title: Delayed chest closure after lung transplantation: techniques, outcomes, and strategies.
abstract: BACKGROUND
  Delayed chest closure (DCC) after lung transplantation is a viable option to be taken in the cases of prolonged cardiopulmonary bypass time, prolonged ischemic time, coagulopathic problems or oversized donor lung grafts. Decision-making for DCC in the operating room remains challenging to surgeons, because the impact of DCC on outcomes after lung transplantation has not yet been fully elucidated.
  
  
  METHODS
  We performed a retrospective review of 90 lung transplantations with DCC and 783 cases with primary chest closure to clarify the reasons for DCC, complications of DCC, and the risk factors for adverse outcomes.
  
  
  RESULTS
  The 30- and 90-day mortality in the DCC group was 7.8% and 9.9%, respectively. Early post-operative bleeding and severe primary graft dysfunction (PGD) were higher in the DCC group (p<0.05). In multivariate analysis, prolonged cardiopulmonary bypass use (>4 hours), post-operative extracorporeal oxygen requirement and use of a DCC technique with open skin and retracted ribs were significantly associated with mortality (p<0.05), whereas prolonged duration of DCC was not. In a matched cohort study to compare the results of a DCC technique with skin closure to similarly matched controls with primary closure, DCC contributed to significantly decreased incidence of severe PGD (9.6% vs. 26%, p<0.05), leading to an improved post-transplant survival and functional status as compared with primary closure.
  
  
  CONCLUSIONS
  Our technical approaches to prevent possible problems in DCC cases are described. DCC can be safely performed with acceptable procedure-related risks. DCC should not be considered a sub-optimal option after lung transplantation.
authors.affiliation: Division of Cardiothoracic Transplantation, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania. Electronic address: shigemuran@upmc.edu.
authors.forename: Norihisa
authors.initials: N
authors.lastname: Shigemura
authors.affiliation: Division of Cardiothoracic Transplantation, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
authors.forename: Yucel
authors.initials: Y
authors.lastname: Orhan
authors.affiliation: Division of Cardiothoracic Transplantation, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
authors.forename: Jay K
authors.initials: JK
authors.lastname: Bhama
authors.affiliation: Division of Cardiothoracic Transplantation, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
authors.forename: Jonathan
authors.initials: J
authors.lastname: D'Cunha
authors.affiliation: Division of Cardiothoracic Transplantation, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
authors.forename: Diana
authors.initials: D
authors.lastname: Zaldonis
authors.affiliation: Division of Pulmonary Allergy and Critical Medicine, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
authors.forename: Joseph M
authors.initials: JM
authors.lastname: Pilewski
authors.affiliation: Division of Cardiothoracic Transplantation, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
authors.forename: James D
authors.initials: JD
authors.lastname: Luketich
authors.affiliation: Division of Cardiothoracic Transplantation, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
authors.forename: Christian A
authors.initials: CA
authors.lastname: Bermudez
mesh_terms: D000328:Adult; D002315:Cardiopulmonary Bypass; D015331:Cohort Studies; D005260:Female; D006801:Humans; D008168:Lung / Q000473:pathology / Q000601:surgery; D016040:Lung Transplantation / Q000379:methods*; D008297:Male; D008875:Middle Aged; D009929:Organ Size; D017063:Outcome Assessment, Health Care; D012189:Retrospective Studies; D013908:Thoracotomy / Q000379:methods*; D013997:Time Factors; D016896:Treatment Outcome; D052096:Warm Ischemia; D058106:Wound Closure Techniques
keywords: delayed chest closure; early complications; extracorporeal membrane oxygenator (ECMO); lung transplantation; post-operative outcomes; primary graft dysfunction; thoracotomy