Perioperative management of esophagectomy in a patient who previously underwent bilateral lung transplantation
© The Author(s) 2016
Received: 28 March 2016
Accepted: 6 July 2016
Published: 12 July 2016
General theory of anesthetic managements for nontransplant procedures in lung transplant patients was proposed. However, there are few literatures reporting the perioperative management of thoracoabdominal major surgery following lung transplantation in detail. Herein, we scrupulously report a perioperative management of esophagectomy in a patient who previously underwent bilateral lung transplantation (BLTx), focusing on protection of the transplanted lungs and the respiratory function of the patient.
A 50-year-old woman was listed for cadaveric BLTx for severe respiratory failure due to end-stage diffuse panbronchiolitis. She underwent BLTx under veno-arterial extracorporeal membranous oxygenation support. Blood loss during the BLTx was 13,675 mL, and mild lung edema developed. She was weaned from the ventilator on the sixth postoperative day (POD) and discharged on the 65th POD. Two years after the BLTx, respiratory function improved markedly, but she was diagnosed with esophageal cancer and was scheduled for thoracoscopic esophagectomy with radical lymph node dissection, hand-assisted laparoscopic gastric mobilization, and anastomosis of the gastric conduit to the cervical esophagus via posterior mediastinum. We were concerned that impaired lymphatic drainage could cause pulmonary edema or lymphangiogenesis could cause a severe immunologic response against the lung grafts. To avoid graft injury and rejection, we addressed lung protective ventilation, reduced transfusion volume, continued immunosuppressive agents, administered volatile anesthetics, and prevented dynamic pain by epidural analgesia. These factors and the improved respiratory function may have contributed to successful management of esophagectomy. During the perioperative period, the major respiratory problems were a slight right lung edema and a persistent pulmonary air leak due to the division of thoracic adhesions, which resolved on 13th POD.
Cancer surgeries in lung transplant recipients become more common. When such patients undergo thoracoabdominal major surgery, we should pay special attention to respiratory function, operative stress, immunosuppressive therapy, transfusion volume for the prevention of lung edema, and thoracic adhesions.
General theory of anesthetic managements for nontransplant procedures in lung transplant patients was discussed . However, there are few literatures reporting the perioperative management of thoracoabdominal major surgery following lung transplantation in detail. And then, we managed an esophagectomy with radical lymph node dissection in a patient who previously underwent bilateral lung transplantation (BLTx). During the perioperative period of the esophagectomy, deterioration of expectoration and lung edema followed by respiratory dysfunction, and graft rejection were issues. Herein, we scrupulously report the perioperative management of the esophagectomy following BLTx, focusing on protection of the transplanted lungs and the respiratory function of the patient.
Arterial blood gas, spirometric, and echocardiographic data of the patient before BLTx and before esophagectomy
Arterial blood gases on room air
Two years after the BLTx, the follow-up chest CT findings suspected esophageal cancer, and the patient was diagnosed with stage II esophageal cancer via esophagogastroduodenoscopy. Three months later, she was scheduled for thoracoscopic esophagectomy with radical lymph node dissection, hand-assisted laparoscopic gastric mobilization, and anastomosis of the gastric conduit to the cervical esophagus via posterior mediastinum.
Postoperative white blood cell counts, serum C-reactive protein, creatinine and lactate levels, and water balance during perioperative period
Infusion volume (mL)
Water output (mL)
Body weight (kg)
Solid organ transplant recipients have elevated cancer risk due to immunosuppression [2, 3]. As a result, cancer surgeries in lung transplant recipients may increase along with the increase in lung transplants. During these surgeries, protection of the lung graft is the top priority, because the 5-year survival for the recipients of cadaveric donor lung transplants is approximately 50 % , which is significantly lower than that of other organ transplants but similar to that of patients with stage II esophageal cancer.
During lung transplantation, anastomosis of donor lymphatic vessels to those of the recipient is not performed. Therefore, pulmonary edema and acute rejection readily occur for several days after transplantation. The graft lymphatics establish new connections with regional lymph nodes no earlier than at least 7 days [5, 6]. Subsequently, lymphatic drainage would remove excess lung fluid and damaging substances, which would improve graft outcome . However, the extent of lymphangiogenesis after transplantation might correlate with the magnitude of donor antigen presentation and may influence the severity of the immunologic response against the donor organ [8, 9]. Therefore, we took great care to avoid enhancement of her immunological response, which could induce graft injury and rejection. The measures were as follows: (1) lung protective ventilation with FIO2 ≤ 0.6, PEEP = 5 cmH2O, PIP ≤ 18 cmH2O; (2) the continuation of immunosuppressive agents and loading of methylprednisolone during the perioperative period; (3) neutrophil elastase inhibitor (sivelestat) infusion; (4) use of volatile anesthetics (desflurane) preventing inflammation for the maintenance of anesthesia ; and (5) adequate control of pain using epidural analgesia. Neuraxial anesthesia is considered to facilitate coughing, expectoration, and active mobilization, and prevent atelectasis and respiratory infections, although neuraxial anesthesia reduce intercostal muscle strength. Furthermore, thoracic epidural analgesia blocks sympathetic nervous system, which inhibits inflammatory reaction supplementarily. Although these measures were used, inflammatory reaction raised maximum level (WBC 19,000/μL and CRP 5.4 mg/dL), indicating moderate-to-intense inflammatory reaction, on the first to second POD and continued until the 13th POD. Therefore, slight right lung edema was observed but graft injury and rejection were not observed.
Transplanted lungs are highly susceptible to fluid overload over a long period. Lymphatic interruption increases the risk of extravascular lung water accumulation  and it may be responsible for pulmonary edema development following even minimal fluid overload . In this case, lymph node dissection, which removed newly established graft lymphatics, division of thoracic adhesions, and the placement of gastric conduit, which passed through the right posterior mediastinum, were performed. These procedures had the potentials to induce interstitial lung edema and subsequent pulmonary dysfunction, because of encouraging inflammation of lung tissue, hemorrhage, prolonged surgery, and increased transfusion. To reduce the transfusions and maintain low central venous pressure, which inhibit the increase in interstitial lung water , we used phenylephrine and noradrenaline for maintenance of adequate blood pressure, and carperitide for excretion of excess lung fluid during anesthesia. These treatments may have contributed to prevent further deterioration of the right lung edema and the progression to pulmonary dysfunction or rejection. In this case, we monitored arterial blood pressure and CVP for the assessment of hemodynamics, but CVP, fluctuating with changes of intrathoracic pressure, was inaccurate index of cardiac preload. Therefore, transpulmonary thermodilution technique might be better to assess the hemodynamics of patients like this case. But we did not use transpulmonary thermodilution technique in this case, because the cardiac function of the patient was normal and lithotomy position during abdominal manipulation could cause femoral arterial catheter kinking, although the measurement of extravascular lung water and pulmonary vascular permeability index would be useful in the postoperative managements of the patient. Furthermore, the reduction in blood flow to her bronchi during esophagectomy was of concern because the bronchial arteries had been eliminated from her lung. However, bronchoscopy during perioperative surgery showed the preservation of blood flow to her bronchi. Whereas, intravascular refilling and diuretic phase occurred in comparatively later POD (during the third POD and fourth POD). This might be because the dissection of the lung graft lymph node impaired the lymphatic drainage and removal of excess lung fluid.
The respiratory function of this patient improved significantly after BLTx. In two-lung ventilation during esophagectomy, her Cdyn, P/F, and ratio of dead space to tidal volume were within normal limit (30 mL/H2O, 500, and 0.15, respectively). Therefore, ventilatory insufficiency did not occur during artificial pneumothorax and pneumoperitoneum, although her PaCO2 was elevated transiently. However, in patients with single lung transplantation and/or poor lung graft function, ventilatory insufficiency might occur, which promotes ventilator-induced lung injury and an inflammatory reaction, followed by pulmonary dysfunction and graft rejection. During the perioperative period of esophagectomy, the major respiratory problems of this case were a slight right lung edema and a persistent pulmonary air leak due to the division of the thoracic adhesions, which needed 13 days to recover.
We report the perioperative management of a patient receiving esophagectomy who previously underwent BLTx. Cancer surgeries in lung transplant recipients increase. When such patients undergo thoracoabdominal major surgery as this case, we should pay special attention to respiratory function, operative stress, immunosuppressive therapy, volume of transfusion for prevention of lung edema, and thoracic adhesions.
Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
BLTx, bilateral lung transplantation; Cdyn, dynamic compliance; CO2, carbon dioxide gas; CT, computed tomography; CVP, central venous pressure; FIO2, fraction of inspired oxygen; P/F, arterial oxygen tension to FIO2 ratio; PEEP, positive end-expiratory pressure; PIP, peak inspiratory pressure; POD, postoperative day; RR, respiratory rate; V-A ECMO, veno-arterial extracorporeal membranous oxygenation
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- Feltracco P, Falasco G, Barbieri S, Milevoj M, Serra E, Ori C. Anesthetic considerations for nontransplant procedures in lung transplant patients. J Clin Anesth. 2011;23:508–16.View ArticlePubMedGoogle Scholar
- Engels EA, Pfeiffer RM, Fraumeni Jr JF, Kasiske BL, Israni AK, Snyder JJ, Wolfe RA, Goodrich NP, Bayakly AR, Clarke CA, Copeland G, Finch JL, Fleissner ML, Goodman MT, Kahn A, Koch L, Lynch CF, Madeleine MM, Pawlish K, Rao C, Williams MA, Castenson D, Curry M, Parsons R, Fant G, Lin M. Spectrum of cancer risk among US solid organ transplant recipients. JAMA. 2011;306:1891–901.View ArticlePubMedPubMed CentralGoogle Scholar
- Acuna SA, Fernandes KA, Daly C, Hicks LK, Sutradhar R, Kim SJ, Baxter NN. Cancer mortality among recipients of solid-organ transplantation in Ontario, Canada. JAMA Oncol. 2016;7:1–8.Google Scholar
- Yusen RD, Shearon TH, Qian Y, Kotloff R, Barr ML, Sweet S, Dyke DB, Murray S. Lung transplantation in the United States, 1999–2008. Am J Transplant. 2010;10:1047–68.View ArticlePubMedGoogle Scholar
- Ruggiero R, Fietsam Jr R, Thomas GA, Muz J, Farris RH, Kowal TA, Myles JL, Stephenson LW, Baciewicz FA Jr. Detection of canine allograft lung rejection by pulmonary lymphoscintigraphy. J Thorac Cardiovasc Surg. 1994;108:253–8.PubMedGoogle Scholar
- Ruggiero R, Muz J, Fietsam Jr R, Thomas GA, Welsh RJ, Miller JE, Stephenson LW, Baciewicz FA Jr. Reestablishment of lymphatic drainage after canine lung transplantation. J Thorac Cardiovasc Surg. 1993;106:167–71.PubMedGoogle Scholar
- Cui Y, Liu K, Monzon-Medina ME, Padera RF, Wang H, George G, Toprak D, Abdelnour E, D'Agostino E, Goldberg HJ, Perrella MA, Forteza RM, Rosas IO, Visner G, El-Chemaly S:. Therapeutic lymphangiogenesis ameliorates established acute lung allograft rejection. J Clin Invest. 2015;125:4255–68.Google Scholar
- Dietrich T, Bock F, Yuen D, Hos D, Bachmann BO, Zahn G, Wiegand S, Chen L, Cursiefen C. Cutting edge: lymphatic vessels, not blood vessels, primarily mediate immune rejections after transplantation. J Immunol. 2010;184:535–9.View ArticlePubMedGoogle Scholar
- Dashkevich A, Heilmann C, Kayser G, Germann M, Beyersdorf F, Passlick B, Geissler HJ. Lymph angiogenesis after lung transplantation and relation to acute organ rejection in humans. Ann Thorac Surg. 2010;90:406–12.View ArticlePubMedGoogle Scholar
- Schilling T, Kozian A, Senturk M, Huth C, Reinhold A, Hedenstierna G, et al. Effects of volatile and intravenous anesthesia on the alveolar and systemic inflammatory response in thoracic surgical patients. Anesthesiology. 2011;115:65–74.Google Scholar
- Sugita M, Ferraro P, Dagenais A, Clermont ME, Barbry P, Michel RP, Berthiaume Y. Alveolar liquid clearance and sodium channel expression are decreased in transplanted canine lung. Am J Respir Crit Care Med. 2003;167:1440–50.View ArticlePubMedGoogle Scholar
- Baker J, Yost CS, Niemann CU. Organ transplantation. In: Miller RD, editor. Miller’s Anesthesia. 6th ed. Philadelphia: Elsevier; 2005. p. 2271.Google Scholar
- Pilcher DV, Scheinkestel CD, Snell GI, Davey-Quinn A, Bailey MJ, Williams TJ. High central venous pressure is associated with prolonged mechanical ventilation and increased mortality after lung transplantation. J Thorac Cardiovasc Surg. 2005;129:912–8.View ArticlePubMedGoogle Scholar