double lung transplantation

Experimental studies of lung transplantation can be traced back to the early 20th century. Human lung transplantation began in 1963. However, in 1963-1983, nearly 40 patients had a maximum survival time of less than 10 months. With the advent of cyclosporin A and the advancement of transplantation technology in the 1970s, the Stanford University Hospital in the United States first achieved the success of cardiopulmonary transplantation in 1981; in 1983 and 1986, the Toronto lung transplantation group successfully performed a single lung. Transplantation and double lung transplantation have created a new era of lung transplantation. Since then, lung transplant work has developed rapidly. By 1997, the number of surgical procedures had reached 6,639, with a 3-year survival rate of over 50% and a 5-year survival rate of over 40%. The quality of life of patients after lung transplantation is good, can return to normal life, and some have been engaged in previous work. Lung transplantation has become the only effective method for the treatment of end-stage lung disease. Curing disease: Indication 1, bilateral lung suppuration, such as cystic fibrosis or bronchiectasis. The index of lung transplantation is FEV1 <30%, PaCO2 is elevated, oxygen is required, and hospitalization is often used to control acute lung infection, and body weight cannot be maintained. 2, younger patients with chronic obstructive pulmonary disease (age <50 years), especially secondary to 1-antitrypsin deficiency. Contraindications 1. Late right ventricular fibrosis or stubborn right heart dysfunction is a contraindication for double lung transplantation. However, if the patient has a reserve of right ventricular contractility, only due to pulmonary hypertension caused by right ventricular dilatation, ejection fraction decreased, it is not a contraindication for double lung transplantation. 2, the age is more than 50 years old, the risk of double lung transplantation is increased, which is a relative contraindication. 3, bilateral lung suppuration, liver and kidney failure, etc., is a contraindication for bilateral lung transplantation. 4, the donor's standard is ABO blood type consistent, chest X-ray clear, inhaled pure oxygen, end-pressure 0,49kPa (5cmH2O), arterial oxygen partial pressure exceeds 40kPa (300mmHg), no purulent secretion by bronchoscopy, for The size of the lung is close to the recipient's chest, and is younger than 55 years old, meeting the criteria for brain death. On the contrary, it is not suitable for use as a lung. Preoperative preparation 1. Preoperative examination including cardiac catheterization, coronary angiography, radionuclide right ventriculography, tissue typing, virus culture and quantitative ventilation-perfusion scan, etc., and cardiology, pulmonary medicine, psychiatry and dentists consultation. Then register the information and find the right lung for it. Preoperative rehabilitation includes riding a stationary bicycle and a bicycle under percutaneous oxygen saturation monitoring. 2, brain death, tracheal intubation donors are prone to lung infection, pulmonary edema and other abnormalities, so in preparation should: 1 with a constant volume ventilator, 40% O2 and 0,49kPa (5cmH2O) end-positive pressure Ventilation; 2 control fluid input, maintain central venous pressure less than 0,98kPa (10cmH2O), mean arterial pressure 9, 33 ~ 10, 7kPa (70 ~ 80mmHg); 3 often sucking; 4 gastrointestinal decompression. Surgical procedure 1, for the lungs to take (1) Protection of the lungs: 3L cold Euro-Collins solution was perfused into the pulmonary artery, and 0,5 mg prostaglandin E1 was injected from the pulmonary artery before perfusion. See the single lung transplant for lung protection. (2) Remove the heart: Dissect the room ditch from the right side to reveal the left atrial wall proximal to the right pulmonary vein 1 to 3 cm. The ascending aorta was transected at the aortic perfusion site, and the pulmonary artery was transected at the midpoint of the total pulmonary artery to cut the superior and inferior vena cava. The treatment of the left atrium is to first cut the left atrial wall from the junction of the left pulmonary vein and the coronary sinus, then pull the heart, extend the incision up and down, and finally cut the left atrium wall in the previously dissected room ditch. This method not only retains enough left atrial sleeves in the left and right pulmonary veins, but also preserves the complete right atrium in the heart. The heart and lung can be used for double lung transplantation and heart transplantation, respectively. (3) Large lung resection: After removing the heart, the mediastinum is dissected along the spine, down to the plane of the diaphragm, up to the midpoint of the trachea on the aortic arch, the trachea and the esophagus at both ends are clipped with a suturing device, and the aortic arch is severed at the thoracic top. The branch, the thoracic aorta is cut off, and the lungs are removed together with the esophagus and the aorta. This makes it quick and safe to remove the lungs. If transported, the lungs can be placed in a plastic bag containing 4 ° C saline, placed in an ice bucket, surrounded by ice. (4) Take the left and right lungs separately: After arriving at the recipient's operating room, the lungs were still placed in cold saline to remove the esophagus and aorta. The bilateral pulmonary arteries were severed at the bifurcation of the total pulmonary artery. Cut the left atrium from the midline and leave enough atrial sleeves on the left and right pulmonary veins. The bilateral main bronchus was cut at the two cartilage rings at the proximal end of the upper bronchial opening. Avoid excessive dissection of the soft tissue around the bronchial stump to preserve the collateral circulation of the bronchial artery as much as possible. 2, the recipient of the large net membrane pedicle free Take the median incision of the abdomen, free the omentum from the transverse colon, and divide its longitudinal direction into two retinal pedicles, carefully retaining the blood supply of each pedicle. Place the tip of the omentum under the xiphoid process and place it in the chest later. Suture the abdominal incision. 3. The chest incision of the recipient Both sides of the thoracic anterior lateral incision + transverse sternum. The incision is made through the fourth or fifth intercostal space on both sides, from the midline of the iliac crest to the sternal border, and then the sternum is transected. The incision provides sufficient visualization of the bilateral thoracic cavity from the pleural apex to the diaphragm and the posterior mediastinum, making the separation of the lungs and hilar structures easier. In recent years, it has been suggested that without traversing the sternum, sufficient exposure can be obtained while avoiding complications of sternal incision. 4. Resection and implantation of the right lung of the recipient (1) Resection of the right lung: separation of the right lung from the chest wall, mediastinum and diaphragm, free pulmonary arteriovenous. Dissect the room ditch to facilitate placement of the left atrium clip. Push the Swan-Ganz catheter into the left pulmonary artery and apply left single-lung ventilation (the left pleural cavity can be opened first to facilitate ventilation). If the patient is intolerant, part of the extracorporeal circulation must be established to maintain the pulmonary systolic blood pressure below 4 kPa (30 mmHg). When the lungs reach the operating room, the first branch and the descending branch of the recipient's pulmonary artery are cut off, and the distal end of the lung is cut off. The main bronchus is severed at the proximal end of the upper leaf opening and the right lung is removed. (2) Anastomotic bronchus: The right side was placed in the right chest of the recipient, and the bronchial membrane was continuously sutured with a 4-0 absorbable monofilament. The cartilage was sutured with a 4-0 Vicryl line. (3) anastomotic pulmonary artery: clamp the right side of the right pulmonary artery of the recipient, and trim the blood vessel as appropriate to match the diameter of the pulmonary artery. Then suture the pulmonary artery continuously with a 5-0 Prolene line. (4) Anastomotic atrial sleeve: a vascular clamp was placed on the proximal left atrium of the recipient's pulmonary vein, the pulmonary vein stump ligature was removed, and the upper and lower pulmonary vein openings were connected to form an appropriate size left atrial sleeve, and the donor's right pulmonary vein. The upper atrial sleeves were sutured continuously with a 4-0 Prolene line. 5. Resection and implantation of the left lung of the recipient The Swan-Ganz catheter was retracted to the total pulmonary artery. Then placed in the right pulmonary artery. Ventilation with a newly transplanted right lung. Open the left pleural cavity and complete the left lung transplant as in the right lung resection and implantation technique. 6, with the mesh membrane pedicle around the bronchial anastomosis Bluntly separate the sternal posterior tunnel, down to the xiphoid, take the omentum into the chest. The two reticular pedicles were completely wrapped around the bronchial anastomosis from the posterior aspect of the lung. Some authors have suggested that it is not necessary to wrap the bronchial anastomosis with a large omentum. 7, close the chest Two chest drainage tubes were placed in each chest. The sternal stump was fixed with 3 sternum wires and the thoracic incision was layered. complication 1, airway complications The original whole double lung transplantation was performed with tracheal anastomosis, and the incidence of anastomotic complications was quite high. The two lungs were transplanted successively, and the bronchial anastomosis was replaced by bilateral bronchial anastomosis. The airway complications were significantly reduced. In addition, the application of the mesh membrane pedicle around the bronchial anastomosis can improve the healing of the anastomosis. 2, early transplantation of pulmonary insufficiency It is one of the most important causes of death in the first 30 days after transplantation. The reasons are not suitable for the lungs, such as inhalation, infection, injury; improper protection of the lungs, prolonged warm ischemia; surgical operations are wrong, such as bronchial anastomotic complications, pulmonary artery or atrial anastomotic stricture. Methods for definitive diagnosis include bronchoscopy to exclude the presence or absence of anastomotic complications. Pulmonary angiography excludes pulmonary artery or atrial anastomotic stenosis. Bronchopulmonary biopsy and open lung biopsy are used to observe diffuse alveolar damage. Most of the treatment may be restored by conventional intensive support, but severe cases require extracorporeal membrane lung support. 3, lung rejection Almost all patients developed acute rejection within 1 week after surgery. The clinical manifestations of rejection were shortness of breath, mild fever, chest radiograph showing interstitial infiltration around the hilum, hypoxemia, and increased white blood cell count. Transbronchial lung biopsy is the primary means of diagnosing lung rejection, and its typical histology is the infiltration of perivascular lymphocytes. Bronchoalveolar lavage is very useful in eliminating pathogenic infections after transplantation. When it is found that there is rejection, intravenous injection of methylprednisolone 500 ~ 1000mg shock treatment. Generally, chest X-ray and arterial oxygenation will be significantly improved within 6 to 12 hours. Obliterative bronchiolitis is considered to be the result of chronic rejection, its etiology is unclear, and there is no effective treatment. The clinical manifestation is a progressive decline in FEV1, often preceded by shortness of breath, and is the most common cause of death in the later stages of lung transplantation. 4, lung infection Bacterial pneumonia occurs most often. In addition to conventional sputum culture, bronchoscopy should be performed frequently to actively identify pathogens and treat them with sensitive antibiotics or broad-spectrum antibiotics. In addition, cell hypertrophic virus pneumonia has attracted people's attention. One concern for the sequential lung transplantation on both sides is that the second ischemic time for the lungs is prolonged (up to 8 to 10 h), but postoperative pulmonary perfusion scans, blood gas analysis and lung function tests prove that the function of the transplanted lung is good. .