Commentary: Creative solutions for lung transplantation with chest wall asymmetry and cystic fibrosis

Nirmal Veeramachaneni, MD, and Varun Puri, MD

Central Message.

Lung transplantation in patients with cystic fibrosis provides unique challenges of chest wall asymmetry.

See Article page 652.

In 1937, John Alexander¹ wrote the definitive treatise on collapse therapy for pulmonary tuberculosis. Nearly a century later, the work remains an important contribution to our field but thankfully no longer a treatise employed in routine practice. The accompanying work by the Vienna Lung Transplant Group demonstrates complex surgical decision-making in the management of very high-risk group of patients undergoing lung transplant. While patients with cystic fibrosis have historically been the group most likely to expect long-term benefit from lung transplantation, this indication for lung transplantation may become of historical interest due to advances in cystic fibrosis therapy applicable to the majority of patients newly diagnosed with cystic fibrosis. Recent therapies, which can begin in childhood, will no doubt change the trajectory of morbidity and mortality from this genetic disease.² We hope that the author's opening paragraph comment of the need for transplantation in the fifth decade of life will prove incorrect.³

Patients with cystic fibrosis are more prone to asymmetry of the chest wall due to increased prevalence of scoliosis and asymmetric destruction of the lung secondary to infection and bronchiectasis. Some patients, during the course of their disease, may in fact benefit from selective lobectomy to treat intractable infection or complications of hemoptysis. The authors describe a series of patients requiring surgical creativity. For this disease, given the risks of contamination to the transplanted lung, single-lung transplantation is typically not feasible. The authors present a small series of patients who in fact underwent single-lung transplantation with delayed pneumonectomy of a smaller contralateral lung or single-lung transplantation in patients who have undergone previous pneumonectomy. The authors also describe a small number of patients wherein the patient received a full-sized lung on one side and lobar transplantation on the contralateral side. As one may expect, these patients have a greater perioperative morbidity and mortality than routine patients. Aggressive surgical treatment such as this should only be done in experienced high-volume centers.

The accompanying article describes the feasibility of nonstandard transplantation strategies. Given the prolonged time frame and small number of patients, it is not reasonable to make broad conclusions. The article highlights surgical possibilities for patients requiring lung transplantation for infectious disease complications. Other investigators have already demonstrated the concept of pneumonectomy to control overwhelming sepsis with plan for delayed transplantation with patients being supported on modified cardiopulmonary bypass circuits.⁴ We applaud the authors on their creativity, and we expect this manuscript to be a useful reference for future generations of surgeons.