A 57-year-old woman with severe bilateral bronchiectasis was evaluated for lung transplant. She was 148 cm tall and weighed 46 kg. Her FEV1 was 0.63 liters (32% of predicted). Her PAO₂ was 64.6 mm Hg, and her Pa_CO2 was 44 mm Hg. All of her cardiac functions were within normal ranges. Her mean pulmonary arterial pressure was 32 mm Hg. She had no infections and no other systemic diseases. She was psychologically well and eager to undergo the lung transplant.

She underwent a bilateral brain dead donor lobar lung transplant. After the recipient pneumo-nectomies had been performed, bilateral lower lobes were implanted sequentially. She was given extracorporeal membrane support during the operation. Her postoperative course was uneventful. Chest drains were removed after 8 days. She went to the general ward on the fifth postoperative day, and was discharged on the 15th day. As of this writing, she has had no problems through the ninth month follow-up. To the best of our knowledge, she is the first case of successful bilateral brain dead donor lung transplant in our country.

Key words : Transplantation, Therapy, Grafts, Utilization, History

Introduction

Size mismatch is frequently encountered in a lung transplant (LTx). To resolve this problem, donor lung resections such as wedge resection, segmentectomy, lobectomy, bilobectomy, or split LTx can be done.^1-3 A lobar LTx can be performed both from deceased donors or living donors. Whereas brain dead donor lobar LTx is suggested and the operation is planned, living lobar LTx is always performed in critical patients and is the previously planned operation. The first bilateral brain dead donor lobar LTx was done by Bisson in 1994.⁴ Since that date, many cases have been done by different centers.^5,6 We present the first case of a successful brain dead donor bilateral lobar LTx done in Turkey in 2013 in our clinic.

Case Report

A 57-year-old woman with severe bilateral bronchiectasis was referred to our clinic for evaluation of an LTx. Her demographics and chest tomographic scans are given in Table 1 and Figure 1. She was an appropriate candidate for an LTx, physically and mentally. She was discussed by the transplant council of the hospital and put on the transplant list. The study was approved by the Ethical Review Committee of the institute, and all protocols conformed with the ethical guidelines of the 1975 Helsinki Declaration. The woman gave her written informed consent.

Lungs were recovered after 80 days. The donor was a 28-year-old man who died from trauma. He was 170 cm tall and weighed 70 kg. He had no infections or lung edema. His lungs were too large for the recipients chest cavity. Donor lungs were recovered and transferred to the hospital. Lobectomies were done at the back table of the operation suite.

The recipient was placed in a supine position. Bilateral anterolateral incisions were performed. The thoracic cavities were entered through fourth intercostal space. Both lungs were released from the chest wall and both hila were dissected. Bleeding was controlled. A right pneumonectomy was performed, and the right lower lobe was implanted.

Arteriovenous extracorporeal membrane oxygen-ator (ECMO) support was given by peripheral cannula. After ECMO support, reperfusion was started for the right lung. After this, a left pneumonectomy was performed in the recipient, and implantation of the left upper lobe was performed in the donor. After the lungs were reperfusion, ECMO support was stopped. The patients were transferred to the intensive care unit still intubated.

The postoperative course was uneventful. The patient was sedated for 48 hours and extubated. Drains were removed on the third and eighth days. She was transferred to the general ward on the fifth day. She discharged 15 days after the surgery. As of this writing, she has had no problems through the ninth month of follow-up (Figure 2).

Discussion

Lung transplant is the accepted treatment for the patients with end-stage lung disease. Although the first human LTx was done in 1963 by Hardy,⁷ the first successful LTx was accomplished in a human being in 1983 by Cooper.⁸ Today, approximately 3500 LTx are performed worldwide every year. In Turkey, the first successful LTx was done in 2009 by Kutlu and associates⁹ at the Sureyyapasa Chest Disease and Chest Surgery Research and Training Hospital in Istanbul, Turkey.

Size matching between the recipient and the donor is important because oversized grafts can lead to atelectasis and deterioration of chest mechanics and pulmonary hemodynamics.¹ In an animal study, Oto and associates reported that both pulmonary vascular resistance and peak airway pressure were significantly increased after chest closure in animals implanted with oversized lungs, but little change was seen in animals implanted with downsized lungs.¹⁰

Perioperative management and postoperative care in an lobar LTx have some differences from total lung transplant patients. After implanting the lobe and during the other native lung dissection, almost all cardiac output goes into 1 lobe. This over increase of pulmonary circulation causes increased pulmonary pressure and extravascular fluid leakage, and finally lung edema. To prevent overloading the pulmonary vascular bed, cardiopulmonary bypass or ECMO support is recommended during the operation.^1,6,11 We started ECMO support before first lobe had been reperfused, but after bilateral lung release, hila dissection, and bleeding control had been done, excessive bleeding due to systemic heparinization was prevented.

To decrease the effects of reperfusion injury, the postoperative course must be more stable in a lobar LTx. Patients are transferred intubated to intensive care unit and should be sedated for the first 48 to 72 hours. Pulmonary pressure should be under control. Fluid restriction should be carefully monitored. In these patients, thoracic drainage may be more and continue longer. Negative suction of chest cavity is not recommended.¹¹

Postoperative outcomes in bilateral lobar LTx are comparable to those of standard bilateral LTx. Bronchial anastomotic complications are reported as 5.5 and 13%.¹ There is no significant difference between 1-year and 5-year survival rates.¹ In conclusion, a lobar LTx is a safe and effective transplant technique for preventing the adverse effects of size mismatch.

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