Lung Transplant Feasibility After Lobar Resection in a Case of Pectus Excavatum and Severe Unilateral Space Loss

A 28-year-old female initially presented in 2022 with a persistent cough. Computed tomography (CT) imaging demonstrated features consistent with pulmonary sarcoidosis, which was subsequently confirmed by bronchoscopic biopsy. She was evaluated for lung transplantation and subsequently listed under the super-urgent category. Her past medical history was unremarkable. As part of the preoperative assessment, CT imaging revealed a significant pectus excavatum deformity with leftward displacement of the heart and severe reduction of the left hemithoracic cavity volume. She successfully underwent lung transplantation, with the donor lung reduced to her size by left upper lobectomy ex-vivo, with extracorporeal membrane oxygenation (ECMO) support due to borderline right ventricle function and high pulmonary artery pressures. The patient tolerated the procedure well. Postoperative ECMO support showed stable flows with effective gas exchange. As she maintained satisfactory ventilatory and hemodynamic parameters, ECMO flows were gradually reduced in a controlled fashion, and she was successfully weaned and liberated from ECMO support.

Her postoperative chest radiograph demonstrated well-expanded lungs with no residual pleural space. She was extubated on the first postoperative day with good gas exchange and transferred to the step-down ward on the third postoperative day. Her apical drains were removed within the first 48 hours. One of the right pleural drains showed a minor, self-resolving air leak, and the drain was subsequently removed one week after surgery.
She made steady progress and was discharged home two weeks postoperatively, with arrangements made for regular follow-up in the clinic.

There are various reasons for reduced intrathoracic space, including (1):

• Congenital or chest wall abnormalities such as pectus excavatum, pectus carinatum with asymmetry, Poland syndrome, and congenital scoliosis or kyphoscoliosis
• Previous thoracic surgery
• Chest wall deformities
• Pleural processes, such as chronic pleural fibrosis
• Diaphragmatic pathology
• Mediastinal shift arising from previous resections
• Lung parenchymal diseases causing volume loss
• Obesity and body habitus
• Extrathoracic compression

In such scenarios where the donor lungs are oversized, several management strategies have been described (2):

1. 1. Accepting only relatively undersized donor lungs for recipients with small chest cavities
   2. Trimming the graft (non-anatomical lung reduction) or performing lobectomy/lobar lung transplantation
   3. Leaving the chest open at the end of surgery
   4. Employing a physiology-based management approach aimed at restoring normal long-term respiratory mechanics

Given the limited availability of suitable donor lungs and the recipient’s super-urgent listing, the surgeons opted for a surgical strategy to reduce donor lung size via lobectomy. Performing the lobectomy ex vivo, after the recipient pneumonectomy, enabled accurate assessment of intrathoracic volume and confirmed that the left lobe would appropriately fit within the left hemithorax.

Hiroshi Date et al. have published extensive work on various combinations of lobar transplantation, particularly in pediatric recipients. Their findings suggest that lobar transplantation in the context of reduced intrathoracic space is effective when the graft size is appropriate for the recipient’s body size. However, caution is advised when lungs are oversized for the chest but proportionally small for overall body size, as this combination has been associated with poorer outcomes (3).

Figure 1: Donor lungs CT image showing supero-inferior dimensions.

Figure 2: Recipient lung CT image showing supero-inferior dimensions.

Figure 3: Donor lungs CT image showing left antero-posterior dimensions.

Figure 4: Recipient lungs CT image showing left antero-posterior dimensions.

Figure 5: Donor lungs CT image showing right antero-posterior dimensions.

Figure 6. Recipient lungs CT image showing right antero-posterior dimensions.

Figure 7: Postoperative chest X-ray with well expanded lungs.

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References

1. Witzke HJ, Simon NL, Kolvekar SK. Acquired chest wall deformities and corrections. In: Kolvekar S, Pilegaard H, editors. Chest wall deformities and corrective procedures. Cham: Springer; 2016. doi:10.1007/978-3-319-23968-2_14.
2. Eberlein M, Reed RM, Gharaibeh K, Charya A, Grazioli A, Henderson R, Krupnick AS, Bittle G. Small recipient chest cavity from fibrotic lung disease in lung transplantation: physiology matters. JHLT Open. 2024;5:100123. doi:10.1016/j.jhlto.2024.100123.
3. Date H, Aoyama A, Hijiya K, Motoyama H, Handa T, Kinoshita H, Baba S, Mizota T, Minakata K, Chen-Yoshikawa TF. Outcomes of various transplant procedures (single, sparing, inverted) in living-donor lobar lung transplantation. J Thorac Cardiovasc Surg. 2016;153(2):479-86.

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