Effect of cardiopulmonary bypass on regional antibiotic penetration into lung tissue.

The use of cardiopulmonary bypass (CPB) during cardiac surgery causes regional ventilation-perfusion mismatch, contributing to regional disturbances in antibiotic penetration into lung tissue. Ventilation-perfusion mismatch is associated with postoperative pneumonia, a frequent and devastating complication after cardiac surgery. In this prospective clinical animal study, we performed in vivo microdialysis to determine the effect of CPB on regional penetration of levofloxacin (LVX) into lung tissue. Six pigs underwent surgery with CPB (CPB group), and another six pigs underwent surgery without CPB (off-pump coronary artery bypass grafting; OPCAB group). LVX (750 mg) was administered intravenously to all pigs immediately after surgery. For regional measurements of LVX in pulmonary concentrations, microdialysis probes were inserted in both lungs of each pig. Pigs were placed in the right lateral position. Time versus concentration profiles of unbound LVX were measured in the upper and lower lung tissue and plasma in all pigs. In all pigs, maximum concentrations (Cmax) of LVX were significantly lower in the upper lung than in the lower lung (OPCAB, P = 0.035; CPB, P < 0.001). Median Cmax of LVX showed a significant difference in the upper versus lower lung in the CPB group (P < 0.05). No significant difference was found in the median Cmax of LVX in the upper and the lower lung in the OPCAB group (P = 0.32). Our data indicate that CPB affects perioperative regional antibiotic penetration into lung tissue. Common clinical antibiotic dosing schemes should be reevaluated in patients undergoing coronary artery bypass grafting with CPB.

Monitoring C2 level predicts exposure in maintenance lung transplant patients receiving the microemulsion formulation of cyclosporine (Neoral).

BACKGROUND: Dosing of the microemulsion formulation of cyclosporine (Neoral) is conventionally based on trough levels (C(0)). However, experience in renal transplantation has shown that cyclosporine exposure during the absorption phase (AUC(0-4)) is critical for optimizing immunosuppression, and that cyclosporine (CsA) concentration at 2 hours post-dose (C(2)) shows the closest correlation with AUC(0-4). This study evaluated whether C(2) values correlate more closely with AUC(0-4) than C(0) in lung transplant patients. METHODS: Pharmacokinetic data were collected prospectively from 20 clinically stable adult lung allograft recipients receiving CsA, mycophenolate mofetil and steroids. Indications for transplantation were emphysema (n = 15), idiopathic fibrosis (n = 2), primary pulmonary hypertension (n = 1), cystic fibrosis (n = 1) and lymphangioleiomyomatosis LAM (n = 1). Blood samples were collected at 0, 1, 2, 3 and 4 hours after administration of CsA, and then AUC(0-4) was calculated. The Correlation between cyclosporine concentration at each time-point and AUC(0-4) was also calculated. RESULTS: C(2) showed the closest correlation with AUC(0-4) (r(2) = 0.85). C(0) had the poorest correlation of all time-points (r(2) = 0.64). Two patients with radiologic signs of gastroparesis had no peak cyclosporine levels at all and were excluded from the correlation analysis. Mean AUC(0-4) was 3,700 ng . h/ml during Year 1 post-transplant, 2,400 ng . h/ml during Years 1 to 3, and 1,500 ng . h/ml thereafter. Mean C(2) values were 1.2 microg/ml during Year 1, 0.8 microg/ml during Years 1 to 3, and 0.5 microg/ml thereafter. CONCLUSIONS: C(2) is the single time-point that correlates most closely with AUC(0-4) in lung transplant recipients without gastroparesis. It remains to be demonstrated whether monitoring CsA based on C(2) levels results in a lower incidence of rejection without additional toxicity.

Size-reduced lung transplantation: an advanced operative strategy to alleviate donor organ shortage.

BACKGROUND: The increasing need for donor lungs, especially for small and pediatric recipients, has not been matched by an adequate supply. This disparity has stimulated the development of new operative techniques, which allow downsizing of larger lungs for use in smaller recipients, thus potentially expanding the donor pool. This approach has recently gained more widespread use, especially for highly urgent recipients; however, is still not considered a standard procedure. PATIENTS AND METHODS: All primary size-reduced lung transplants performed from January 2001 to December 2003 were retrospectively reviewed. Downsizing was achieved by either split-lung transplantation, lobar transplantation, or by means of a peripheral wedge resection. Waiting list time, perioperative complications, and outcomes of those patients were compared to patients undergoing primary standard single or double lung transplantation during the observation period. RESULTS: Among 163 primary lung transplantations 51 (31.3%) were size-reduced procedures. Size reduction was achieved by lobar transplantation (n = 18), split-lung transplantation (n = 2), or peripheral segmental resection (n = 31). There was a slightly decreased waiting time among the size-reduced group (74 +/- 72 vs 98 +/- 90 days, P = .13). No statistically significant difference between the size-reduced and the standard lung transplantation group was evident with regard to the rate of bronchial healing problems (n = 3/9; P = .62) or the rate of revision due to postoperative bleeding (n = 6/15; P = .77). No other major thoracic surgical complications were observed. The 3-month survival rate was 86.3% in the size-reduced 92.0% in the standard group (P = .09). CONCLUSION: Size-reduced lung transplantations, including split-lung transplantation, lobar transplantation, and peripheral segmental resection, may be considered reliable procedures that provide results comparable to standard lung transplantation. It allows the use of oversized grafts for small and pediatric recipients and the use of single lobes if localized pathologies exist, thus enlarging the donor pool and potentially helping to reduce waiting times and waiting list mortality.

[The influence of major connectors of partial dentures of phonation: an instrumental analysis of speech]. / Der Einfluss der grossen Verbinder von zahnärztlichen Teilprothesen auf die Lautbildung. Eine instrumentalphonetische Untersuchung

After the insertion of removable dentures for restoring partially edentulous arches, phonation is affected by many factors, of which many influences are not completely understood. The aim of this study was to investigate the influence of various construction elements of maxillary and mandibular partial dentures on the formations of plosives, nasals, lateral approximates and fricatives. Twenty-four patients were included in the study. For each patient five different test dentures were constructed. Over a period of 24 h, six digital tape records were made for each patient. By this time, the patient had worn the dentures maximally 6 h. With the help of a computer-supported frequency analysis based on the principle of fast Fourier transformation (FFT), it was possible to demonstrate the differences in phonation in regard to denture design. During the test period, the patients were asked to fill in a questionnaire on denture comfort and phonation. This study also quantifies the influence of the sublingual bar on phonation. It can be assumed that the speaker tries to retain his habitual way of articulation despite the inserted test denture. Therefore, a phonation test immediately after insertion of a new constructed partial denture should be interpreted with caution because of the assumed compensation process. The results of this study could have consequences for dental therapy plans.

Initial experience with lung transplantation in Slovakia--an example for successful bilateral cooperation between countries.

OBJECTIVE: To review initial experiences, results of single lung transplantation (SLT) and double lung transplantation (DLT) on the basis of bilateral cooperation between Slovakia and Austria. PATIENTS AND METHODS: During the period between July 1998 and January 2003 ten patients from Slovakia underwent lung transplantation in Vienna, Austria. There were 7 males and 3 females with an age range from 21 to 48 years. Eight patients underwent double lung transplantation, two patients had single lung transplantation. Indications were: pulmonary fibrosis in 2, cystic fibrosis in 2, emphysema in 2, primary pulmonary hypertension (PPH) in 4 cases. In the PPH patients (n = 4) and in the patients with cystic fibrosis (n = 2), bilateral lung transplantation under ECMO support was performed. One patient (n = 1) with postradiative pulmonary fibrosis and intracardial myxoma underwent bilateral lung transplantation under cardiopulmonary bypass. Only three patients (e.i. the two with emphysema and one with pulmonary fibrosis) underwent lung transplantation without any intraoperative circulatory support. RESULTS: No perioperative mortality was recorded. Two patients died in late postoperative period: one due to multiorgan failure on 93rd day after DLT, the other one--on a liver failure caused by cirrhosis after 2.5 years after LTX. All the remaining eight patients, but the two ones who underwent LTX several days ago, are with improved functional status in full work activity. The follow up period for all patients ranges between 10 days and 54 months. CONCLUSION: Both unilateral and bilateral lung transplantations are accepted treatment modalities in patients with end-stage pulmonary disease. Bilateral cooperation for such countries as Slovakia (with limited possibilities) offers a unique example of possible and successful way how to deal with such demanding procedures. (Tab. 3, Fig. 2, Ref. 19.).

Single running suture--the new standard technique for bronchial anastomoses in lung transplantation.

OBJECTIVE: The aim of this retrospective study is to assess the results of a single running suture technique for bronchial anastomoses in lung transplantation. In a previous pilot study, equal results compared to the established standard technique --using single stitches on the cartilaginous part--have been described by our group. This report reviews the results obtained over a period of 3 years. METHODS: Between January 1999 and December 2001, 154 consecutive lung transplantations (91 bilateral sequential, 35 right single lung and 28 left single lung) were performed in 141 patients using single running sutures for bronchial anastomoses. Thirteen transplantations (25 anastomoses) were performed in lobar or split lung technique. Bronchial healing was assessed at routine bronchoscopes performed in increasing time intervals from 7 days to 1 year postoperatively and depending upon clinical necessity. RESULTS: Six patients (4.2%) died earlier than 7 days postoperatively and were excluded from further analysis. No bronchial complication was observed in any of them. Three months and 1-year survival rates were 82.9 and 72.7%, respectively. Two hundred and thirty-four anastomoses were subjected to examination. Mean ischemic time was 5.1h (+/-1.5). In 228 anastomoses (97.4%), excellent primary airway healing was observed. In four anastomoses (1.7%), small healing defects less than 5mm without necessity for intervention were detected. Two anastomoses (0.9%) developed a cicatriceal stenosis requiring intraluminal stenting. CONCLUSIONS: The single running suture technique for bronchial anastomoses in lung transplantation provides excellent results with regard to primary and long-term airway healing and its use as a standard suturing technique is, therefore, recommended.

[Bronchial anastomoses after lung transplantation: results with single running suture technique]. / Bronchialanastomosen nach Lungentransplantation: Ergebnisse mit fortlaufender Naht.

BACKGROUND: The standard technique for the bronchial anastomosis in LTX is a running suture on the membranous and single stitches on the cartilaginous portion of the bronchus. The aim of this retrospective study was to compare the results of this technique to the new single running suture technique. METHODS: Between January and December 1998, 56 consecutive single (n = 17) and bilateral (n = 39) lung transplants in 52 patients were performed. Eighty-three bronchial anastomoses were retrospectively analyzed and evaluated by separating into two groups: group 1 (24 patients, 39 anastomoses) with standard technique and group 2 (24 patients, 44 anastomoses) with single running suture. The two groups were comparable with regard to age, primary diagnosis, intraoperative use of extracorporeal circulation, ischemia time, duration of mechanical ventilation, ICU and number of acute rejections/100 days. Bronchial healing was assessed with bronchoscopic follow-up (5-16 months). RESULTS: Primary excellent airway healing was observed in 36 anastomoses (92%) in group 1 and in 41 (93%) in group 2. In 2 anastomoses in group 1 (5%) and in 2 anastomoses in group 2 (4.6%) necrosis less than 5 mm was observed. In one anastomosis in group 1 (2.7%) a 10-mm bronchial necrosis with partial occlusion of the bronchial lumen by necrotic tissue necessitated temporary intraluminal stenting. In one anastomosis in group 2 (2.3%) malacia of the bronchus intermedius occurred. CONCLUSION: The single running suture technique for bronchial anastomosis is a safe technique providing the same results as the established technique and we advocate its use for bronchial anastomosis.

Tacrolimus versus cyclosporine after lung transplantation: a prospective, open, randomized two-center trial comparing two different immunosuppressive protocols.

BACKGROUND: The need for better immunosuppressive protocols after lung transplantation led us to investigate tacrolimus (Tac) in combination with mycophenolate mofetil (MMF) and steroids or cyclosporine (CsA) in combination with MMF and steroids in a prospective, open, randomized trial after lung transplantation. METHODS: Between September 1997 and April 1999, 50 lung transplant recipients were randomized to receive either Tac (n = 26) or CsA (n = 24) in combination with MMF and steroids. All patients underwent induction therapy with rabbit antithymocyte globulin (ATG) for 3 days. Freedom from acute rejection (AR), patient survival, infection episodes, and side effects were monitored. RESULTS: There was no difference in patient demographics between the two groups. Six-month and 1-year survival was similar (84.6% and 73.1% in the Tac group vs 83.3% and 79.2% in the CsA group). Freedom from AR at 6 months and 1 year after lung transplantation was slightly higher in the Tac group (57.7% and 50% vs 45.8% and 33.3%, p = not significant [n.s.]), whereas the number of treated rejection episodes per 100 patient days in the Tac group was significantly lower (0.225 vs 0.426, p < .05). Four patients in the CsA group had to be switched to Tac. Two patients in the CsA group had to be retransplanted. Incidence of infections was similar in both groups with a trend toward more fungal infections in the Tac group (n = 7 vs n = 1, p = n.s.). CONCLUSIONS: The combination of Tac and MMF seems to have slightly higher immunosuppressive potential compared with CsA and MMF. The effectiveness of Tac as a rescue agent is not paralleled with undue signs of overimmunosuppression.

Continuous beta-lactam antibiotic therapy in a double-lung transplanted patient with a multidrug-resistant Pseudomonas aeruginosa infection.

BACKGROUND: It is well known that the bactericidal effect of beta-lactam antibiotics is closely related to the time which the serum concentration of the antibiotic remains above the minimal inhibitory concentration of the target pathogen. Thus, the optimal administration of beta-lactam antibiotics would be the continuous infusion of the drug. METHODS: We present a case report with a critically ill double-lung transplanted patient with pneumonia due to a multidrug-resistant Pseudomonas aeruginosa who received continuously 8 g meropenem/24 hr. Based on a previous pharmacokinetic study showing that continuous infusion of meropenem is at least equivalent to intermittent administration this case report is reported to demonstrate the clinical efficacy of continuous infusion. RESULTS: C-reactive protein and pneumonia decreased rapidly when clinical conditions were improved significantly. Continuous administration of meropenem did not interfere with cyclosporine, no side effects were seen, and the patient's renal function was not impaired during the whole period of treatment. CONCLUSION: The continuous administration of beta-lactam antibiotics is a powerful application in critically ill patients to intensify antimicrobial therapy.

The effects of thoracic epidural analgesia with bupivacaine 0.25% on ventilatory mechanics in patients with severe chronic obstructive pulmonary disease.

UNLABELLED: Optimal analgesia is important after thoracotomy in pulmonary-limited patients to avoid pain-related pulmonary complications. Thoracic epidural anesthesia (TEA) can provide excellent pain relief. However, potential paralysis of respiratory muscles and changes in bronchial tone might be unfavorable in patients with end-stage chronic obstructive pulmonary disease (COPD). Therefore, we evaluated the effect of TEA on maximal inspiratory pressure, pattern of breathing, ventilatory mechanics, and gas exchange in 12 end-stage COPD patients. Pulmonary resistance, work of breathing, dynamic intrinsic positive end-expiratory pressure, and peak inspiratory and expiratory flow rates were evaluated by assessing esophageal pressure and airflow. An increase in minute ventilation (7.50 +/- 2.60 vs 8.70 +/- 2.10 L/min; P = 0.04) by means of increased tidal volume (0.46 +/- 0.16 vs 0.53 +/- 0.14 L/breath; P = 0.003) was detected after TEA. These changes were accompanied by an increase in peak inspiratory flow rate (0.48 +/- 0.17 vs 0.55 +/- 0.14 L/s; P = 0.02) and a decrease in pulmonary resistance (20.7 +/- 9.9 vs 16.6 +/- 8.1 cm H(2)O. L(-1). s(-1); P = 0.02). Peak expiratory flow rate, dynamic intrinsic positive end-expiratory pressure, work of breathing, PaO(2), and maximal inspiratory pressure were unchanged (all P > 0.50). We conclude that TEA with bupivacaine 0.25% can be used safely in end-stage COPD patients. IMPLICATIONS: Thoracic epidural anesthesia with bupivacaine 0.25% does not impair ventilatory mechanics and inspiratory respiratory muscle strength in severely limited chronic obstructive pulmonary disease patients. Thus, thoracic epidural anesthesia can be used safely in patients with end-stage chronic obstructive pulmonary disease.

Is long-term functional outcome after lung volume reduction surgery predictable?

OBJECTIVE: The aim of this retrospective study was to analyze which preoperative parameters might predict a persistent improvement in forced expiratory volume in 1 s (FeV1) 1 year after surgery. METHODS: Seventy consecutive lung volume reduction surgery (LVRS) patients (age, 56.5+/-1.2 years) with a follow-up period of at least 1 year were analyzed (from September 1994 to September 1997). The patients were described by lung function tests, blood gas analysis, ventilatory mechanics (intrinsic positive endexpiratory pressure (PEEP)) and morphometric data (degree of heterogeneity, DHG; degree of hyperinflation, DHI; severity of parenchymal destruction, SPD) preoperatively. Based on the postoperative course of FeV1 (percentual increase compared with preoperative values, % increase), patients were divided into four groups: group A, (n=21) no improvement (FeV1/=20% increase, which declined to preoperative values after 1 year; group C, (n=18) FeV1, 20-40% increase, sustaining at 1 year; group D, (n=21) FeV1>/=40% increase, sustaining at 1 year. The statistics comprised of analysis of variance (ANOVA) and chi-square testing, with values presented as means+/-SEM. RESULTS: No differences were found for lung function parameters (FeV1: 27.7+/-2.7, 26.0+/-2.5, 23. 9+/-2.2 and 23.9+/-1.9% predicted, in groups A, B, C and D, respectively). Arterial blood gas levels preoperatively revealed significant differences between the groups; the arterial pO(2) was 66.2+/-1.2 mmHg in groups A+B compared with 61.8+/-1.5 mmHg in groups C+D (P=0.030). The arterial pCO(2) was 39.2+/-1.1 mmHg in groups A+B compared with 43.3+/-1.5 mmHg in groups C+D (P=0.038). The morphometric data had a strong trend towards higher heterogeneity in groups C and D. Marked DHI was found in 59 and 81% of patients in groups A+B versus C+D, respectively (P=0.121). Marked DHG was present in 22 and 54% of patients in groups A+B versus C+D, respectively (P=0.010). CONCLUSION: Preoperative arterial pO(2) and pCO(2), and the DHG are predictors for long-term benefit after LVRS with regard to the FeV1, 1 year postoperatively.

Lung transplantation following lung volume reduction surgery.

OBJECTIVE: Lung volume reduction surgery (LVRS) has been proposed as a possible alternative treatment to lung transplantation (LTX) for selected patients with end-stage emphysema. But whether LVRS is a temporary or permanent alternative to LTX is still under investigation. The aim of this study was to analyze the course of patients undergoing LVRS followed by subsequent LTX. METHODS: Fifteen patients (10 male, 5 female, mean age 53.3 +/- 1.7 years) out of 102 patients, who underwent LVRS between September 1994 and August 1998, underwent LTX 19.6 +/- 3.1 months after LVRS (range 1.7 to 37.6 months) between June 1996 and October 1998. In 9 patients bilateral LVRS was performed, in 6 patients unilateral LVRS. Subsequent LTX was performed bilaterally in 10 patients and unilaterally in 5 patients (1 of these on the contralateral side) to the previous LVRS. The course of lung function and clinical outcome were analyzed in these 15 patients. RESULTS: Mean forced expiratory volume in 1 second (FEV(1)) in the 15 patients prior to LVRS was 18.3 +/- 1.2% of predicted (%p) and increased to 27.0 +/- 2.9 %p (best value within the first 6 months postLVRS) (p = 0.043). In 8 of these patients (non-responders) (53%) LVRS failed to improve FEV(1), whereas in the other 7 patients (responders) (47%) a significant improvement was detected (FEV(1) 18.1 +/- 1.8 %p and 31.9 +/- 3.7 %p, pre- and post-LVRS, respectively, p = 0.003), but declined after 6 to 36 months. At the time of listing for LTX the mean FEV(1) was 18.0 +/- 1.9 %p (no difference between the 2 groups). LTX was performed 15.5 +/- 3.6 months (non-responders) and 25.7 +/- 4.6 months (responders) after LVRS. FEV(1) improved to 81.0 +/- 5.6 %p after LTX (p < 0.001 compared to pre-LTX). The mortality after LVRS was 0%. The 3-month mortality after LTX was 20% (1 patient with primary organ failure, 1 patient with ongoing rejection, 1 patient with sepsis). All 3 patients belonged to the group of nonresponders. Two patients died 5. 5 and 8.5 months after LTX (13.3%) due to fungal infection (Aspergillus spp.) and MRSA sepsis, respectively (1 non-responder, 1 responder). CONCLUSIONS: Successful LVRS delays the need for LTX and offers better conditions for LTX. However, patients without functional improvement after LVRS have a high perioperative risk at subsequent LTX.

Buttressing the staple line in lung volume reduction surgery: a randomized three-center study.

BACKGROUND: The intention of buttressing the staple line in lung volume reduction surgery is to reduce air leaks and to shorten the hospital stay. A randomized three-center study was carried out to test this hypothesis. METHODS: Sixty-five patients with a mean age of 59.2 +/- 1.2 years underwent bilateral lung volume reduction surgery by video-assisted thoracoscopy using endoscopic staplers (ET 45B; Ethicon Endo-Surgery, Cincinnati, OH) either without or with bovine pericardium for buttressing (Peri-Strips Dry; Bio-Vascular, Inc, Saint Paul, MN). There were no differences between the control and treatment groups in lung function, degree of dyspnea, and arterial blood gases before and 3 months after LVRS. RESULTS: Seven patients (3 in the treatment group) needed a reoperation because of persistent air leak. The median duration of air leaks was shorter in the treatment group (0.0 day [range, 0 to 28 days versus 4 days [range, 0 to 27 days); p < 0.001), confirmed by a shorter median drainage time in this group (5 days [range, 1 to 35 days] versus 7.5 days [range, 2 to 29 days); p = 0.045). Hospital stay was comparable between the two groups (9.5 days [range, 6 to 44 days] versus 12.0 days [range, 5 to 46 days]; p = 0.14). CONCLUSIONS: Buttressing the staple line significantly shortens the duration of air leaks and the drainage time. As hospital stay did not differ significantly between the two groups, cost-effectiveness may depend on the local situation.

Neural drive to the diaphragm after lung volume reduction surgery.

STUDY OBJECTIVES: The aim of this study was to investigate prospectively the changes in neural drive to the diaphragm in the first year after lung volume reduction surgery (LVRS) in patients with COPD. PATIENTS AND METHODS: In 14 patients with severe emphysema (mean +/- SD; age, 53.7 +/- 8.3 years; FEV(1), 0.64 +/- 0. 18 L; residual volume [RV], 5.33 +/- 1.25 L; PaO(2), 62.3 +/- 9.0 mm Hg; PaCO(2), 39.0 +/- 6.0 mm Hg), we assessed lung function, arterial blood gases, maximal exercise capacity (Wmax), and oxygen uptake (f1.gif" BORDER="0">O(2)max); intrinsic positive end-expiratory pressure (PEEPi); diaphragmatic strength (transdiaphragmatic pressure, Pdisniff) and endurance capacity (tlim); central diaphragmatic drive assessed by root mean square analysis of the esophageal electromyogram (rmsdia); and isotime dyspnea during loaded breathing tests (BS). RESULTS: Despite a significant increase (expressed as a percentage of baseline) in FEV(1) (40.6%) and a decrease in RV (30.0%) and PEEPi (75.7%) 1 month after LVRS, the improvements in Wmax (31.2%) and f1.gif" BORDER="0">O(2)max (13.7%); Pdisniff (25.4%) and tlim (64.9%); rmsdia (34.6%); and BS (21.7%) did not reach statistical significance (p < 0.05) until 6 months after LVRS. Arterial blood gases did not change significantly. Significant correlations were found between decrease in rmsdia and changes in PEEPi (r = 0.69), Wmax (r = -0.56), Pdisniff (r = -0.65), tlim (r = -0.59), and BS (r = 0.71) 6 months after LVRS. CONCLUSIONS: Our results show that LVRS is able to increase the efficacy of the respiratory pump and by this way reduce ventilatory drive and respiratory effort sensation.

[Results of lung-volume reduction surgery in end-stage lung emphysema]. / Ergebnisse der lungenvolumenreduzierenden Operation bei diffusem Lungenemphysem.

BACKGROUND: Surgical treatment of diffuse, nonbullous emphysema was first described by Brantigan et al. in 1957 and was reintroduced by Cooper et al. in 1995 as lung-volume reduction surgery (LVRS). Meanwhile it has become an internationally established procedure in the treatment of lung emphysema. We report our results after LVRS in 91 patients. METHODS: Between September 1994 and August 1998 LVRS was performed through median sternotomy (n = 15), videoendoscopy (n = 49), thoracotomy (n = 18) or combined video endoscopy on one side and thoracotomy on the other (n = 9) in 91 patients (aged 33-80 years; mean 56,4 years). All patients showed progression of severe dyspnea despite maximum medical and physical therapy. RESULTS: Perioperative mortality was 5.5 % (5 patients). Seventy-five percent of the patients showed significant functional improvement [postoperatively above 120 % of the preoperative forced expiratory volume in 1 s (FeV1)]. Mean FeV1 significantly increased by 28.6 % from 25.5 +/- 1.2 % predicted (% p) preoperatively to 32.8 +/- 1.9 % p during the first 6 months postoperatively (p < 0.005). Furthermore, the mean RV was reduced from 320.3 +/- 7.9 % p preoperatively to 248.4 +/- 7.5 % p 6 months postoperatively and mean TLC from 140.2 +/- 2.4 % p to 126.1 +/- 2.1 % p (p < 0.005). Intrinsic PEEP decreased significantly from 5.1 +/- 0.4 cm H(2)O preoperatively to 2.3 +/- 0.3 cm H(2)O postoperatively (p < 0.05). CONCLUSION: LVRS is an excellent therapeutic option for selected patients with severe emphysema and additional signs of severe hyperinflation. It results in significant postoperative functional improvement and marked increase in quality of life. The long-term benefit of LVRS remains to be defined.

Bilateral lung transplantation via two sequential anterolateral thoracotomies.

OBJECTIVE: Bilateral anterior trans-sternal thoracotomy (clam shell incision) is the standard approach used for bilateral sequential lung transplantation (BLTX). The morbidity of this large incision can be considerable. Two separate sequential anterolateral thoractomies represent a less invasive approach. METHODS: The value of this approach was investigated in a prospective 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 anterolateral thoracotomies, without the use of cardiopulmonary bypass. The anterior mediastinum and the sternum with all the surrounding tissue were left completely intact. Twenty-one patients underwent spirometrical examination during the postoperative in-hospital stay. Follow-up is 7+/-4 months (range: 3 to 15). RESULTS: The only intraoperative complication was severe reperfusion edema of the first transplanted lung seen in one patient at the end of the operation, which required pneumonectomy during the same session. All other operations were uneventful. The difference between the cold ischemic time of the first and second transplanted lung was 83+/-17 min. Median intubation duration, ICU- and in-hospital-stay were 1.5, 5 and 20 days, respectively (ranges: 1 to 96, 2 to 96 and 15 to 96, respectively). One major perioperative complication occurred and was due to gross donor/recipient size mismatch: the patient required lobectomy of the consolidated right upper lobe 11 days after transplantation. In 19 patients (86.4%), this less extensive incision allowed early postoperative mobilization, which resulted in good ventilatory performance, with VC of 53+/-15 and FEV1 of 60+/-20% of the predicted, respectively, at the first spirometry, 3 weeks after the operation. 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 potential spread of unilateral complications to the other pleural cavity.