PULMONARY BIPARTITIONING AND LOBAR TRANSPLANTATION - A NEW APPROACH TO DONOR ORGAN SHORTAGE

The scarcity of small donors has significantly limited lung transplant ation for pediatric and small adult patients, Use of single lobes proc ured from size-unmatched donors has overcome this difficulty, but only in a few selected cases and, in addition, it represents a waste of lu ng tissue, In an animal model we have shown that it is possible to div ide one lung with careful partitioning of the vascular and bronchial s tructures and thus obtain two viable lobar grafts suitable for bilater al implantation in a smaller animal, We have now applied this procedur e clinically in seven patients operated on between May 1993 and Novemb er 1994. The indications were cystic fibrosis in three children, prima ry pulmonary hypertension in two adults, bronchiectasis in one, and id iopathic 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 a nterior thoracotomy in the recipient, and, with the use of cardiopulmo nary bypass, implantation of the lo,ver lobe in the left hemithorax an d the upper lobe in the right hemithorax, Vascular and bronchial conne ctions were facilitated by leaving a long pedicle on the recipient sid e, 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 prob lem of size discrepancy, Six patients are alive and well 10 to 27 mont hs (median 19) after operation, One patient with cystic fibrosis died of systemic aspergillosis infection, All were discharged from the hosp ital within the first or second postoperative month, No technical prob lems were identified: repeated bronchoscopy has demonstrated satisfact ory healing without early structure formation, All patients remain wel l subjectively with good exercise tolerance and all patients achieve g reater than 70% of predicted values of forced expiratory volume in 1 s econd, Perfect adaptation of the transplanted lobes to the recipient p leural space has been demonstrated by postoperative computed tomograph ic scan, In conclusion, bilateral lobar transplantation from a single donor lung is possible in small adults or children when there is a lar ge size discrepancy with the donor, This may help resolve the problem of donor availability in the pediatric population.