Surgical Considerations in Infant Lung Transplantation

Challenges and Opportunities

John P. Costello; Horacio G. Carvajal; Aaron M. Abarbanell; Pirooz Eghtesady; Dilip S. Nath

Disclosures

American Journal of Transplantation. 2021;21(1):15-20. 

In This Article

Surgical Preoperative Considerations

To ameliorate the scarcity of available donor organs, ABO-incompatible lung transplantation has been used successfully in infants, and is currently used at SLCH. Although ABO-compatible transplantation is the preferred technique, various reports have documented the safety and feasibility of utilizing ABO-incompatible lung allografts, particularly in infants.[19] Once a suitable donor has been identified, it is important to consider the surgical approach to lung transplantation. In children, the two main approaches utilized are bilateral sequential lung transplantation and en bloc double lung transplantation; both are also technically feasible in infants. Despite differing preferences between centers and surgeons, the favored technique in the published literature is the bilateral sequential approach. There is no element of bronchial artery revascularization (BAR) with this bilateral sequential surgical technique. Given that there are fewer reported bronchial anastomotic complications with bilateral sequential transplants compared to the feared tracheal anastomotic healing complications initially seen in the classic en bloc technique when looking at all age groups, surgeons have shown a clear preference for bilateral sequential transplantation in the modern era. Unlike in adults, the incidence of bronchial stenosis among infants transplanted with the bilateral sequential technique is high.[20] When paired with BAR, the en bloc technique may additionally result in a lower observed rate of bronchiolitis obliterans syndrome compared to those without BAR.[20] Given the association between bronchiolitis obliterans and decreased blood flow to the small airways,[21] the observed reduction may reflect the preservation of the allograft's bronchial arterial supply compared to other surgical techniques.

Before pursuing surgery, it is also crucial to consider the clinical ethics of this undertaking. Although infant lung transplantation is technically feasible and well described, the questions of do we improve survival in these patients, and if so, for how long, must be continually re-assessed. For children younger than 12 years, waitlist mortality dropped from 32.2% to 25% following the 2005 implementation of the lung allocation score;[22] however, of the 128 infants listed between 1995 and 2011, 52 (40.6%) died while awaiting transplant.[1] Postoperative outcomes, although less than ideal, are similar to those of older children. One year and 5-year survival rates for infants are 61% and 43%, respectively, compared to 64% and 35% for the remainder of pediatric patients, with an allograft half-life of 4 years (vs 3.4 years).[1] However, infants who survive the first year after transplant have much better outcomes than their older counterparts, with 85% and 66% alive at 3 and 5 years, respectively, (compared to 68% and 51% in older patients), and a half-life of 7.4 years (vs 5 years).[1] Unfortunately, multi-center studies have not reported how many infant lung transplant recipients survive to adulthood. As such, it must be acknowledged that this is not long-term survival. Ethically, it is paramount that these outcomes be discussed with parents as part of the prelung transplant informational and counseling process so that they can make the most informed decision possible for their children.

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