title: Outcomes of minimally invasive lung transplantation in a single centre: the routine approach for the future or do we still need clamshell incision?
abstract: Minimally invasive lung transplantation (MILT) via bilateral anterior thoracotomies has emerged as a novel surgical strategy with potential patient benefits when compared with transverse thoracosternotomy (clamshell incision, CS). The aim of this study is to compare MILT with CS by focusing on operative characteristics, postoperative organ function and support and mid-term clinical outcomes at Harefield Hospital.
  
  
  
  It was a retrospective observational study evaluating all bilateral sequential lung transplants between April 2010 and November 2013.
  
  
  
  CS was performed in 124 patients and MILT in 70 patients. Skin-to-skin surgical time was less in the MILT group [285 (265, 339) min] compared with CS [380 (306, 565) min] and MILT-cardiopulmonary bypass [426 (360, 478) min]. Ischaemic time was significantly longer (502 ± 116 vs 395 ± 145 min) in the MILT group compared with CS (P < 0.01). Early postoperative physiological variables were similar between groups. Patients in the MILT group required less blood [2 (0, 4) vs 3 (1, 5) units, P = 0.16] and platelet transfusion [0 (0, 1) vs 1 (0, 2) units, P < 0.01]. The median duration of mechanical ventilation was shorter (26 vs 44 h, P < 0.01) and intensive therapy unit stay was 2 days shorter (5 vs 7) in the MILT group. While overall survival was similar, fraction of expired volume in 1 s (FEV1) and forced vital capacity (FVC) were consistently higher in the MILT group compared with CS during mid-term follow-up after transplantation. Specifically, FEV1 and FVC were, respectively, 86 ± 21 and 88 ± 18% predicted in the MILT group compared with 74 ± 21 and 74 ± 19% predicted in the CS group (P < 0.01) at the 6-month follow-up.
  
  
  
  MILT was successfully introduced at our centre as a novel operative strategy. Despite longer ischaemic times and a more complex operation and management, MILT appears to offer early postoperative and mid-term clinical benefits compared with our traditional approach of clamshell operations. These observations warrant larger definite studies to further evaluate the impact of MILT on physiological, clinical and patient-reported outcomes.
authors: Department of Anaesthetics, Harefield Hospital, Royal Brompton and Harefield NHS Foundation Trust, Harefield, Middlesex, UK Department of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK Department of Anaesthesia and Intensive Therapy, Semmelweis University, Budapest, Hungary.
authors: Nandor
authors: N
authors: Marczin
authors: Department of Cardiothoracic Transplantation and Mechanical Circulatory Support. Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust, Harefield, Middlesex, UK.
authors: Aron-Frederik
authors: AF
authors: Popov
authors: Department of Cardiothoracic Transplantation and Mechanical Circulatory Support. Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust, Harefield, Middlesex, UK.
authors: Bartlomiej
authors: B
authors: Zych
authors: Department of Anaesthetics, Harefield Hospital, Royal Brompton and Harefield NHS Foundation Trust, Harefield, Middlesex, UK Department of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.
authors: Rosalba
authors: R
authors: Romano
authors: Department of Anaesthetics, Harefield Hospital, Royal Brompton and Harefield NHS Foundation Trust, Harefield, Middlesex, UK Department of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.
authors: Rudolf
authors: R
authors: Kiss
authors: Department of Cardiothoracic Transplantation and Mechanical Circulatory Support. Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust, Harefield, Middlesex, UK a.sabashnikov@gmail.com.
authors: Anton
authors: A
authors: Sabashnikov
authors: Department of Cardiothoracic Transplantation and Mechanical Circulatory Support. Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust, Harefield, Middlesex, UK.
authors: Simona
authors: S
authors: Soresi
authors: Department of Cardiothoracic Transplantation and Mechanical Circulatory Support. Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust, Harefield, Middlesex, UK.
authors: Fabio
authors: F
authors: De Robertis
authors: Department of Cardiothoracic Transplantation and Mechanical Circulatory Support. Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust, Harefield, Middlesex, UK.
authors: Toufan
authors: T
authors: Bahrami
authors: Department of Cardiothoracic Transplantation and Mechanical Circulatory Support. Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust, Harefield, Middlesex, UK.
authors: Mohamed
authors: M
authors: Amrani
authors: Department of Cardiothoracic Transplantation and Mechanical Circulatory Support. Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust, Harefield, Middlesex, UK.
authors: Alexander
authors: A
authors: Weymann
authors: Department of Anaesthetics, Harefield Hospital, Royal Brompton and Harefield NHS Foundation Trust, Harefield, Middlesex, UK Department of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.
authors: Grainne
authors: G
authors: McDermott
authors: Department of Cardiothoracic Transplantation and Mechanical Circulatory Support. Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust, Harefield, Middlesex, UK.
authors: Heike
authors: H
authors: Krueger
authors: Department of Cardiothoracic Transplantation and Mechanical Circulatory Support. Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust, Harefield, Middlesex, UK.
authors: Martin
authors: M
authors: Carby
authors: Department of Cardiothoracic Transplantation and Mechanical Circulatory Support. Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust, Harefield, Middlesex, UK.
authors: Paras
authors: P
authors: Dalal
authors: Department of Cardiothoracic Transplantation and Mechanical Circulatory Support. Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust, Harefield, Middlesex, UK.
authors: André Ruediger
authors: AR
authors: Simon
mesh_terms: D000328:Adult; D005260:Female; D006801:Humans; D016040:Lung Transplantation / Q000379:methods*; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000379:methods*; D061646:Operative Time; D012189:Retrospective Studies; D013908:Thoracotomy / Q000379:methods*
keywords: Cardiopulmonary bypass; Lung transplantation; Minimally invasive