Bilateral lung transplantation via two sequential anterolateral thoracotomies

Bilateral anterior trans-sternal thoracotomy (clam shell incision) is the standard approach used for bilateral sequential lung transplantation (BLTX). The morbidity of this large incision can be considerable. Two separate sequential anterolateral thoractomies represent a less invasive approach.

The value of this approach was investigated in a prospective series of 22 consecutive patients who received BLTX between June 1997 and July 1998. Their underlying diseases were COPD (n = 16), cystic fibrosis (n = 4) and other (n = 2). All patients underwent BLTX through two anterolateral thoracotomies, without the use of cardiopulmonary bypass. The anterior mediastinum and the sternum with all the surrounding tissue were left completely intact. Twenty-one patients underwent spirometrical examination during the postoperative in-hospital stay. Follow-up is 7+/-4 months (range: 3 to 15).

The only intraoperative complication was severe reperfusion edema of the first transplanted lung seen in one patient at the end of the operation, which required pneumonectomy during the same session. All other operations were uneventful. The difference between the cold ischemic time of the first and second transplanted lung was 83+/-17 min. Median intubation duration, ICU- and in-hospital-stay were 1.5, 5 and 20 days, respectively (ranges: 1 to 96, 2 to 96 and 15 to 96, respectively). One major perioperative complication occurred and was due to gross donor/recipient size mismatch: the patient required lobectomy of the consolidated right upper lobe 11 days after transplantation. In 19 patients (86.4%), this less extensive incision allowed early postoperative mobilization, which resulted in good ventilatory performance, with VC of 53+/-15 and FEV1 of 60+/-20% of the predicted, respectively, at the first spirometry, 3 weeks after the operation. Three months survival was 100%.

The bilateral sequential anterolateral thoracotomy represents a safe and minimal invasive approach for BLTX compared with the clam shell incision. It minimizes the operative trauma, improves postoperative functional recovery and prevents the potential spread of unilateral complications to the other pleural cavity.