It is rarely necessary to transplant a lung on thecontralateral side, and this technique should be usedwith caution. However, in case of donor shortage, alloptions should be considered in order to use the poten-tial of available donors to its maximum.
References1. De Hoyos AL, Patterson GA, Maurer R, et al. Pulmonary
transplantation. Early and late results. J Thorac CardiovascSurg 1992;103:295–306.
2. Piotrowski JA, Splittgerber FH, Donovan TJ, Ratjen F,Zerkowski HR. Single-lung transplantation in a patient withcystic fibrosis and an asymmetric thorax. Ann Thorac Surg1997;64:1456–9.
3. Couetil JP, Tolan MJ, Loulmet DF, et al. Pulmonary bipartion-ing and lobar transplantation: a new approach to donor organshortage. J Thorac Cardiovasc Surg 1997;113:529–37.
4. Puskas JD, Winton TL, Miller JD, Scavuzzo M, Patterson GA.Unilateral donor lung dysfunction does not preclude success-ful contralateral single lung transplantation. J Thorac Cardio-vasc Surg 1992;103:1015–8.
5. Calhoon JH, Grover FL, Gibbons WJ, et al. Single lungtransplantation. Alternative indications and technique. J Tho-rac Cardiovasc Surg 1991;101:816–24.
6. Couetil JP, Tolan MJ, Grousset A, et al. Experimental bilaterallobar lung transplantation and its application in humans.Thorax 1997;52:714–7.
Management of CongenitalAbnormalities of the Donor LungFrank Schmidt, MD, David C. McGiffin, MD, GeorgeZorn, MD, K. Randall Young, MD, David Weill, MD,and James K. Kirklin, MD
Lung Transplant Program, Division of Cardiothoracic Surgery,and Division of Pulmonary, Allergy, and Critical CareMedicine, University of Alabama at Birmingham, Birmingham,Alabama
Congenital abnormalities were encountered in three do-nor lungs. A donor tracheal bronchus was incorporatedinto the right bronchial anastomosis. Anomalous pulmo-nary venous return of the right upper lobe to the superiorvena cava and the left upper lobe to the innominate veinwere managed by bridging the anomalous veins to theleft atrial cuff with autologous pericardium and donoriliac vein, respectively.
The increasing disparity between the number of donorlungs available and the number of patients requir-
ing lung transplantation obligates surgeons to considerall potential donor lungs for transplantation, includingthose with congenital abnormalities. This report de-scribes the intraoperative management of a donor lungwith anomalous origin of the apical segmental bronchusof the right upper lobe from the trachea as well as 2patients with partial anomalous pulmonary venousdrainage.
Case ReportsCase 1A 49-year-old woman underwent bilateral sequentiallung transplantation for smoking-related emphysema.The apical segmental bronchus of the right upper lobe ofthe donor lung arose anomalously from the trachea. Afterdivision of the right main stem bronchus, the origin of theanomalous bronchus was excised with a cuff of donortrachea. After transection of the recipient right mainbronchus, a small wedge of recipient right main bron-chus was excised from the upper border to accommodatethe cuff of donor trachea. The bronchial suture line wasperformed with continuous 4-0 polydioxanone suture tothe membranous floor and interrupted sutures of 4-0prolene to the cartilaginous arch incorporating the anom-alous apical segmental bronchus into the cartilaginousportion of the anastomosis (Fig 1). A wrap of peribron-chial adventitial tissue was sutured over the bronchialanastomosis. The patient’s recovery was uneventful androutine surveillance bronchoscopy has continued to
Accepted for publication Sept 14, 2000.
Address reprint requests to Dr McGiffin, University of Alabama atBirmingham, 1530 3rd Ave South, LHRB 780, Birmingham, AL 35294-0007;e-mail: [email protected].
Fig 2. Postoperative pulmonary angiogram showing normal aspectof the pulmonary artery (arrow).
935Ann Thorac Surg CASE REPORT SCHMIDT ET AL2001;72:935–7 ANOMALIES OF THE DONOR LUNG
demonstrate a patent apical segmental bronchus, now 3years after transplantation.
Case 2A 24-year-old man who had previously undergone repairof a fossa ovalis type atrial septal defect at 4 years oldsubsequently developed Eisenmenger’s syndrome. Heunderwent bilateral sequential lung transplantation re-quiring the use of cardiopulmonary bypass. The donorright upper lobe pulmonary vein drained anomalously tothe superior vena cava. The pulmonary venous anasto-mosis was performed by anastomosing the donor lowerpulmonary vein to the recipient left atrial cuff with aconduit of autologous pericardium. Postoperatively, graftfunction was initially good without radiologic or clinicalevidence of right upper lobe venous thrombosis. Thepatient subsequently succumbed from multiorgan sys-tem failure precipitated by cyclosporine-induced acuterenal failure. No autopsy was performed.
Case 3A 56-year-old man with smoking-related emphysemaunderwent a left single lung transplant. The donor leftupper lobe pulmonary vein was found to drain anoma-lously to the innominate vein. The donor inferior pulmo-nary vein was anastomosed directly to the recipientinferior pulmonary vein and the anomalous superiorpulmonary vein was bridged to the recipient superiorpulmonary vein with a segment of donor iliac vein (Fig 2).Graft function was good and the patient made an un-eventful recovery. A magnetic resonance angiogram withgadolinium was performed 1 year after transplantation,which demonstrated a patent iliac vein graft (Fig 3).
Fig 1. Excision of the anomalous segmental bronchus with a cuff ofdonor trachea and incorporation of the cuff into the bronchial sutureline.
Fig 2. Bridging the donor anomalous left upper lobe pulmonary veinto the recipient upper lobe pulmonary vein with a segment of donoriliac vein.
Fig 3. Magnetic resonance angiogram with gadolinium demonstrat-ing a patent iliac vein graft.
936 CASE REPORT SCHMIDT ET AL Ann Thorac SurgANOMALIES OF THE DONOR LUNG 2001;72:935–7
CommentThese congenital abnormalities of the lung should notexclude organs for transplantation since their manage-ment is straightforward. The use of donor iliac vein tobridge an anomalous pulmonary vein to the recipient leftatrial cuff simplifies the reconstruction. Partial anoma-lous pulmonary venous drainage of the left or right upperlobe [1–3] and anomalous origin of the apical segmentalbronchus from the trachea [4, 5] are uncommon anoma-lies that may be encountered at the time of donor lungprocurement. These technical modifications to the lungtransplant procedure will allow transplantation of donorlungs with these congenital abnormalities.
3. Babb JD, McClynn TJ, Pierce WS, Kirkman PM. Isolatedpartial anomalous venous connection: a congenital defectwith late and serious complications. Ann Thorac Surg 1981;31:540.
4. Barat M. Konrad HR. Tracheal bronchus. Am J Otolaryngol1987;8:118.
5. Le Roux BT. Anatomical abnormalities of the right upper lobebronchus. J Thorac Cardiovasc Surg 1962;44:225.
Chylothorax ComplicatingGorham’s DiseaseNicolas Chavanis, MD, Philippe Chaffanjon, MD, GilFrey, MD, Gabrielle Vottero, MD, and Pierre-YvesBrichon, MD
Departments of Thoracic Surgery and Pneumology, HopitalAlbert Michallon, Grenoble, France
Gorham’s disease is a rare disorder characterized by aproliferation of thin-walled lymphatic vessels (lymphan-giectasia) resulting in an osteolysis. A chylothorax ispresent in about one-fifth of the patients and carries apoor prognosis. In this circumstance, surgery includingthoracic duct ligation, pleurodesis, and excision of in-volved tissue is probably the treatment of choice. It isfacilitated by a precise radiological assessment using acomputed tomographic scanning coupled with a lympho-graphy. We report such a case.
Gorham’s disease is an unusual proliferation of ab-normal lymphatic vessels leading to an osteolysis.
The occurrence of a chylothorax has a poor prognosis andthe treatment of this complication remains controversial.Aggressive surgery supported by a precise radiologicalassessment seems better than medical therapy.
A 45-year-old woman was referred to us for a leftspontaneous chylothorax. Past medical history revealed aleft idiopathic facial muscle paralysis and multiple occur-rences of lymphoedema of the left upper limb, thatappeared 10 years ago during a gestation. No diagnosiswas made at that time. X-ray examination of the left handshowed a massive osteolysis, and the diagnosis ofGorham’s disease was suspected at referral. During 1month, total parenteral hyperalimentation and pleuraldrainage were unsuccessful, and the chylothorax per-sisted. A lymphography coupled with a computed tomo-graphic scan was performed and showed a mediastinallymphomatous process on the left upper mediastinumabove a normal thoracic duct (Figs 1 and 2). A leftpostero-lateral thoracotomy was performed with ligationof the thoracic duct (without division) at the lower part ofthe chest and excision of the pathologic lymphangioma-tous mediastinal tissue that stayed in a subpleural loca-tion within the thymic area (a thymectomy was not
Accepted for publication Aug 23, 2000.
Address reprint requests to Dr Brichon, Service de Chirurgie Thoracique,Centre Hospitalier Universitaire Albert Michallon, BP 217, F-38043Grenoble Cedex 09, France; e-mail: [email protected].
Fig 1. Chest roentgenogram during lymphography: normal thoracicduct (long arrow) continued by mediastinal lymphangiectasy at thesuperior part of the chest (thick arrow).
937Ann Thorac Surg CASE REPORT CHAVANIS ET AL2001;72:937–9 CHYLOTHORAX IN GORHAM’S DISEASE
