Combined lung and liver transplantation in patients with cystic fibrosis: A 4 1/2-year experience

Abstract

Patients with cystic fibrosis who have end-stage respiratory failure and associated liver cirrhosis have been considered poor candidates for lung transplantation because of high morbidity and mortality resulting from hepatic insufficiency after the operation. Since April 1989, our policy has been to combine heart-lung or lung and liver transplantation in this group of patients. Between June 1990 and March 1995, among 25 patients accepted in the program for combined transplantation, nine died awaiting transplantation and 10 underwent one of the following procedures: heart-lung-liver transplantation (n = 5), en bloc double lung-liver transplantation (n = 1), sequential double lung-liver transplantation (n = 3), and bilateral lobar lung transplantation from a split left lung and reduced liver transplantation (n = 1). There were 5 male and 5 female patients. The ages of the recipients ranged from 10 to 24 years. Mean forced expiratory volume in 1 second was 29% and mean forced vital capacity was 35% of predicted values. All patients were infected with resistant Pseudomonas, three with Pseudomonas cepaceia, and two patients had Aspergillus species in addition. All patients had severe cirrhosis with portal hypertension. Four patients had a history of esophageal variceal bleeding and two had had previous portosystemic shunts. The operation was performed as a two-stage procedure, the intrathoracic operation being completed before the abdominal stage was begun. Cardiopulmonary bypass was used in all patients because of poor clinical condition. Immunosuppression consisted of azathioprine, cyclosporine, and prednisone, as for isolated lung transplantation. There were two perioperative deaths, one caused by primary liver failure and the second by early lung dysfunction. For the first 3 months after transplantation pulmonary infection was the most common cause of morbidity. Other complications included tracheal stenosis (n = 1), bronchial stenosis (n = 1), biliary stricture (n = 2), and severe ascites (n = 3). All were successfully treated. Obliterative bronchiolitis developed in three patients. This was stabilized with FK 506 in two patients; the other patient underwent retransplantation at 38 months but eventually died of bleeding. Actuarial survival was 70% at 1 year and remained unchanged at 3 years. Significant functional improvement was observed in all survivors. For patients who have chronic respiratory failure with advanced cirrhosis, lung transplantation combined with liver transplantation can be performed with a satisfactory outcome.

Hepatobiliary complications of cystic fibrosis

“…Therefore, patients with CF and end-stage complications due to liver disease (portal hypertension, variceal bleeding, ascites) and stable pulmonary function should be considered for liver transplantation. Combined lung and liver transplantation has been performed in patients with CF, but experience is limited [55]. The most appropriate intervention (repeated sclerotherapy or banding, portosystemic shunt, partial splenectomy, or liver transplantation) for the management of end-stage CF liver disease and portal hypertension is still unknown, and its identification will require larger, long-term outcome studies in subgroups of CF patients with well-defined liver disease.…”

Cystic Fibrosis: Present and Future

“…Whilst the combination of end-stage lung and liver disease in these patients is particularly challenging both surgically and in their post-operative management the outcome is surprisingly optimistic. One study has shown an actuarial survival of 70% at 3 years which is as good if not better than other reports of isolated lung transplantation [46]. The genetic nature of the condition is such that recurrence in transplanted organs is highly unlikely and this has been demonstrated for lung transplantation and liver transplantation.…”

Cardiac and Multi-Organ Transplantation in Patients with Amyloidosis

“…Transplantation of the heart with discontinuation of cardio-pulmonary bypass, leaving the chest opened. The liver transplantation was performed as a second step through a bilateral sub-costal incision with extension in the midline to the sternotomy (Couetil et al, 1995) and was accomplished by a caval sparing hepatectomy with an anastomosis between the donor supra-hepatic cava and the recipient left/middle hepatic vein trunk. Biliary tubes were inserted through the donor cystic duct stumps whenever possible, and the abdomen was closed over drains after achieving hemostasis.…”