Comparison of clinical efficacy between Clamshell incision and bilateral posterolateral incision for double lung transplantation
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摘要:
目的 探讨Clamshell切口和双侧后外侧切口序贯双肺移植术治疗终末期肺病的疗效差异。 方法 回顾性分析接受双肺移植的120例受者的临床资料,按照手术方式不同分为双侧后外侧切口组(108例)和Clamshell切口组(12例)。收集并比较两组术中相关指标,包括手术时间、出血量、输血量、是否体外膜肺氧合(ECMO)支持、第一侧冷缺血时间、第二侧冷缺血时间,同时比较两组术后相关指标,包括住院时间、重症监护室(ICU)入住时间、气管插管时间、ECMO支持时间、用力肺活量(FVC)、第1秒用力呼气容积(FEV1)、吻合口狭窄发生率、支气管胸膜瘘发生率、围手术期病死率、术后第1次6 min步行距离。 结果 Clamshell切口组出血量、输血量均多于双侧后外侧切口组(均为P < 0.05),Clamshell切口组ECMO支持率和第二侧冷缺血时间低于或短于双侧后外侧切口组(均为P < 0.05)。Clamshell切口组气管插管时间及ECMO支持时间均短于双侧后外侧切口组(均为P < 0.05)。 结论 Clamshell切口和双侧后外侧切口的手术方案应用于序贯双肺移植均安全有效,双侧后外侧切口在不明显增加手术时间的情况下,可显著减少受者的出血量和输血量。而与双侧后外侧切口比较,Clamshell切口供肺冷缺血时间、气管插管时间和ECMO支持时间显著缩短。 Abstract:Objective To compare the clinical efficacy between Clamshell incision and bilateral posterolateral incision in the sequential double lung transplantation for end-stage lung disease. Methods Clinical data of 120 recipients undergoing double lung transplantation were retrospectively analyzed. All recipients were divided into bilateral posterolateral incision group (n=108) and Clamshell incision group (n=12) according to different surgical methods. Intraoperative parameters were collected and statistically compared between two groups, including operation time, amount of blood loss, amount of blood transfusion, use of extracorporeal membrane oxygenation (ECMO) or not, cold ischemia time on the first side, and cold ischemia time on the second side. Postoperative parameters were also compared between two groups, including the length of hospital stay, length of intensive care unit (ICU) stay, tracheal intubation duration, ECMO duration, forced vital capacity (FVC), forced expiratory volume in one second (FEV1), incidence of anastomotic stenosis, incidence of bronchopleural fistula, perioperative fatality, and 6-minute walk test for the first time after operation. Results In the Clamshell incision group, the amount of blood loss and blood transfusion was significantly higher than those in the bilateral posterolateral incision group (both P < 0.05). The proportion of ECMO and cold ischemia time on the second side in the Clamshell incision group were significantly lower or shorter than those in the bilateral posterolateral incision group (both P < 0.05). In the Clamshell incision group, the tracheal intubation duration and ECMO duration were significantly shorter compared with those in bilateral posterolateral incision group (both P < 0.05). Conclusions Both Clamshell incision and bilateral posterolateral incision are safe and effective in sequential double lung transplantation. Bilateral posterolateral incision approach can significantly reduce the amount of blood loss and blood transfusion of the recipients without significantly prolonging the operation time. Compared with bilateral posterolateral incision approach, the cold ischemia time of lung graft, tracheal intubation duration and ECMO duration are significantly shortened via the Clamshell incision. -
表 1 两组受者术中相关指标的比较
Table 1. Comparison of intraoperative indexes of recipients between the two groups
指标 双侧后外侧切口组(n=108) Clamshell切口组(n=12) P值 手术时间(x ± s,min) 422±65 404 ±113 0.599 出血量[M(P25,P75),mL] 1 200(800,1 781) 2 025(1 544,3 038) 0.001 输血量[M(P25,P75),mL] 1 200(800,1 500) 2 000(1 500,3 000) < 0.001 ECMO支持率[n(%)] 100(93) 8(67) 0.020 第一侧冷缺血时间(x ± s,min) 382±84 395±104 0.602 第二侧冷缺血时间(x ± s,min) 541±89 482±113 0.037 表 2 两组受者术后相关指标的比较
Table 2. Comparison of postoperative indexes of recipients between the two groups
指标 双侧后外侧切口组(n=108) Clamshell切口组(n=12) P值 住院时间[M(P25,P75),d] 37(25,59) 31(25,42) 0.505 ICU入住时间[M(P25,P75),d] 6(4,10) 6(3,10) 0.745 气管插管时间[M(P25,P75),h] 44(40,92) 24(17,34) 0.002 ECMO支持时间[M(P25,P75),h] 20(15,49) 0(0,26) 0.019 FVC[M(P25,P75),L] 2.3(1.9,2.8) 1.9(1.5,2.7) 0.477 FEV1[M(P25,P75),L] 1.9(1.6,2.3) 1.8(1.3,2.4) 0.726 吻合口狭窄发生率[n(%)] 28(26) 2(17) 0.725 支气管胸膜瘘发生率[n(%)] 2(2) 1(8) 0.273 围手术期病死率[n(%)] 15(14) 1(8) 0.929 术后第1次6 min步行距离(x ± s,m) 435±119 443±133 0.898 -
[1] ZHOU J, CHEN J, WEI Q, et al. The role of ischemia/reperfusion injury in early hepatic allograft dysfunction[J]. Liver Transpl, 2020, 26(8): 1034-1048. DOI: 10.1002/lt.25779. [2] BOS S, VOS R, VAN RAEMDONCK DE, et al. Survival in adult lung transplantation: where are we in 2020?[J]. Curr Opin Organ Transplant, 2020, 25(3): 268-273. DOI: 10.1097/MOT.0000000000000753. [3] 肖漓, 解立新, 石炳毅. 肺移植免疫学相关基础与临床研究进展[J]. 器官移植, 2021, 12(6): 637-642. DOI: 10.3969/j.issn.1674-7445.2021.06.001.XIAO L, XIE LX, SHI BY. Progress on basic and clinical research of immunology in lung transplantation[J]. Organ Transplant, 2021, 12(6): 637-642. DOI: 10.3969/j.issn.1674-7445.2021.06.001. [4] HAYES D JR, CHERIKH WS, CHAMBERS DC, et al. The International Thoracic Organ Transplant Registry of the International Society for Heart and Lung Transplantation: twenty-second pediatric lung and heart-lung transplantation report-2019; focus theme: donor and recipient size match[J]. J Heart Lung Transplant, 2019, 38(10): 1015-1027. DOI: 10.1016/j.healun.2019.08.003. [5] CHAMBERS DC, PERCH M, ZUCKERMANN A, et al. The International Thoracic Organ Transplant Registry of the International Society for Heart and Lung Transplantation: thirty-eighth adult lung transplantation report - 2021; focus on recipient characteristics[J]. J Heart Lung Transplant, 2021, 40(10): 1060-1072. DOI: 10.1016/j.healun.2021.07.021. [6] PASQUE MK, COOPER JD, KAISER LR, et al. Improved technique for bilateral lung transplantation: rationale and initial clinical experience[J]. Ann Thorac Surg, 1990, 49(5): 785-791. DOI: 10.1016/0003-4975(90)90023-y. [7] LOOR G, MATTAR A, SCHAHEEN L, et al. Surgical complications of lung transplantation[J]. Thorac Surg Clin, 2022, 32(2): 197-209. DOI: 10.1016/j.thorsurg.2022.01.003. [8] ELGHARABLY H, JAVORSKI MJ, MCCURRY KR. Bilateral sequential lung transplantation: technical aspects[J]. J Thorac Dis, 2021, 13(11): 6564-6575. DOI: 10.21037/jtd-2021-22. [9] RUCKER AJ, NELLIS JR, KLAPPER JA, et al. Lung retransplantation in the modern era[J]. J Thorac Dis, 2021, 13(11): 6587-6593. DOI: 10.21037/jtd-2021-25. [10] COPPOLINO A, MODY GN, RINEWALT D, et al. Sternotomy for lung transplantation: a description of technique[J]. Ann Cardiothorac Surg, 2020, 9(1): 65-67. DOI: 10.21037/acs.2020.01.05. [11] 陈文慧, 郭丽娟, 赵丽, 等. 单中心50例肺移植临床特点分析[J/CD]. 中华移植杂志(电子版), 2020, 14(6): 349-354. DOI: 10.3877/cma.j.issn.1674-3903.2020.06.003.CHEN WH, GUO LJ, ZHAO L, et al. A single-center experience of 50 cases of adult lung transplantation[J/CD]. Chin J Transplant (Electr Edit), 2020, 14(6): 349-354. DOI: 10.3877/cma.j.issn.1674-3903.2020.06.003. [12] GIMÉNEZ-MILÀ M, VIDELA S, PALLARÉS N, et al. Impact of surgical technique and analgesia on clinical outcomes after lung transplantation: a STROBE-compliant cohort study[J]. Medicine (Baltimore), 2020, 99(46): e22427. DOI: 10.1097/MD.0000000000022427. [13] ZHANG J, LIU D, YUE B, et al. A retrospective study of lung transplantation in patients with lymphangioleiomyomatosis: challenges and outcomes[J]. Front Med (Lausanne), 2021, 8: 584826. DOI: 10.3389/fmed.2021.584826. [14] YUE B, YE S, LIU F, et al. Bilateral lung transplantation for patients with destroyed lung and asymmetric chest deformity[J]. Front Surg, 2021, 8: 680207. DOI: 10.3389/fsurg.2021.680207. [15] KELLER MB, MEDA R, FU S, et al. Comparison of donor-derived cell-free DNA between single versus double lung transplant recipients[J]. Am J Transplant, 2022, 22(10): 2451-2457. DOI: 10.1111/ajt.17039. [16] WU S, PENG G, XU C, et al. The outcome of lung transplantation for end-stage pulmonary diseases with pulmonary hypertension: a single-center experience[J]. J Thorac Dis, 2022, 14(4): 1020-1030. DOI: 10.21037/jtd-21-1738. [17] HADDAD O, JACOB S, PHAM A, et al. Harvesting left internal thoracic artery via clamshell incision for coronary bypass and lung transplant[J]. J Surg Case Rep, 2020, 2020(10): rjaa363. DOI: 10.1093/jscr/rjaa363. [18] EHRHARDT JD JR, BAROUTJIAN A, MCKENNEY M, et al. Historical observations on clamshell thoracotomy[J]. World J Surg, 2021, 45(4): 1237-1241. DOI: 10.1007/s00268-020-05913-4. [19] WEINGARTEN N, SCHRAUFNAGEL D, PLITT G, et al. Comparison of mechanical cardiopulmonary support strategies during lung transplantation[J]. Expert Rev Med Devices, 2020, 17(10): 1075-1093. DOI: 10.1080/17434440.2020.1841630. [20] RECK DOS SANTOS P, D'CUNHA J. Intraoperative support during lung transplantation[J]. J Thorac Dis, 2021, 13(11): 6576-6586. DOI: 10.21037/jtd-21-1166. [21] MEYERS BF, SUNDARESAN RS, GUTHRIE T, et al. Bilateral sequential lung transplantation without sternal division eliminates posttransplantation sternal complications[J]. J Thorac Cardiovasc Surg, 1999, 117(2): 358-364. DOI: 10.1016/S0022-5223(99)70434-4. [22] OLLAND A, REEB J, GUINARD S, et al. Clamshell closure with absorbable sternal pins in lung transplant recipients[J]. Ann Thorac Surg, 2017, 104(2): e207-e209. DOI: 10.1016/j.athoracsur.2017.04.036. [23] MACCHIARINI P, LADURIE FL, CERRINA J, et al. Clamshell or sternotomy for double lung or heart-lung transplantation?[J]. Eur J Cardiothorac Surg, 1999, 15(3): 333-339. DOI: 10.1016/s1010-7940(99)00009-3. [24] RUIZ LÓPEZ E, CEREZO MADUEÑO F, GONZÁLEZ GARCIA FJ, et al. Thoracotomy wound dehiscence after lung transplant is an effective surgical solution: a case report[J]. Transplant Proc, 2020, 52(2): 584-586. DOI: 10.1016/j.transproceed.2019.11.035. [25] DELL'AMORE A, CAMPISI A, CONGIU S, et al. Extracorporeal life support during and after bilateral sequential lung transplantation in patients with pulmonary artery hypertension[J]. Artif Organs, 2020, 44(6): 628-637. DOI: 10.1111/aor.13628. [26] 陈静瑜, 郑明峰, 何毅军, 等. 不横断胸骨双侧前胸切口双肺移植[J]. 中华器官移植杂志, 2006, 27(2): 72-74. DOI: 10.3760/cma.j.issn.0254-1785.2006.02.003.CHEN JY, ZHENG MF, HE YJ, et al. Bilateral sequential lung transplantation through bilateral anterolateral thoracotomy without sternal division[J]. Chin J Organ Transplant, 2006, 27(2): 72-74. DOI: 10.3760/cma.j.issn.0254-1785.2006.02.003. [27] DÜRRLEMAN N, MASSARD G. Posterolateral thoracotomy[J]. Multimed Man Cardiothorac Surg, 2006. DOI: 10.1510/mmcts.2005.001453. [28] THABUT G, MAL H, CERRINA J, et al. Graft ischemic time and outcome of lung transplantation: a multicenter analysis[J]. Am J Respir Crit Care Med, 2005, 171(7): 786-791. DOI: 10.1164/rccm.200409-1248OC. [29] HASENAUER A, BÉDAT B, PARAPANOV R, et al. Effects of cold or warm ischemia and ex-vivo lung perfusion on the release of damage associated molecular patterns and inflammatory cytokines in experimental lung transplantation[J]. J Heart Lung Transplant, 2021, 40(9): 905-916. DOI: 10.1016/j.healun.2021.05.015. [30] NĘCKI M, ANTOŃCZYK R, PANDEL A, et al. Impact of cold ischemia time on frequency of airway complications among lung transplant recipients[J]. Transplant Proc, 2020, 52(7): 2160-2164. DOI: 10.1016/j.transproceed.2020.03.047.