Pediatric lung transplantation and "lessons from green surgery"

During the past decade, lung transplantation has emerged as the definitive treatment for children with end-stage lung disease. Pediatric transplantati on presents unique challenges with respect to diagnostic indications, donor -recipient size disparities, perioperative management, and growth. Lessons from the early development of cardiac surgery at the University of Minnesot a (Green Surgical Service) provide a useful model for novel surgical challe nges. Since 1990, 25 lung transplantations have been performed at our insti tution, including 4 heart-lung, 3 single-lung, 17 bilateral-lung, and 1 liv ing-related lobar allograft. Age at transplantation ranged from 7 months to 27 years. The most common indication was cystic fibrosis. Given the limite d donor pool, size disparities between donor and recipient were frequent. E xcessive donor size was addressed by parenchymal reduction. Accommodation o f small donor allografts was facilitated by elective cardiopulmonary bypass and pulmonary vasodilation using inhaled nitric oxide. Epidural anesthesia was routinely used for postoperative pain management and to enhance good p ulmonary hygiene. Immunosuppression is presently achieved using cyclosporin e, mycophenolate mofetil, and corticosteroids. Monitoring for rejection is accomplished with spirometry and transbronchial biopsies. Bronchial complic ations in 2 patients required placement of Palmaz stents. The living-relate d allograft was performed in a previous bone marrow transplant recipient ob viating the need for longterm immunosuppression. The potential for growth o f mature lung parenchyma postoperatively was studied and verified in a shee p model. Our experience parallels that of other frontiers such as early car diac surgery in which medical and technologic innovations can be applied in a supportive environment to permit surgical progress. (C) 1999 by The Soci ety of Thoracic Surgeons.