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.
Transplantation and Immunobiology Research Group, University of Newcastle Upon Tyne and Freeman Hospital, Newcastle Upon Tyne, United Kingdom. helencurtis@doctors.org.uk
Helen Jane
HJ
Curtis
Stephen J
SJ
Bourke
Jonathon H
JH
Dark
Paul A
PA
Corris
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