Lung transplantation outcome in cystic fibrosis patients with previous pneumothorax.
BACKGROUND
High perioperative mortality that results from hemorrhage from pleural adhesions was reported in the early experience of heart-lung transplantation. This led to previous pleural procedures becoming a relative/absolute contraindication to transplantation in some centers, despite the advent of bilateral lung transplantation. Has this lead to a more conservative approach to pneumothorax management in patients with cystic fibrosis (CF)? And what is the effect of previous pleural procedures on surgical outcome of lung transplantation?


METHODS
We reviewed 3 groups of patients transplanted at this center from 1989 to 2002, matched for year of lung transplantation. Group A comprised 16 patients with CF with a history of previous pneumothorax with or without pleural procedure. Group B comprised 16 patients with CF with no history of pneumothorax. Group C comprised 16 noninflammatory/nonbronchiectatic patients with no history of pneumothorax. Measured outcomes included blood products provided intraoperatively; operation and cardiopulmonary bypass times; postoperative hemorrhage; times to extubation, discharge from the intensive care unit and hospital discharge; forced expiratory volume at 1 second at 6 months; 30-day mortality; pleural adhesions graded descriptively; and previous pneumothorax management (Group A only). There were 35 pneumothorax episodes in the 16 patients in Group A. Nine episodes were managed with observation alone. Nine patients required invasive management, 25 chest drains were placed, 3 patients received medical pleurodesis, and 2 underwent thoracic surgical intervention.


RESULTS
No significant difference was observed between the 3 groups regarding blood products intraoperatively or duration of procedure. Pleural adhesions found at operation were significantly more in Group A, with dense adhesions found only in Group A (p<0.05). Group C was significantly more likely to be free from adhesions, with 13 patients clear (p<0.01 Group C vs Group A, Group C vs Group B). No statistically significant difference was found in the other measured parameters.


CONCLUSIONS
Pneumothorax is treated conservatively in a potential lung transplant population. Patients with CF and previous pneumothorax with or without pleural procedures undergoing lung transplantation have dense pleural adhesions; however, this does not affect surgical outcome significantly. Patients with emphysema, fibrosing alveolitis, or obliterative bronchiolitis were significantly more likely to be free of pleural adhesions, suggesting that the inflammatory/chronic infective component of CF independently contributes to the increased pleural adhesions. Previous pleural procedures for pneumothorax should not be considered a contraindication in the assessment of suitability for lung transplantation.
Curtis
Helen Jane
HJ
Transplantation and Immunobiology Research Group, University of Newcastle Upon Tyne and Freeman Hospital, Newcastle Upon Tyne, United Kingdom. helencurtis@doctors.org.uk
Bourke
Stephen J
SJ
Dark
Jonathon H
JH
Corris
Paul A
PA
D000293:Adolescent; D000328:Adult; D000075202:Contraindications; D003550:Cystic Fibrosis / Q000601:surgery*; D005260:Female; D006801:Humans; D016040:Lung Transplantation; D008297:Male; D008875:Middle Aged; D011030:Pneumothorax / Q000601:surgery / Q000628:therapy*; D012189:Retrospective Studies; D016896:Treatment Outcome