67. A Case of Living-Donor Segmental Lung Transplantation and Concomitant Nuss Procedure in a Pediatric Patient with Pectus Excavatum
Cleveland Clinic
Cleveland, OH
United States - Contact Me
I have practiced General Thoracic Surgery at the Cleveland Clinic for the past 15 years. I am an AssociateProfessor of Surgery at the Lerner College of Medicine, Chief Quality Officer for Thoracic Surgery, lead the Enterprise VTE & Anticoagulation Committee and am the Chief of the Center for Chest Wall Disease at the Cleveland Clinic. My clinical interests include mininimally invasive pulmonary surgery, mediastinal pathology, surgical quality, surgical infection and both malignant and benign chest wall disease. I formerly served as faculty at the University of Rochester for five years following completion of my training at the University of Pennsylvania (CT fellowship) and University of Virginia (General Surgery).
Kyoto University Hospital
Kyoto, MA
Japan - Contact Me
Hiroshi Date, MD, serves as the Chairman and Professor in the Department of Thoracic Surgery at Kyoto University, Japan. After graduating from Okayama University School of Medicine in 1984, he underwent training under Drs. Joel D. Cooper and G. Alexander Patterson at Washington University, both as a research fellow from 1989 to 1991 and a clinical lung transplant fellow from 1994 to 1995. He also spent a year, from 1993 to 1994, as a general thoracic fellow at The Cleveland Clinic Foundation.
In 1998, Dr. Date achieved a significant milestone by successfully performing the first living-donor lobar lung transplantation in Japan. Since then, he has conducted approximately 400 lung transplants, resulting in a 70% survival rate at the 10-year mark. Dr. Date has performed more than 4,000 thoracotomies and has authored more than 600 peer-reviewed publications in various fields of general thoracic surgery including thoracic malignancy and lung transplantation.
Abstract
Case Video Summary: A ten-year old boy with severe pectus excavatum was referred to us due to drug-induced interstitial pneumonia after chemotherapy for neuroblastoma. While on a wait-list of deceased-donor lung transplantation, he developed intractable pneumothorax and became bedridden. It was unlikely for the patient to survive until deceased-donor was allocated, thus we planned living-donor lung transplantation. His chest cavities were very small due to the progression of restrictive lung disease and pectus excavatum. The donors were his old sisters in their twenties. It was obvious that donors' lower lobes were two large for the boy. We planned to use bilateral basal segmental grafts, however, anatomical size-matching based on CT volumetry was estimated to be 255%. Expanding boy's chest cavities appeared to be mandatory to implant oversized segmental grafts. Therefore, we planned to perform concomitant Nuss procedure. In donor basal segmentectomy, intersegmental plane was developed in vivo by a cautery based on indocyanine green orientation and S6 segment was preserved. The divided intersegmental planes were then covered with fibrin glue and absorbable pieces of polyglycolic acid sheet in order to prevent air leakage. Bilateral basal segmental graft implantation was performed though the clamshell incision under cardiopulmonary bypass (CPB). The implant technique of the basal segment was similar to that of the lower lobe graft. The basal segments were vertically rotated 90° after implantation. Right pulmonary venous anastomosis required an auto-pericardial conduit. After discontinuation of CPB, 2 pectus bars were placed to expend chest cavities. Delayed chest closure was required and the chest was closed on postoperative day (POD) 7. The patient discharged home without oxygen therapy 2 months after the transplantation. Six months after the operation, the boy is able to carry out daily activities. As for the two donors, postoperative course was uneventful and preserved S6 segments expanded well.
Conclusion: Living-donor segmental lung transplantation with concomitant Nuss procedure is feasible for a selected patient with pectus excavatum.
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