Bilateral lung transplantation via two sequential anterolateral thoracotomies

Objective: Bilateral anterior trans-sternal thoracotomy (clam shell incisio n) is the standard approach used for bilateral sequential lung transplantat ion (BLTX). The morbidity of this large incision can he considerable, Two s eparate sequential anterolateral thoractomies represent a less invasive app roach. Methods: The value of this approach was investigated in a prospectiv e series of 22 consecutive patients who received BLTX between June 1997 and July 1998. Their underlying diseases were COPD (n = 16), cystic fibrosis ( n = 4) and other (n = 2). All patients underwent BLTX through two anterolat eral thoracotomies, without the use of cardiopulmonary bypass. The anterior mediastinum and the sternum with all the surrounding tissue were left comp letely intact. Twenty-one patients underwent spirometrical examination duri ng the postoperative in-hospital stay. Follow-up is 7 +/- 4 months (range: 3 to 15). Results: The only intraoperative complication was severe reperfus ion edema of the first transplanted lung seen in one patient at the end of the operation, which required pneumonectomy during the same session. All ot her operations were uneventful. The difference between the cold ischemic ti me of the first and second transplanted lung was 83 +/- 17 min. Median intu bation duration, ICU- and in-hospital-stay were 1.5, 5 and 20 days, respect ively (ranges: 1 to 96, 2 to 96 and 15 to 96, respectively). One major peri operative complication occurred and was due to gross donor/recipient size m ismatch: the patient required lobectomy of the consolidated right upper lob e 11 days after transplantation. In 19 patients (86.4%), this less extensiv e incision allowed early postoperative mobilization, which resulted in good ventilatory performance, with VC of 53 +/- 15 and FEV 1 of 60 +/- 20% of t he predicted, respectively, at the first spirometry, 3 weeks after the oper ation. Three months survival was 100%. Conclusion: The bilateral sequential anterolateral thoracotomy represents a safe and minimal invasive approach for BLTX compared with the clam shell incision. It minimizes the operative trauma, improves postoperative functional recovery and prevents the potenti al spread of unilateral complications to the other pleural cavity. (C) 1999 Elsevier Science B.V. All rights reserved.