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Lung Volume-Reduction Surgery (LVRS) is a surgical method to correct hyperinflation in end-stage emphysema patients. Despite its proven effectivity, the procedure’s safety and patient selection criteria remain to be questioned. Endoscopic lung volume-reduction, the broadening of LVRS indications and confirmation of its effectivity caused the field of LVRS to expand. We aim to report our patient selection strategy and compare the complication- and mortality ratios between unilateral and bilateral LVRS. We aim to give an overview of the chosen targets and compare the effectivity of unilateral, one- and two-staged LVRS. We conducted a combined retro- and prospective single-center observational cohort study containing 119 consecutive LVRS cases (January 1st ,2020 - September 30th ,2022). All patients (n=105) were treated in accordance with the Enhanced-Recovery Protocol which standardized peri-operative care. We compared the complication- and mortality ratios between unilateral and bilateral executed LVRS and compared the functional outcomes between unilateral, one-stage bilateral and two-staged bilateral treated patients. Complication- and mortality ratios are primary outcomes. Length-of stay, air leakage incidence and duration and functional evolution post-LVRS are secondary outcomes. One-hundred and five patients were treated (36 unilateral, 52 one-stage and 17 two-staged bilateral) with an average of 1.5 ( 0.5) and 1.3 ( 0.5) targets for respectively the right and left lung. The median pre-operative forced expiration value in one second (FEV1) and residual volume (RV) were respectively 32 ( 12) and 215 ( 38). Thirty-six (32%) patients experienced complications. Complication ratios did not differ between unilateral and bilateral LVRS (p 0.830). The 30-day LVRS-related mortality was 0.9%. The prolonged air leakage incidence was 28% for unilateral and 25% for bilateral LVRS (p 0.779). The median duration of an air leakage was respectively 2 ( 8) and 4 ( 5.5) days for unilateral and bilateral LVRS if present. The average gain in FEV1 (L) was 0.32 ( 0.39) which generates an average gain in FEV1 (%) of 37 ( 35). There are no long-term differences in outcome when unilateral, one- and two-staged LVRS are compared. We confirm that LVRS is safe and effective in treating end-stage emphysema if the peri-operative care is organized and physiotherapy is accentuated. Patient selection is preferably done by a multidisciplinary team of experts. A staged bilateral approach is a valid way to allow more patients to be treated bilaterally and broaden LVRS indications without compromising the effectivity of the procedure. The functional outcome does not differ based on the chosen approach.

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Introduction: Lung transplantation (LTx) is the ultimate treatment for patients suffering from end-stage pulmonary conditions. Despite vast improvements in surgical techniques over the last several years, complications are still frequent. Development of an esophageal fistula after LTx is a rare complication, characterized by significant morbidity, requiring re-intervention, a prolonged stay in the intensive care unit and a long period of nil per os. Given the rarity of this complication, limited literature on this topic is available. The aim of this case series is to describe this complication in detail, its clinical presentation and treatment options as well as to discuss potential risk factors. Methods: This study is a retrospective case series on the development of an esophageal fistula after bilateral LTx at the University Hospitals Leuven Belgium between 2019 and 2020. A total of 4 patients presented with an esophageal fistula post-LTx. Case series: Case 1: A 63-year-old male received a bilateral LTx for end-stage combined pulmonary fibrosis and emphysema. 26 days after LTx, he developed a right-sided hydropneumothorax with subcutaneous emphysema. Gastroscopy revealed an esophageal fistula. The fistula was closed by an intercostal muscle flap, hemo-clips and stenting. Follow up showed no remaining fistula. He was discharged after a 156-day stay in the hospital. Case 2: a 33-year-old female underwent a bilateral lobar transplant for end-stage cystic fibrosis. 13 days after LTx, she deteriorated due to hemorrhagic shock. Bilateral redo anterior thoracotomy showed a fistula that was subsequently covered by an intercostal muscle flap. Follow up showed remaining leakage of the fistula and conservative therapy was set. Control CT confirmed a positive evolution of the fistula and after 98 days in the hospital, she was discharged home. Case 3: A 62-year-old male underwent a bilateral LTx for terminal interstitial lung disease due to systemic sclerosis with secondary severe pulmonary and right heart failure. 16 days post-LTx, he developed a pneumopericardium with bilateral pneumothorax. A week later he showed acute respiratory decline and a gastroscopy showed an esophageal fistula. A conservative management was set. However, control endoscopy showed a larger fistula and clips were placed. 109 days after LTx, CT showed a relapse of the esophageal pleural fistula and the fistula was primarily closed and covered with two intercostal muscle flaps. Follow up showed no remaining fistulas. After a 273-day hospital-stay, he was discharged to a rehabilitation center. Case 4: A 38-year-old male received a bilateral LTx because of idiopathic pulmonary arterial hypertension. 42 days after LTx, the patient presented with persistent respiratory distress. CT scan showed an esophagobronchial fistula due to bronchial dehiscence. The fistula was surgically revised with an intercostal muscle flap. Afterwards, there was limited leakage of the fistula and a conservative management was set. The fistula showed a favorable evolution. After an 88-day stay in the hospital he was discharged. Conclusion: An esophageal fistula is a rare, but severe post lung transplantation complication that presents itself in patients in poor condition with a high morbidity. A high level of clinical suspicion is required, followed by rapid diagnosis and management. If treated in time, this complication has a good short-term outcome.

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Background Recently there has been a growing awareness of the deleterious effect of prolonged donor hepatectomy time (dHT) on liver transplantation outcome, particularly in “donation after circulatory death” (DCD) donors. Lung grafts seem more protected due to its unique oxygen storage capacity. These observations led to an official change of protocol in February 2017 at our centre: prioritizing hepatectomy over pneumectomy in DCD procedures if simultaneous procurement is not achievable. Methods In this single centre study we aim to primarily evaluate whether the change of protocol in 2017 reduced dHTs in multi-organ DCD procedures in our centre and to secondarily evaluate whether donor pneumectomy times (dPTs) were impaired and also post-transplant outcomes. Regarding liver transplantation, non-anastomotic biliary strictures (NAS), early allograft dysfunction (EAD), graft and patient survival were analysed. For lung transplantation, primary graft dysfunction (PGD), graft and patient survival were analysed. Results The change of protocol in 2017 did not significantly reduce dHTs. In the past decade we observed a significant downward slope in dHT in our centre (P-value 0,0199), with a stabilizing trend after February 2017. The estimated slope from March 19, 2010 until February 1st, 2017 is -1,7242 (p-value 0,0383). The improvement in dHT did not result in a significant change in dPT neither in outcome after liver or lung transplantation. Conclusion Growing awareness for the importance of dHT and thus prioritizing donor hepatectomy in multi-organ DCD has resulted in a gradual decrease in dHT at our centre without rendering a negative effect on pneumonectomy or outcome after lung transplantation. The change of protocol did not further reduce dHTs.

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Background: Lung transplantation (LTx) is the ultimate treatment for patients with end-stage lung disease. Despite major developments, organ transplantation remains hampered by a lack of suitable organs. In countries with a legal framework for euthanasia, organ donation following euthanasia could be addressed to expand the donor pool. However, apart from the initial experience, lung donation and transplantation after euthanasia (donation after circulatory death (DCD-V)) remain relatively unacquainted and long-term outcomes have not been reported. We aim to describe our experience with lung donation after euthanasia and evaluate long-term outcome in comparison to a matched cohort of controlled donation after circulatory death (DCD-III) and donation after brain death (DBD). Methods: All sequential single-lung transplantations (SSLTx) performed at the University Hospitals Leuven between 2007 and 2020 were retrospectively analyzed. Propensity score matching was performed using recipient gender and age, indication for LTx, use of extracorporeal lung support (ECLS) and donor age as matching variables, which resulted in a one-to-two DCD-III and a one-to-three DBD matching. Chronic lung allograft dysfunction (CLAD)-free survival was the primary outcome. Results: A total of 769 SSLTx were performed of which 22 were from DCD-V donors (2.9%), accounting for 14% of all DCD cases. Thirteen women and nine men (suffering from neuromuscular disorders (n = 9), psychiatric disorders (n = 8) or unbearable pain (n = 5)) expressed their wish for organ donation after euthanasia. Donor warm ischemia time (DWIT) was 11 minutes. Twenty-two patients (13 women and 9 men) with a median age of 57 years underwent a SSLTx for chronic obstructive pulmonary disease (COPD) (n = 11), pulmonary fibrosis (n = 5), cystic fibrosis (n = 4) or bronchiolitis obliterans (n = 2). CLAD-free 3- and 5-year survival were 86.4% and 58.9%, equal to DCD-III (83.7% and 61.1%, p=0.816) and DBD (62.2% and 50.5%, p=0.120). Five-year patient survival was 90.9%, comparable to both the DCD-III (84.8%, p=0.969) and DBD (73.9%, p=0.252) cohort. Despite a significantly longer cold ischemia time in the DCD-V group compared to DBD donors (261 versus 214 minutes and 431 versus 391 minutes for the first and second lung, respectively), a trend towards less PGD was observed. Conclusion: The findings of this propensity-matched cohort study suggest for the first time that SSLTx with DCD-V grafts yield similar long-term outcome as SSLTx with DCD-III and DBD grafts. Therefore, grafts donated after euthanasia may be a justifiable option for increasing the organ donor pool.

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Introduction Lung volume reduction surgery (LVRS) is one of few therapies targeting hyperinflation in advanced emphysema patients, however safety and benefits of this procedure are often misprized. We implemented an LVRS enhanced recovery program (ERP) to standardize perioperative care, facilitate recovery and re-emphasize the procedure’s potential. This study analyses the ERP safety and efficacy. Methods This retrospective single-centre study included all consecutive patients who underwent LVRS (01/01/2017-15/09/2020) at the University Hospitals Leuven (Belgium). The ERP was implemented on 01/08/2019 and consisted of integration of a preoperative emphysema multidisciplinary-board evaluation; change of surgical technique (volume-/target-area oriented and peripheral shaving technique acquired from an expert-centre), on-table extubation and early rehabilitation. Comparative analyses were performed between pre-ERP and ERP groups, for uni- and bilateral LVRS procedures. Primary outcome was length-of-stay; secondary outcomes were chest tube duration and complication incidence. Functional evaluation was measured by spirometry at 3m post-LVRS. Results Seventy-six LVRS patients were included (pre-ERP (n=41): 7 unilateral and 34 one-stage bilateral; ERP (n=35): 9 unilateral, 20 one-stage bilateral and 6 two-stage bilateral (including 3 high-urgent LVRS)). For one stage bilateral LVRS, length-of-stay decreased from 14.5 to 6 days (p<0.001), air leak incidence (day 1) reduced from 91% to 50 (p=0.002), chest tube duration decreased from 13 to 5 days (p<0.001) and minor complications (Dindo-Clavien I/II) declined from 65% to 25% (p=0.002). No 90-day mortality occurred in the ERP-cohort versus 7.3% in the pre-ERP. The FEV1 improvement after bilateral LVRS showed a more positive trend in the ERP group (n=23/26) +0.48L [interquartile range, 0.25-0.72] versus the pre-ERP group (n=21/34) +0.34L [0.24-0.49] (p=0.06). We did not observe different outcomes for unilateral LVRS. Conclusion The implementation of an ERP for LVRS resulted in a decreased length-of-stay for bilateral procedures related to decreased air leak incidence and duration. Excellent 3m functional outcomes after ERP were accomplished with less postoperative morbidity/mortality as compared to pre-ERP. Key words: chronic obstructive pulmonary disease; emphysema; hyperinflation; lung volume reduction surgery; enhanced recovery program