Minimally Invasive Approach Has Advantages in Lung Transplantation

BOSTON — A novel, minimally invasive approach for lung transplant surgery produces small, cosmetically superior incisions and causes less pain than the conventional surgical method, according to results from a series of 116 patients.

In 68 patients treated with an anteroaxillary approach and 48 patients treated with a conventional approach, survival rates to 180 days after surgery were very similar—more than 90% in both groups. Patients in the anteroaxillary group were more likely to be extubated within 48 hours of surgery and less likely to need mechanical ventilation for more than 5 days, Dr. Yoshiya Toyoda reported at the annual meeting of the International Society for Heart and Lung Transplantation.

The anteroaxillary approach also preserved bilateral internal mammary arteries and the sternum, permitted rapid use of cardiopulmonary bypass, resulted in quick chest closure because of a small incision, and required less manipulation of the heart and phrenic nerve.

Because of these and other advantages, the anteroaxillary approach has become the standard surgical method used for lung transplants at the University of Pittsburgh Medical Center, where Dr. Toyoda is a thoracic surgeon and head of cardiopulmonary transplantation.

Dr. Toyoda reviewed his experience performing single- or double-lung transplantation at the university since the start of 2006. The conventional surgical approach, used in 48 patients, usually consisted of a posterolateral thoracotomy for single-lung transplantation, or a clamshell approach for double lung.

Since the new approach was first used last year, it has been performed on 68 patients, including 60 of 63 consecutive patients treated through April 2008. This series included 23 patients (34%) aged 65 or older, of whom 10 patients were aged 70 or older. The oldest patient he has treated with the anteroaxillary approach was 81.

Cardiopulmonary bypass use and time were similar in the two surgical groups, and the outcomes were also very similar. The survival rate to 180 days following surgery was 91% in the patients treated by the anteroaxillary route and 92% in patients having conventional surgery.

The anteroaxillary approach led to a significant increase in the rate of patients becoming extubated within 48 hours of surgery (68% vs. 48% of those having conventional surgery), and a significant drop in the rate of mechanical ventilation greater than 5 days (15% vs. 35%). The average hospital length of stay was shorter with the anteroaxillary approach, 31 days, compared with 37 days with standard surgery, but this difference was not significant.

The only contraindications to use of the anteroaxillary approach are in patients who require multivessel coronary artery bypass surgery, and patients who need aortic repair in the region from the aortic root to the arch, Dr. Toyoda said.

An anteroaxillary incision decreases recovery time after lung transplantation. Courtesy Dr. Yoshiya Toyoda