Living-related lung transplantation

Abstract

Living-donor lobar lung transplantation (LDLLT) was developed to deal with the severe shortage of brain dead door for patients who would not survive the long waiting period. In standard LDLLT, right and left lower lobes removed from two healthy donors are implanted into a recipient after right and left pneumonectomies using cardiopulmonary bypass (CPB). The number of LDLLT has decreased in the USA due to the recent change in allocation system for cadaveric donor lungs. For the past several years, most of the reports on LDLLT have been from Japan, where the average waiting time for a cadaveric lung is exceeding 800 days. LDLLT has been performed both for adult and pediatric patients suffering from various end-stage lung diseases including restrictive, obstructive, vascular and infectious lung diseases. Since only two lobes are implanted, size matching is a very important issue. Functional size matching by measuring donor pulmonary function and anatomical size matching by three-dimensional computed tomography (3D-CT) volumetry are very useful. For oversize graft, we have employed several techniques, including single lobe transplantation, delayed chest closure, downsizing the graft, and middle lobe transplantation. In cases of undersize mismatch, native upper lobe sparing transplant or right-left inverted transplant was performed. The 5-, 10- and 15-year survivals were 80.8%, 72.6% and 61.7%, respectively. There was no difference in survival between standard LDLLT and non-standard LDLLT such as single, sparing and inverted transplant. All donors have been discharged without any restrictions. LDLLT is a viable option for very ill patients who would not survive a long waiting time for cadaveric lungs. We have successfully developed various surgical techniques to overcome size mismatching with favorable outcome.

Keywords: Lung transplantation; cadaveric lung transplantation (CLT); living-donor lobar lung transplantation (LDLLT); size matching.

Figure 1

Bilateral living-donor lobar lung transplantation. Right and left lower lobes from two healthy donors are implanted in a recipient in place of whole right and left lungs, respectively.

Figure 2

Three-dimensional computed tomography angiography in a left donor. A yellow-dotted line shows the planned cutting oblique line of the pulmonary artery, thus to preserve ligula branches.

Figure 3

Anatomical size matching for the donor grafts and the recipient thorax using three-dimensional volumetry. The recipient was an adult male with pulmonary fibrosis. His right and left hemithorax was 1,483 and 1,149 mL, respectively. The right donor was a male whose right lower lobe was 1,637 mL. The left donor was a female whose left lower lobe was 716 mL. The right graft was oversize (110%) and the left graft was undersize (62.3%). Uneventful bilateral living-donor lobar lung transplantation was performed.

Figure 4

Native upper lobe sparing living-donor lobar lung transplantation. Bilobectomy and left lower lobectomy are performed in the recipient, and lower lobar grafts are implanted.

Figure 5

Right-to-left inverted living-donor lobar lung transplantation. The donor right lower lobe (5 segments) is inverted and implanted into the recipient’s left chest cavity instead of the donor left lower lobe (4 segments).

Figure 6

Survival after living-donor lobar lung transplantation (n=124). The 5-, 10- and 15-year survivals were 80.8%, 72.6% and 61.7%, respectively.