Pulmonary bipartitioning and lobar transplantation: A new approach to donor organ shortage

Abstract

The scarcity of small donors has significantly limited lung transplantation for pediatric and small adult patients. Use of single lobes procured from size-unmatched donors has overcome this difficulty, but only in a few selected cases and, in addition, it represents a waste of lung tissue. In an animal model we have shown that it is possible to divide one lung with careful partitioning of the vascular and bronchial structures and thus obtain two viable lobar grafts suitable for bilateral implantation in a smaller animal. We have now applied this procedure clinically in seven patients operated on between May 1993 and November 1994. The indications were cystic fibrosis in three children, primary pulmonary hypertension in two adults, bronchiectasis in one, and idiopathic pulmonary fibrosis in one. There were three children aged 13 to 17 years (median 14) and four adults aged 40 to 53 years (median 45). There was a 46% to 50% discrepancy for weight between recipient and donor and a 12% to 17% discrepancy for height. The surgical technique consisted of careful partitioning of the left donor lung, bilateral anterior thoracotomy in the recipient, and, with the use of cardiopulmonary bypass, implantation of the lower lobe in the left hemithorax and the upper lobe in the right hemithorax. Vascular and bronchial connections were facilitated by leaving a long pedicle on the recipient side. The pulmonary artery anastomosis for the donor left upper lobe was done with the "fissure" side of the artery to ensure an anastomosis without tension. An end-to-end bronchial anastomosis overcame the problem of size discrepancy. Six patients are alive and well 10 to 27 months (median 19) after operation. One patient with cystic fibrosis died of systemic aspergillosis infection. All were discharged from the hospital within the first or second postoperative month. No technical problems were identified: repeated bronchoscopy has demonstrated satisfactory healing without early stricture formation. All patients remain well subjectively with good exercise tolerance and all patients achieve greater than 70% of predicted values of forced expiratory volume in 1 second. Perfect adaptation of the transplanted lobes to the recipient pleural space has been demonstrated by postoperative computed tomographic scan. In conclusion, bilateral lobar transplantation from a single donor lung is possible in small adults or children when there is a large size discrepancy with the donor. This may help resolve the problem of donor availability in the pediatric population.

Right and Left Inverted Lobar Lung Transplantation

“…In deceased-donor lung transplantation, several surgical modifications have been performed to counter the severe donor shortage worldwide, such as pulmonary bipartitioning, lobar transplantation, and inverted left lung transplantation into the right thorax (12)(13)(14)(15)(16). In LDLLT, native lungsparing bilateral LDLLT and single LDLLT with contralateral lung resection also have been reported (17,18); however, there are no reports of right and left inverted lobar lung transplantation.…”

Overview of Clinical Lung Transplantation

“…For larger size discrepancies, an adult donor lung can be downsized anatomically to implant a lower or upper lobe on either side in a smaller recipient (bilateral lobar transplant) (Starnes et al 1994). Another innovative operation is the split left-lung bilateral lobar transplantation technique, which allows for a large donor to donate a single left lung to a smaller recipient or child, where the left upper lobe and left lower lobe are implanted to the right and left chest, respectively (Couetil et al 1997). Living donor lobar transplantation is applied in jurisdictions where the legal and cultural climate is not conducive toward deceased donor transplantation, such as in Japan.…”

Strategies to increase limited donor resources

“…Donor lungs can be downsized by peripheral nonanatomic segmental resections (tailoring) or by transplantation of cadaveric lobes in recipients with smaller thorax size [62]. COUETIL and co-workers [63,64] have developed a technique of bilateral LTx inspired from previous experience with bipartitioning of the liver. They split the left lung into two separate lobes.…”

“…The rotation of the left upper lobe into the right pleural space requires anastomosing the membranous portion of the bronchus to the cartilaginous ring on each of the donor and recipient side, but this did not cause any delay in healing. This technique allows bilateral LTx to be performed in a small-size recipient with excellent short-and long-term outcome [64,65].…”