Living donor lobar lung transplantation ( LDLLT)

Policy:
our programme has been to limit LDLLT to critically ill patients
who are unlikely to survive the long wait for cadaveric lungs.
Criteria of the donor:

 ABO blood group compatibility

 General good health
• Age ≤ 55 years
• No significant past medical history
• No recent viral infections
• Normal echocardiogram
• Normal electrocardiogram
• Oxygen tension > 80 mmHg on room air
• Forced expiratory volume in 1 s and forced vital
capacity> 85 % predicted
• No significant pulmonary pathology on computed tomography
(completely normal on donor side)
• No previous thoracic operation on donor side
Whereas we originally considered only parents as appropriate
potential donors, we have expanded our criteria to include siblings,
extended family members, and occasionally unrelated individuals
who can demonstrate an appropriate nonfinancial relationship to
the recipient. Potential donors are carefully interviewed and
analyzed from a psychological and social standpoint to determine
their relationship with the recipient, motivation for donation,
ability to withstand the pain and recovery from the operation, and
their understanding and ability to withstand a potentially poor
recipient outcome. They are also interviewed independently in
order to identify potential evidence of coercion or other emotional
issues that might exclude them from participating.

LDLLT usually requires two healthy donors who donated either a

right or a left lower lobe. When only one donor was available with
adequate size matching, we performed a single LDLLT.
Aim from donor selection is to identify healthy donors with
adequate pulmonary reserve, appropriate motivation, and an
understanding and willingness to accept the risks of donation.

Investigations :
 ABO blood group compatibility with the potential recipient.
 Routine labs including liver functions, kidney functions,
bleeding profile and complete blood count.
 Cultures to exclude current and previous bacterial, viral,
and fungal infections( blood, sputum, urine, stool).
 Serologic tests for hepatitis A, B, and C, human
immunodeficiency virus, varicella, Epstein-Barr virus, herpes
simplex virus, and cytomegalovirus
 Room air arterial blood gas and spirometry.
Ventilation-perfusion (VQ) scan.
 Computed tomography (CT) scan of the chest to exclude
pulmonary pathology and to allow volumetric assessment (
3D CT volumetry).
Determination of the cytomegalovirus status was performed
to predict which patients would need prophylactic antiviral
therapy. Cytomegalovirus mismatch was not used as an
exclusion to transplantation.
Size matching:
Functional and anatomical size matching is very important. given
that the right lower lobe consists of 5 segments, the left lower lobe
of 4, and the whole lung of 19, total forced vital capacity (FVC) of
the 2 grafts was estimated by the following equation.

Total FVC of the 2 grafts = Measured FVC of the right donor

X 5/19 + Measured FVC of the left donor X 4/19
When the total FVC of the 2 grafts was >50% of the predicted
FVC of the recipient (calculated from a knowledge of height, age,
and sex), we accepted the size disparity regardless of the
recipient’s diagnosis.
This ‘functional size matching’ has been used to determine the
lower threshold undersized grafts. For ‘anatomical size matching’,
three-dimensional computed tomography (3D-CT) volumetric
images are now in practice.

Complications of the donor:

Pulmonary
Air leak >5 days
Atelectasis requiring bronchoscopy
Pneumonia
ARDS
Bronchopleural fistula
Pulmonary embolus
Initial vent support
Reintubation
Tracheostomy
Other pulmonary event
Cardiovascular
Atrial arrhythmia
Ventricular arrhythmia
Myocardial infarct
DVT
Other CV event
Gastrointestinal
Gastric outlet obstruction
Ileus
Other GI event
Hematology
Bleeding requiring reoperation
Blood transfusion intraop or postop
Other hematology/bleeding event
Infection
Urinary tract infection
Empyema
Wound infection
Sepsis
Neurology
New central neurologic event
Recurrent laryngeal nerve paresis or paralysis
Other neurologic event
Miscellaneous
New renal failure requiring Rx or worsening
Chylothorax requiring drainage/medical Rx
Chylothorax requiring surgical intervention
Delerium tremens
Other events requiring medical Rx
Other events requiring OR with general anesthesia
Oversized graft
The use of oversized grafts could cause high airway resistance,
atelectasis and hemodynamic instability by the time of chest
closure. segmentectomy of the superior segment of an oversized
right lower lobe graft obtained
Undersized graft
When grafts are too small, a limited amount of vascular bed might
cause high pulmonary artery pressure, resulting in lung edema.
Intrathoracic dead space can remain and cause complications, such
as postoperative bleeding, persistent air leakage and empyema.

Eithical issues:
In this situation they are being asked to operate on two fit people,
leaving them with four, instead of five, lung lobes, in the hope of
saving the life of a critically ill third person.

A donor with four lung lobes instead of five lung lobes will have
less exercise tolerance for competitive sports, but will be able to
live a normal life in all other respects. The reason why the
individual wishes to donate must be explored. No money, or other
reward, must be involved. The reason given is usually to see a
loved one survive
Potential donors were interviewed by 3 physicians with an
observer to safeguard against coercion and to ensure donor
comprehension of the procedure. The interview was performed at
least 3 times to provide potential donors multiple opportunities to
question, reconsider, or withdraw as a donor.

The ethical principles involved in decision making for living organ

donors were extensively analyzed by a multidisciplinary group
from the transplant community, which included physicians, nurses,
psychologists, attorneys, social workers, transplant donors,
recipients, and several ethicists It provides a template for the
structure of an ethically sound clinical program. Emphasis is
placed on ensuring both medical and psychosocial suitability of the
potential donor and an optimal informed consent.

Selection of the lobe:

In this procedure, right and left lower lobes from two healthy
donors are implanted in the recipient in place of whole right and
left lungs, respectively. The middle lobe is asmall lobe can give
suboptimal function besides difficult technical anastomosis but it
can be implanted with the lower lobe. The obstacle of the upper
lobe is that it needs reconstruction .