The two standard surgical approaches for bilateral sequential lung transplantation, the “clamshell” incision and two separate anteriolateral thoracotomies, are both associated with significant postoperative pain. This pain is often responsible for decreased respiratory effort, delayed ambulation, and poor pulmonary toilet. Clinical studies suggest that a median sternotomy approach for lung surgery significantly reduces post-operative pain. Utilizing cardiac stabilization devices to eliminate the need for cardiopulmonary bypass, we assessed the safety, efficacy, and pain associated with this procedure.
Sixteen bilateral sequential lung transplants were performed via bilateral thoracotomy (BT, n=6) and median sternotomy (MS, n=10) between January 1999 and December 2003. Retrospective review of patient charts compared demographics, medical histories, surgical outcomes, and subjective pain scores.
Demographics were not significantly different between groups except for age (BT: 59.3±6.0 vs MS: 49.4±7.0, p<0.01;mean±SD). Three patients who had prior lung volume reduction surgery were done via BT. One of 10 transplants performed with MS required intraoperative conversion to cardiopulmonary bypass. Ischemic times (BT: 376±69 min vs MS: 378±84 min, p>0.05), time to extubation (BT: 4.0 days vs MS: 3.0 days, p>0.05; median) and 30 day mortality (BT: 17% vs MS: 0%, p=0.38; Fisher exact test) were similar between groups. All transplant surgeons (AKS, MM, JM, SF) utilized both approaches and subjectively felt that the MS afforded satisfactory operative field and rapid control of the pulmonary hilum. Compared to the BT group, severity of pain on postoperative days 1–14 was significantly less in the MS group (p<0.05, Chi square).
Off pump bilateral sequential lung transplantation can be performed via median sternotomy using cardiac stabilization devices. Ischemic time, time to extubation, and 30 day mortality were equivalent in both groups. Postoperatively, patients had significantly less pain in the median sternotomy group relative to the bilateral thoracotomy group.
The observed decrease in postoperative pain with median sternotomy should enhance recovery and reduce complications such as pneumonia. Furthermore, this approach provides optimal exposure in the event cardiopulmonary bypass is required.
A.K. Singhal, None.