COMMENT
Bronchiectasis, regardless of etiology, can result in a significant
decrease in quality of life. While surgical treatments are not the first
line of treatment, it is therefore important to relegate these treatment
options for those that would benefit in quality of life due to relief
from symptoms such as chronic cough, excessive sputum production and
hemoptysis, when medical therapies fail. Among all surgical forms for
bronchiectasis treatment, lung resection (sublobar and lobar) of focal
compromised areas is the most frequent and acceptable possibility.
Resection of the compromised segments may reduce the bouts of infection.
This results in a significant improvement in the patient quality of life
and low morbidity and mortality after surgery (4). Improvements in
surgical technique and use of effective antibiotics led to this dramatic
change in surgical results.
Lung transplantation is another viable surgical option for selected
patients with advanced bronchiectasis of any origin (CF’s and non-CF’s),
who have poor quality of life and are at risk of death once the decrease
on their lung capacity compromises their daily activities or leads to
recurrent hospital admissions. Cystic fibrosis encompasses approximately
26% of all total bilateral lung transplantations while non-CF
bronchiectasis patients accounts for 4.5% of all bilateral lung
transplantations (5). Despite the challenges that CF patients present,
the overall survival after lung transplantation is more favorable than
that seen in patients with chronic obstructive pulmonary disease or
pulmonary fibrosis.
In rare, advanced cases patients may present with a completely collapsed
ipsilateral lung with concurrent retracted asymmetric hemithorax. This
often poses significant surgical challenges in lung transplantation and
several surgical techniques have been presented in several small case
reports with good results. Jougon et al. reported long term outcomes in
a case report of a patient undergoing a left lung transplantation with a
concurrent right pneumonectomy in a patient who developed right sided
bronchiectasis. They expressed concern with regards to an extensively
retracted right hemithorax that would have compromised respiratory
mechanics and therefore allograft function if a normal sized right lung
was implanted without any major volume reduction (6). Other groups would
also describe the combination of an unilateral lung transplant after a
staged pneumonectomy. Samano and colleagues presented a case series of
two patients who underwent bilateral sequential lung transplantation in
the setting of bronchiectasis and asymmetric thoraces after undergoing
lower lobectomies. In their series, due to the difference in size of the
retracted hemithoraces, the surgical group elected to perform lower
lobectomies of the donor lungs at the time of transplantation. This
allowed for chest closure without any cardiopulmonary compromise (7).
In the current report, because of the extensive mediastinal shift
resulting from their disease process, three possible surgical approaches
were discussed at our lung transplant multidisciplinary meeting.
Unilateral lung transplantation with contralateral pneumonectomy, left
lung transplant plus right lobar transplant or sequential double lung
transplantation. Unilateral lung transplantation was not considered as
an option because the risk of allograft contamination via the
non-transplanted native lung is high (8). Unilateral lung
transplantation with contralateral pneumonectomy was deemed a feasible
technique and has been previously described as well. In this situation,
the pneumonectomy could be done in a staged fashion or at the time of
unilateral transplantation (9,10).
Ultimately, as described, we elected to perform bilateral sequential
lung transplantation despite the reduced size of the right chest cavity.
Although the mediastinal shift required significant dissection of the
pericardium and the atelectatic lung in the operating room at the time
of transplantation, we found that the accommodation of the donor lungs
and the return of the mediastinum to a more anatomical situation
happened early after the surgery without significant hemodynamic
compromise. This response shows that the sequential double lung
transplantation is thoroughly possible, even in non-optimal anatomical
conditions. Furthermore, this procedure leads to an increased
post-transplantation pulmonary capacity.
In order to accomplish these transplants, three surgical aspects are
worth mentioning. First, we elected to leave the chest open after
successful implantation due to size mismatch especially in the setting
of a shifted mediastinum. This allowed for the allografts as well as the
chest cavities to accommodate to one another, noting a return to normal
anatomy on the first POD1 chest x-ray. The second aspect is the use of
antibiotic solution during the chest washout and closure. These patients
are frequently colonized by many different species of bacteria and it is
common to develop an empyema after lung transplantation. Therefore,
chest washouts with antibiotics may prevent this complication, and we
have used this procedure in all of our patients with such
characteristics. The third aspect is the use of antibiotics targeting
those species of bacteria or fungus previously cultured in the sputum in
the pre-operative evaluation. In our practice this is a sine qua
non condition after lung transplantation.
In conclusion, double lung transplantation is a safe and feasible option
in patients with bronchiectasis with concurrent mediastinal shift.
Favorable outcomes seen after sequential double lung transplantation in
these patients were achieved by the used of delayed chest closure with
concurrent antibiotic driven thoracic cavity washout.