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The utility of thoracic organ transplantation for end-stage lung disease was not realized until the development of cyclosporine in the 1980s. In the preceding decades (1963–1983), fewer than 50 lung transplants were performed worldwide, and no recipient survived for more than 10 months. Early lung transplants failed for four principal reasons: nonfunction of the primary graft, dehiscence of the bronchial anastomosis, acute lung rejection, and pneumonia. Developments in surgical technique, perioperative care, and immunosuppressive drugs culminated in the first successful long-term lung transplant, which was reported by Cooper and colleagues in 1987 in a patient with idiopathic pulmonary fibrosis.1 The technical highlights of this operation included the concept of using an omental wrap around the bronchial anastomosis to restore bronchial artery circulation and prevent dehiscence, careful patient selection, and effective long-term immunosuppression with cyclosporine. Shortly thereafter, Patterson and colleagues performed the first successful double-lung transplant in a patient with emphysema2 (Fig. 94-1).

Figure 94-1.

Four categories of lung transplant: single-lung transplant, double-lung transplant, bilateral heart-lung transplant, and lobar lung transplant including the living-related donor.

As the discipline matured, the application of these surgeries changed based on disease-specific factors. Single-lung and double-lung transplantations are the current mainstays of treatment for end-stage pulmonary disease. Combined heart-bilateral lung transplantation for multiple-organ failure in patients with primary pulmonary disease was once a more common surgery until it was observed that transplanting lungs earlier rather than later in these patients could prevent cardiac failure. Heart-bilateral lung transplantation is now reserved for patients with other coexisting primary pulmonary and cardiac diseases, primarily of a congenital nature. The number of heart-lung transplantation procedures has declined over the years; however, new indications continue to arise for select patients. Despite the overall feasibility of thoracic organ transplant, its use continues to be limited by the number of available donor organs, the morbidity of mandatory lifelong immunosuppression, and the apparent biologic incompatibility of host and allograft.

Lung transplantation entails the replacement of a native diseased lung with a cadaver lung (see Chap. 95) or lobar transplant from a living-related donor(s) (see Chap. 96). All adult lung transplants are orthotopic procedures. For most septic diseases and certain pulmonary hypertensive disorders, the extent of disease mandates a bilateral lung transplant. In 2004, 1188 lung transplants were performed in the United States. The number of double-lung transplants was virtually equal to single-lung transplants and has continued to increase annually.3 During this same interval, heart-bilateral lung transplants numbered only 31.4

Lung transplantation surgery involves three major anastomoses: (1) bronchial, (2) pulmonary artery, and (3) atrial. The bronchial anastomosis is associated with the highest complication rate (3–6%)5 compared with atrial and arterial anastomoses (<1%, respectively). Complications of bronchial anastomosis include dehiscence and stricture. If there is breakdown of the anastomosis, it usually occurs within several weeks of transplantation. Airway obstruction secondary to stricture or malacia manifests within several months. A common area for additional stricture is the postanastomotic donor bronchus. The tissue here is relatively ischemic and remains so for several weeks. Short donor bronchi and overlapping donor/recipient bronchi are techniques used to lessen this area of ischemic injury.

It is interesting to note that certain pulmonary structures (e.g., bronchial and lymphatic vessels) are not reanastomosed after implantation. The bronchial circulation ...

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