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284 Lung transplantation
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INCISION
The bilateral trans-sternal anterior
8a,b
or the fifth interspace. The former is advantageous in patients with cystic fibrosis where particularly good access to the apices of the chest is
required. The internal mammary arteries are ligated and divided prior to sternal division to minimize bleeding. Once both pleural cavities have
been opened, twin child’s Finnochetto retractors
are placed, and the chest is easily opened.
thoracotomy is made at the fourth
8a
8b
Alternatively bilateral anterior thoracotomies without transverse sternal division may be
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9
performed. This approach eliminates the potential problems with sternal healing but does
not provide as good an exposure as is obtained with sternal division.
A thorough examination should be made of both pleural spaces and adhesions divided as far
as possible. For children or small adults, patients with pulmonary hypertension or where it is
local custom, cardiopulmonary bypass can be adopted at this stage. Cannulation is via the
ascending aorta and two separate caval cannulae. If a single atrial cannula is used, intermittent
and troublesome SVC obstruction may occur, while retracting the structures at the right hilum.
Operation 285
9
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Assuming the patient is stable and recourse to cardiopulmonary bypass is not anticipated, the right lung is deflated
and ventilation continued on the left side only. Structures of
the hilum are exposed and then divided; it is important to ligate the vessels relatively long so as to leave good sized stumps.
Intrapericardial dissection is avoided at this stage. The patient
can be tilted fairly steeply to the left side to improve access to
the right hilum. The inferior pulmonary ligament can be
divided by cautery, taking care to avoid the vagus nerve. The
bronchus is stapled some way out from the hilum to avoid
incorporation of the vagus nerve. Once the lung has been
removed, the hilum is prepared as for a single lung transplantation.
IMPLANTATION OF THE FIRST LUNG
The right donor lung is placed in the field, lying posteriorly
and surrounded in ice-cold saline-soaked swabs. After suitable suctioning by the anesthetist, the staple line on the right
main bronchus is amputated and hemostasis resecured.
Access to the back of the hilum after completing the anastomosis is awkward so there should be a meticulous search for
bleeding points at this stage.
The bronchus is anastomosed in a standard end-to-end
fashion as for a single lung transplantation. Side-biting
clamps are placed on the intrapericardial pulmonary veins
and on the pulmonary artery to allow appropriate anastomosis to be performed. After de-airing the lung (again as for the
single lung transplantation), the lung is cautiously reperfused. Ventilation of the transplanted site is commenced. The
bronchus is checked for air leaks and the rest of the hilum for
bleeding points. If donor lung selection has been careful and
preservation successful, the newly implanted lung readily
takes over the function when right-sided one-lung ventilation
is adopted.
IMPLANTATION OF THE SECOND LUNG
The patient is rolled steeply over on to the right side and the
pericardium retracted within the limits of hemodynamic stability. A similar left-sided pneumonectomy is performed, ligating and dividing the vascular structures and stapling the
bronchus at a convenient point. The left lung is removed
from the field; and again, great care is taken to avoid spilling
infected secretions. The pleural space is again irrigated with
an antiseptic solution. Left lung implantation is performed as
for the single lung transplantation starting with a bronchial
anastomosis, followed by pulmonary venous anastomosis
with a side-biting clamp on the pulmonary veins on the lefthand side and ending with the pulmonary artery anastomosis. Hemodynamic embarrassment is not uncommon during
the pulmonary venous anastomosis, and it may be necessary
to carry out the suture line in a series of stages, resting the
heart and the circulation after every few stitches. When the
implantation is complete, de-airing and reperfusion is performed as before, and both lungs can be ventilated.
Apical and basal chest drains are placed and the chest
closed in a standard fashion with three stainless steel wires to
the sternum, absorbable pericostal wires for pulling anterior
ribs together, and muscle and overlying skin closed with continuous absorbable sutures.
POSTOPERATIVE CARE
This care is broadly similar for the two types of transplantation although each can provide particular problems. After
returning to the intensive care unit, ventilation is continued
for at least several hours. Primary lung dysfunction, which
occurs in 10–20% of patients, may be evident even on the
operating table with frothy, proteinaceous secretions or over
the first few hours with the appearance of a pulmonary edema
picture on chest X-ray, increasing hypoxia, and decreased
compliance. Management is with the application of positive
end expiratory pressure and use of inhaled nitric oxide doses
up to 40 parts/million. The problem is more easily contained
in the bilateral lung transplantation recipient. Management is
much more difficult in the setting of a single lung and
obstructive disease because of the difficulty of applying positive end expiratory pressure without causing air trapping and
overdistension of the residual native lung. It may be necessary
to resort to split lung ventilation with a double-lumen tube,
ventilating the transplant vigorously and often leaving the
contralateral lung completely unventilated, merely insufflating oxygen to prevent a shunt.
Pain control is a major problem, and in bilateral lung
transplantation we use an opiate epidural for a minimum of 5
days. Epidural analgesia is also useful in the natural thoracotomy of a single lung transplantation although a paravertebral catheter, carefully placed before the chest is closed, can
give equivalent and excellent analgesia. Chest drains are left
for several days as a leak of fluid from the newly implanted
lung is always present at least partly because lymphatics have
been divided. Any air leak at this stage is almost invariably
from the lung parenchyma and should not cause concern
over integrity of the bronchial anastomosis.
Antibiotics are continued but for only a few days in the
“clean” setting of transplantation for obstructive or restrictive
disease. Patients with septic lung disease will require broader
spectrum and appropriately selected antibiotics. Information
from some of the donor airways’ secretions may prompt a
change of antibiotics and particularly the addition of antifungals if Candida species are present in the donor.
Immunosuppressants are obviously essential for the newly
implanted lungs. A standard regimen incorporates a calcineurin inhibitor such as cyclosporin or tacrolimus given
intravenously for 4 or 5 days together with a second line of
attack such as azathioprine or mycophenolate and supplemented by high dose steroids. This triple drug regimen has
toxicities to both the kidneys and the bone marrow; the former is a particular problem. A conflict exists between the
need to avoid overhydration in the setting of an invariably
damaged lung endothelium and combating overtoxicity with
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good renal perfusion. A compromise is often achieved by giving relatively low dose calcineurin inhibitors and use induction therapy with either a polyclonal antithymal cytoglobulin
(ATG) or one of the modern monoclonal IL2 receptor antagonists.
FURTHER READING
Cooper JD, Pearson FG, Patterson GA, et al. Technique of successful lung
transplantation in humans. Journal of Thoracic and Cardiovascular
Surgery 1987; 93: 173–81.
ISHLT International Guidelines for the selection of lung transplant
candidates. Journal of Heart and Lung Transplantation 1998;
17:703–9.
Patterson GA, Cooper JD, Dark JH, et al. Experimental and clinical
double lung transplantation. Journal of Thoracic and Cardiovascular
Surgery 1988; 95: 70–4.
Pasque MK, Cooper JD, Kaiser LR, Haydock DA, Triantafillou A, Trulock
EP. Improved technique for bilateral lung transplantation: rationale
and initial clinical experience. Annals of Thoracic Surgery 1990; 49:
785–91.
Sundaresan S, Trachiotis GD, Aoe M, Patterson GA, Cooper JD. Donor
lung procurement: assessment and operative technique. Annals of
Thoracic Surgery 1993; 56: 1409–13.
Wilson IC, Hasan A, Healy M, et al. Healing of the bronchus in
pulmonary transplantation. European Journal of Cardiothoracic
Surgery 1996; 10: 521–7.
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Thoracic outlet syndromes
HAROLD CLIFTON URSCHEL, JR. MD
Chair; Cardiovascular and Thoracic Surgical Research, Education and Clinical Excellence, Baylor University Medical Center, Professor of
Cardiothoracic Surgery (Clinical), University of Texas Southwestern Medical Center at Dallas Southwestern Medical School, Dallas, Texas, USA
HISTORY
Clinical manifestations of thoracic outlet syndromes have
afflicted humankind since prerecorded history. One of the
first cases is described in Genesis 22:1. Abraham was planning
to sacrifice his son Isaac to prove his devotion to God. As
Abraham raised the knife, an angel of the Lord came to him
and with omnipotent compassion created an ‘acute thoracic
outlet syndrome,’ causing Abraham’s arm to become numb
and weak. He dropped the knife, thus sparing Isaac and forever ending human sacrifice in the Judeo-Christian religions.
The earliest recorded reference to thoracic outlet syndrome
was the anatomical recognition of cervical ribs by Galen and
Vesalius. The first scientific study reported in the modern literature was in 1740 by the German anatomist Hunauld. Sir
Astley Cooper in 1821 was the first to describe symptoms of
vascular compression from a cervical rib.
Paget in 1875 in London and von Schrötter in Vienna in
1874 independently described thrombosis of the axillary subclavian vein in the area of the thoracic outlet. The occlusion
of the vein today is called the Paget-von Schrötter syndrome or
effort thrombosis.
The term thoracic outlet syndrome was first used by Peet in
1956. The purpose of using a single term to encompass the
various anatomical abnormalities such as the scalenus anticus, costoclavicular, and neurovascular compression syndromes was to promote simplification, particularly when the
abnormalities produced similar symptoms. The first rib was
recognized as the ‘common denominator’ against which the
axillary subclavian artery and vein or brachial plexus was
compressed by a variety of muscles, ligaments, or bone structures.
In 1962, O. T. Claggett in his presidential address to the
American Association of Thoracic Surgery presented the posterior high thoracoplasty approach for removal of the first rib
in thoracic outlet syndrome. In 1966, Roos described the
transaxillary approach following the technique of Atkins and
Palumbo for transaxillary sympathectomy. Neurophysiological testing was initiated by Caldwell, Krusen, and Crane
in the 1960s and reported in 1968. They measured nerve conduction velocities across the outlet in the median, ulnar, and
musculocutaneous nerves. To perform reoperations for
recurrent thoracic outlet syndrome, Urschel and Razzuk recommended the posterior ‘high thoracoplasty’ approach.
Thoracic outlet syndrome masquerading as coronary artery
disease (‘pseudo’ angina) was described by Urschel et al. in
1973.
A 50-year experience of over 5 000 cases of thoracic outlet
syndrome coming to surgery was presented by Dr. Urschel to
the American Surgical Association in 1998, summarizing the
changes in diagnosis and management of that disease process
over half a century.
PRINCIPLES AND JUSTIFICATION
Indications for surgery include the failure of conservative
measures to attenuate the symptoms caused by nerve compression after a 3-month period and the presence of prolonged conduction velocities in the ulnar or median nerve.
Other surgical indications include (1) the presence of atypical
chest pain unrelieved by conservative management (not
related to coronary artery, esophageal, or pulmonary pathological conditions); (2) the presence of hypersympathetic
activity; (3) the narrowing or occlusion of the axillary subclavian artery with or without peripheral emboli; and (4) thrombosis of the axillary subclavian vein (Paget-von Schrötter
syndrome, effort thrombosis).
For nerve compression, the preferred initial surgical proce-
dure is the transaxillary approach for first rib resection, with
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decompression of the axillary subclavian artery and vein as
well as the brachial plexus. In contrast to the supraclavicular
approach, the transaxillary approach allows the first rib to be
removed, the scalene muscles divided and resected if necessary, and the outlet decompressed with minimal risk to the
critical neurovascular structures that lie away from the first
rib. Removing the rib completely is particularly important to
minimize recurrence of the symptom complex as a result of
regeneration of bone or fibrocartilage from an incompletely
removed stump or rib remnant. To remove the first rib completely using a supraclavicular approach, the brachial plexus
and neurovascular structures must be retracted, which is a
situation that results in a higher complication rate.
For recurrent thoracic outlet syndrome after either primary transaxillary or supraclavicular operations, the posterior ‘thoracoplasty’ operation provides a safer approach and
better access for removing bone remnants and scar from the
brachial plexus and subclavian vessels. This approach also
allows dorsal sympathectomy to be performed for causalgia
and sympathetic maintained pain syndrome.
For arterial reconstruction, the combined supraclavicularinfraclavicular approach is often used when bypass grafts are
necessary for either occlusion or aneurysm. For venous
occlusion (Paget-von Schrötter syndrome), the ideal management combines clot lysis with administration of urokinase
through a catheter, followed by prompt decompression of the
thoracic outlet by transaxillary resection of the first rib.
Prolonged delay of clot lysis markedly increases morbidity,
and failure to perform prompt first rib resection and thoracic
outlet decompression leads to extremely high rates of recurrence. Compression and sympathetic nerve hyperactivity not
relieved by medical therapy should be treated by dorsal sympathectomy, usually performed in conjunction with resection
of the fist rib through the same exposure.
OPERATION
First rib resection: transaxillary approach
The incision is transaxillary below the hairline and
1a
eriorly and the latissimus dorsi muscle posteriorly. The incision is carried directly to the chest wall without angling up
toward the first rib. When the chest wall is encountered, the
dissection is carried superiorly to the first rib, with identification of the intercostal brachial nerve that exits between the
first and second ribs. This nerve is preserved by retracting it
anteriorly or posteriorly. Division produces 6 months to 1
year of paresthesia on the inner surface of the upper arm. The
first rib is dissected subperiosteally with a Shaw-Paulson
periosteal elevator, and the scalenus anticus muscle is identified. A right-angle clamp is placed behind the muscle, with
care taken not to injure the subclavian artery or vein. The
scalenus anticus muscle is divided near its insertion on the
first rib. This step avoids injury to the phrenic nerve, which
courses away from the muscle at this level.
transverse between the pectoralis major muscle ant-
1a
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After the scalenus anticus muscle is divided, the first
1b
from the pleura. A triangular piece of the rib is removed in
the avascular plane. The apex of the triangle removed is at the
scalene tubercle. The anterior part of the rib is removed by
dividing the costoclavicular ligament and resecting the rib
subperiosteally back to the costicartilage of the sternum.
rib is dissected free subperiosteally and separated
1b
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The posterior part of the rib is dissected sub-
1c
divided by a pair of rib shears. The rib may be resected posteriorly with an Urschel-Leksell reinforced rongeur. Care is
taken to avoid injury to the C8 and T1 nerve roots as the
scalenus medius muscle is dissected from the rib.
periosteally to the transverse process, where it is
1c
After the transverse process articulation is visualized,
1d
Urschel reinforced pituitary rongeur. Removing the complete
head and neck of the rib is important to minimize regeneration. Care is taken not to injure the T1 nerve root below nor
the C8 nerve root above. After the complete removal of the
first rib, neurolysis of the C7, C8, and T1 nerve roots as well
as the middle and lower trunks of the brachial plexus is performed. A video thoracoscope is used for this purpose
because of its magnification and light. The scalenus medius
and scalenus anticus muscles are resected up into the neck so
that they will not reattach to the Sibson’s fascia or the pleura.
Bands and adhesions are removed from the axillary-subclavian artery and the axillary-subclavian vein so that they are
completely free. Hemostasis is secured.
the head and neck of the rib are removed with an
1d
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First rib resection: posterior approach
In the posterior approach, the patient is placed in the
2a
side. The upper arm is placed as for a thoracotomy. An incision of approximately 6 cm is made with the midpoint at the
angle of the scapulae halfway between the scapula and the
spinous process. The incision is carried through the skin and
subcutaneous tissue down to the trapezius muscle. The
trapezius and rhomboid muscles are split.
lateral position with an axillary roll under the ‘down’
2a
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