Anterolateral vs. Clamshell Thoracotomy for Bilateral Lung Transplantation

Clamshell thoracotomy is the traditional approach for bilateral sequential lung transplantation (LuTx), despite considerable morbidity. The bilateral anterolateral thoracotomy without sternal division is proposed as an alternative, less invasive method. Since this technique is more surgically challenging, the aim of this study was to evaluate the more favorable surgical approach.

Adult patients undergoing LuTx between 2010 and 2022 were included in this single-center retrospective cohort study. Multivariable regression analyses were performed to assess the effect of surgical approach on mortality, operative outcomes, and complications.

A total of 249 patients (anterolateral thoracotomy: n = 132, clamshell: n = 117) were included. Recipients in the anterolateral thoracotomy group were older, on the waiting list for a shorter period of time, classified less often as highly urgent, and differed in their indications for LuTx. After multivariable correction, operating and ischemic times were longer for patients in the anterolateral thoracotomy group. However, patients with an anterolateral thoracotomy incision had less intraoperative extracorporeal circulation (ECC) use, blood loss, and need for transfusion. While survival was similar, ICU and hospital stay, and duration of mechanical ventilation were shorter. Patients in the anterolateral thoracotomy group also had significantly less wound-related complications. The use of intraoperative ECC, which was much higher in the clamshell group, seemed to play an important role in these differences in outcomes.

Performing LuTx through the less invasive anterolateral thoracotomy is a favorable alternative to the clamshell incision. Despite increased technical difficulty and a limited increase in operating and ischemic times, survival is similar, but the anterolateral thoracotomy patients had significantly less peri- and post-operative complications and a faster recovery.