Prior resection poses certain risks in lung transplantation



ORLANDO – Prior lung resection is associated with increased early mortality and with a more than twofold increased risk of renal failure requiring dialysis in lung transplant recipients, data from the United Network for Organ Sharing suggest.

Prior resection is not, however, associated with increased long-term mortality, prolonged hospital length of stay, or airway dehiscence, Dr. Asvin M. Ganapathi reported at the annual meeting of the Society of Thoracic Surgeons.

Of 15,300 adult lung transplant recipients in the UNOS database who received lungs between October 1999 and December 2011, 80 had a prior lobectomy and 22 had a prior pneumonectomy. After 3:1 propensity matching based on 17 recipient variables known to affect perioperative morbidity and mortality, 90-day mortality in 306 nonresection patients was 5.8%, compared with 13.9% in the 102 with prior resection. Renal failure requiring dialysis occurred in 6.6% and 13.9% of patients in the groups, respectively, said Dr. Ganapathi of the anesthesiology division of Duke University, Durham, N.C.

Hospital length of stay longer than 25 days was required in 36.9% and 36.4% of the nonresection and resection groups, respectively, and airway dehiscence occurred in 1.3% and 2%, he said.

Survival at 1 and 5 years was 83.6% and 48.4% in the nonresection group, and 78.9% and 45.6% in the prior-resection group.

A subanalysis comparing the prior-lobectomy patients with patients with no prior resection revealed no differences between the two groups in any of the examined outcomes, although there was a trend toward increased 90-day mortality in the lobectomy patient, and a more than twofold increase in renal failure requiring dialysis. A subanalysis comparing those with prior pneumonectomy with those with no prior resection showed a significantly greater need for dialysis in the pneumonectomy patients (8.9% vs. 3.8%), and a trend toward increased 90-day mortality in the pneumonectomy patients, but no differences in the other examined outcomes.

The propensity-matched groups were similar with respect to recipient, donor, and operative characteristics. There were 10 double and 12 single lung transplants after pneumonectomy, and 51 double and 29 single transplants after lobectomy.

Lung transplantation provides a durable, efficacious treatment for end-stage lung disease, but indications for transplant can vary, and as a result, a select group of patients may have had prior lung resection for treatment of their underlying disease, Dr. Ganapathi said.

Both lobectomy and pneumonectomy are known to cause anatomic changes such as mediastinal shift and vascular abnormalities.

"As such, a history of previous lung resection may affect selection of donor organs and increase the difficulty of transplantation," he said.

In fact, historically, prior thoracic surgery was considered a relative contraindication to lung transplantation because of increased risk of poor outcomes, but recent case reports and single-institution case series – though limited by small patient numbers and the inclusion of both major and minor thoracic procedures ranging from chest tube insertion to pneumonectomy – have suggested that transplantation is feasible in these patients, he said.

Studies specifically looking at lung transplant after resection are lacking; the largest series involved pneumonectomy and included only 14 patients, he said.

The current findings suggest that prior resection should not preclude lung transplantation.

Notable limits of the study include its retrospective design, which may have introduced unexpected bias into the analysis; the fact that the analysis is limited to the variable collected for the UNOS database; and the number of patients with prior resection, although this may be secondary to underreporting of prior thoracic procedures in the UNOS candidate registration form or a result of data being collected only from 1999 onward.

Other variables that may have been of interest for the current analysis were knowledge of laterality of prior resection, time from resection to treatment, days of postoperative ventilator use, and operative time, Dr. Ganapathi noted. Specifically, in cases of single lung transplant, the issue of laterality would be of great interest, he said.

"In conclusion, lung transplantation subsequent to previous major lung resection is associated with an increased risk of early mortality, but did not demonstrate any significant long-term survival differences. Additionally, prior major lung resection predisposes to increased morbidity in the form of renal failure requiring dialysis," he said. The increased rate of dialysis may be secondary to longer operative time, the need for cardiopulmonary bypass, or other unquantified factors, he added.

Careful, individualized preoperative recipient evaluation and technical planning are necessary to minimize these risks in the patients, he concluded.

Dr. Ganapathi reported having no relevant disclosures.

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