failure.
One patient required an allograft lobectomy for pulmonary infarction secondary to a pulmonary embolus and remains alive at 18.1 months postresection.
In the surviving patients, review of the medical records revealed no significant complications, including bronchial stump leaks. Mean survival after lobectomy was 34.1 ± 10.1 (38.3) months and after wedge resection was 16.3 ± 0.68 (0.34) months. Overall mean survival postpulmonary resection was 17.2 ± 5.8 (8.3) months. Actuarial survival at 1, 12, and 48 months after lobectomy was 85%, 68%, and 34%. Actuarial survival at 1, 12, and 48 months after wedge resection was 60%, 40%, and 0%. Postresection survival is compared with the actuarial survival rate of 90%, 74%, and 52% at 1, 12, and 48 months of transplant recipients not requiring resection (Fig 2).
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Comment |
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Native lung hyperinflation in the early postoperative period is a common radiographic finding that usually resolves within a few months and is generally not associated with any poor outcomes [20]. Progressive hyperinflation can cause contralateral hemithorax encroachment and a decrement in pulmonary function. Lung volume reduction surgery has been reported to improve FEV1 and exercise tolerance, while reducing subjective dyspnea and oxygen dependence [21]. The mortality rate for patients undergoing LVR in our study was 40% (2 of 5). In both instances, where patients died postprocedure, resection was delayed until respiratory function was severely compromised. Performing a pulmonary resection likely directly resulted in the death of 1 patient from aspiration pneumonia and accelerated the course of BOOP in the other patient. Improvement in 3 of 5 patients, measured by pulmonary function studies and exercise tolerance, suggest that LVR can be done safely with a reasonable expectation for success. Earlier consideration for surgical resection before severe pulmonary compromise may improve outcome. Our series was not large enough to detect any independent risk factors precluding resection or predictive of outcome. However, there are, as suggested by this and other studies, other important patient characteristics that may be helpful in predicting outcome [14].
Infection is the most common cause of perioperative morbidity and mortality in lung-transplant recipients. Ventilator dependence, prolonged intensive care unit and hospital stays, native lung colonization, and immunosuppressive regimens increase exposure to virulent pathogens [22]. We routinely treat our posttransplant patients with broad-spectrum antibiotics, and antifungal (aerosolized) and antiviral therapy tailored to donor and recipient cultures. Each patient requiring resection for infection failed aggressive medical therapy including pulmonary toilet, frequent bronchoscopy, and long-term antibiotic or antifungal (intravenous and aerosolized) therapy. Resection was undertaken to reduce infectious load and relieve ventilation-perfusion (V/Q) defects. Differences in mean time to resection for bacterial or fungal infection reflects the natural history of infection in transplant patients. Bacterial infections are most common immediately posttransplant, reflecting native lung colonization or a perioperative event, whereas opportunistic viral and fungal infections increase in incidence later secondary to immunosuppressive regimen. There was no discernable relationship in our study between recipient indication for transplantation, cause of donor death, duration of intubation, and length of hospital stay with the development of infection requiring resection. Lobar resection for infection after failed medical therapy can improve outcome by preventing adjacent segmental involvement, pulmonary sepsis, reducing occurrence of resistance, and improving V/Q mismatches.
Minimal data exists regarding the incidence of malignancy following lung transplantation. The incidence in other solid organ transplants ranges from 4% to 18% and is, most commonly, either skin cancer or lymphoma [23]. Recipient characteristics, such as cigarette smoking, underlying medical conditions (IPF), and immunosuppressive carcinogenic effects likely increase risk of malignancy in lung transplant recipients. Evaluation of a mass in a lung transplant recipient should be identical to any other patient and include pulmonary function tests, imaging studies, bronchoscopy, and percutaneous biopsy. Attempts at percutaneous biopsy were unsuccessful in our patients and there were no contraindications to resection. In both patients subsequent histopathology demonstrated BOOP without any evidence of carcinoma. Both patients exhibited rapid postoperative decline, succumbing to respiratory failure. Pulmonary resection likely accelerated their decline and death may have been preventable if biopsy had been successful. There were no independent variables predicting outcome identified in our study. Although transplant recipients have an increased risk, surgical resection of a mass should be performed in the absence of standard contraindications.
Posttransplant vascular complications, including embolus, stenosis, or anastomotic rupture, cause significant morbidity and mortality. Previous reports are limited to hemorrhage [3] and pulmonary venous thrombosis [5] necessitating urgent lobectomy. Our patient developed pulmonary infarction secondary to a pulmonary embolus associated with an unrecognized donor contusion. The resultant V/Q mismatch prevented extubation and infarcted tissue caused fever and hypotension, unresponsive to conventional therapy. Lobectomy resulted in immediate improvement. The incidence of thrombosis or embolism is unknown after lung transplantation and clinically it is difficult to diagnose because shunts are common. It is necessary to maintain a high index of suspicion and, if vascular catastrophes compromise pulmonary function, operation can be performed safely.
Pulmonary resection after lung transplantation often involves a redo thoracotomy and its attendant risks, including pleural adhesions, prolonged air leaks, and inflamed, fragile tissue. Careful preoperative evaluation of transplant recipients, intraoperative examination of donor lungs, and postoperative critical care can limit posttransplant surgical interventions. With the increased risk of operation, it is imperative that medical therapy be optimized, but in the event resection is necessary, it can be undertaken with a reasonable expectation for success.
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Discussion |
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DR CONTE: I agree 100%. I think if we were able to pull donor organs off the shelf, we would do double-lung transplants all the time, and certainly after 3 years, in all types of patients, the data supports doing bilateral lung transplants. And as we all know, the reality of it is we just don't have enough donor organs to go around, and then we are left with the situation, do we go and help more patients for, albeit, perhaps a shorter period of time or do we go and try to help fewer patients for a longer period of time, and that is an ethical/moral judgment that individual programs need to make I think.
DR JOHN H. CALHOON (San Antonio, TX): A very nice presentation from you and your colleagues at Hopkins. It looked like you were trying to preserve lung, as we all would, and you are very cautious to operate on them. We had a similar experience with a number of wedge resections and lobectomies, but early in our experience with lung transplantation we had a patient that we didn't want to remove much lung because of the inflammation surrounding a big Aspergilloma, and simply did a pneumonostomy tube drainage of his Aspergilloma cavity, and excised it (the Aspergilloma itself), simply because things were so inflamed.
I was wondering if you used any other techniques of sparing lung and/or removing infection in your series. Would consider it in some case and what your thoughts on it would be? Thanks again for a nice presentation.
DR CONTE: That is a very good question. We did not attempt anything else, and I think the feeling was that the patient would have a hard time healing anything, and, again, with the immunosuppression I don't know if conventional treatments have the same effect. But it certainly is an option. We just did not consider it.
DR FREDERICK L. GROVER (Denver, CO): This was a very nice paper, and I think your point is well taken: when these patients require surgery, by and large they tolerate it well and it should be performed.
I wanted to just probe a little bit into the lung volume reduction area. We have done over 120 single lungs for COPD patients at our University of Colorado program. The problem of really severe hyperinflation of the contralateral native lung is pretty unusual in our hands because we try to have a reasonable size match (ie, good-sized donor lung) when we select the donors. We have had five lung volume reductions after native lung with four survivors with reasonably good results.
One of the important issues I think is how you make the decision of whether to perform a lung volume reduction in this patient population because sometimes the hyperexpansion is because the transplanted lung is rejecting and performing a lung volume reduction on the opposite side in that group of patients can be devastating. Maybe you can tell us a little bit about your decision process in that group of patients.
DR CONTE: We intentionally did not perform volume reduction in patients who were acutely ill or having rejection in the later series after having a bad experience with one patient. The one patient who died early was a patient who in fact was very ill, we did volume reduction, and that patient died the day after the operation.
I think the real algorithm that we used was that if the patient had significant hyperexpansion but was still active, living a normal lifestyle, and was not on oxygen, we did not attempt lung volume reduction. Once they required oxygen again and their functional status decreased, then it was at that point that we performed the volume reduction. Strictly going by the pulmonary function testing without considering the overall clinical picture, was not effective.
There are some patients, as you know, posttransplant who have great pulmonary function tests and do well and some whose pulmonary function tests are not so great and do well. We found that pulmonary function testing in patients with asymptomatic hyperinflation was often more confusing than helpful. So it was when the patients seemed to be doing a little bit worse clinically, on their spirometry, and were without infection or rejection, but were still stable, that was the time that we referred them for lung reduction.
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References |
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This article has been cited by other articles:
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  T. B. Reece, J. D. Mitchell, M. R. Zamora, D. A. Fullerton, J. C. Cleveland, M. Pomerantz, D. M. Lyu, F. L. Grover, and M. J. Weyant Native lung volume reduction surgery relieves functional graft compression after single-lung transplantation for chronic obstructive pulmonary disease. J. Thorac. Cardiovasc. Surg., April 1, 2008; 135(4): 931 - 937. [Abstract] [Full Text] [PDF]
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Pulmonary artery thrombosis caused by hyperinflation of the native lung six years after single lung transplantation for emphysema. J. Thorac. Cardiovasc. Surg., March 1, 2006; 131(3): 746 - 747.
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= lobectomy (n = 7); 
= wedge (n = 5).