Patients with end-stage pulmonary emphysema are usually proposed for either heart-lung or double-lung transplantation. The single-lung transplantation is reversed for patients with pulmonary fibrosis. Patients with emphysema are thought to be unsuitable for single-lung transplantation because of the ventilation-perfusion imbalance that is supposed to occur, the ventilation being preferentially distributed to the native lung when the perfusion is distributed to the transplanted lung. We now report a preliminary success with single-lung transplantation in two consecutive patients with end-stage pulmonary emphysema. Despite the persistence after transplantation of an obstructive syndrome, the clinical status was good, the blood gases were markedly improved, and ventilation-perfusion imbalance did not occur on lung scans. After discharge from the hospital, the patients could return to an almost normal life. Thus, our data support the feasibility of single-lung transplantation in patients with end-stage pulmonary emphysema, and we consider that single-lung transplantation could be the optimal form of lung transplantation in these patients.

To explore possible mechanisms responsible for the absence of cell re-colonization of mural thrombi in aneurysms, we analyzed the release and storage of leukocyte proteases in the most luminal layer versus intermediate and abluminal layers of 10 mural thrombi of human abdominal aortic aneurysms. The luminal layer contained many polymorphonuclear leukocytes (PMNs), which released pro-matrix metalloproteinase (MMP)-9 and MMP-8. Leukocyte elastase was also stored and released by the luminal layer (immunohistochemistry, activity on synthetic substrates, and casein zymography). Acid buffer allowed extraction of leukocyte elastase from the luminal layer, which was inhibited by elastase inhibitors. Casein zymography of luminal extracts and conditioned medium from formyl-methionyl-leucyl-phenylalanine (fMLP)-stimulated PMNs exhibited a similar lysis pattern, corresponding to elastase activity. Smooth muscle cell (SMC) seeding resulted in colonization of the intermediate thrombus layer ex vivo but not of the luminal layer. Extracts of the luminal layer induced loss of anchorage of both cultured human smooth muscle cells and stromal cells of bone marrow origin (anoikis). This anoikis was prevented by preincubation of the extracts with serine protease inhibitors. Moreover, adhesion of human SMCs and stromal bone marrow cells on fibrin gels was strongly inhibited when the gel was preincubated with pure elastase, medium of fMLP-stimulated PMNs, or extracts of luminal layers of mural thrombi. This loss of cell anchorage was prevented by the preincubation of the medium or extracts with alpha(1)-antitrypsin, but not when alpha(1)-antitrypsin was added after binding of elastase to the fibrin gel. In conclusion, elastase released by PMNs trapped within the mural thrombus impairs the spontaneous anchorage of mesenchymal cells to a fibrin matrix. This phenomenon could be one mechanism by which cellular healing of the mural thrombus in aneurysms is prevented.

Because of the rarity of adrenocortical carcinoma, survival rates and the prognosis for patients who have undergone operation are not well known. The purpose of the French Association of Endocrine Surgery was to evaluate these factors over an 18-year period. A trend study was associated to assess changes in the clinical and biochemical presentations as well as the surgical evolution. A total of 253 patients (158 women, 95 men) with a mean age of 47 years were included. Cushing syndrome was the main clinical presentation (30%), and hormonal studies revealed secreting tumors in 66% of the cases. Altogether, 72% ( n =182) of patients underwent resection for cure, and 41.5% ( n =105) of them had an extensive resection because of metastatic cancer. A lymphadenectomy was performed in 32.5% ( n =89) of the cases. The operative mortality was 5.5% ( n =14). Patients were given mitotane as adjuvant therapy in 53.8% of the cases ( n =135). The results of staging were stage I in 16 patients (6.3%), stage II (local disease) in 126 patients (49.8%), stage III (locoregional disease) in 57 patients (22.5%), and stage IV (metastases) in 54 patients (21.3%). Neither tumor staging nor the rate of curative surgery changed during the study period. More subcostal incisions were performed, and the use of mitotane increased significantly. The 5-year actuarial survival rates were 38% overall, 50% in the curative group, 66% for stage I, 58% for stage II, 24% for stage III, and 0% for stage IV. Multivariate analysis showed that mitotane benefited only the group of patients not operated on for cure. A better prognosis was found in patients operated on after 1988 ( p =0.04), in those with precursor-secreting tumors ( p =0.005), and in those at local stages of the disease ( p =0.0003). Thus mitotane benefited only patients not operated on for cure. Curative resection, precursor secretion, recent diagnosis, and local stage were favorably associated with survival.

To establish the optimal conditions for achieving endothelial cell coverage of the luminal surfaces of small-caliber vascular grafts in vitro, the attachment of endothelial cells (ECs) cultured from human umbilical veins to polytetrafluoroethylene (PTFE) grafts was studied. Cell attachment and spreading were compared after PTFE grafts were (a) precoated with fibronectin (HFN), type I collagen, type IV collagen, plasma and fibrin with or without thrombin, singly or in combination; (b) seeded with cell densities varying from 0.5 x 10(5) to 6 x 10(5) cells/cm2; and (c) incubated at 30, 60, or 90 min. Cell coverage and spreading were assessed by means of scanning electron microscopy. Quantification of graft surface coverage was performed with computer-assisted image analysis. To determine optimal conditions of endothelialization among the 189 treatment combinations, analysis of variance was used. We conclude that a virtually confluent cell monolayer can be established on small-caliber PTFE grafts when precoated with fibrin glue or plasma, seeded with cell densities >/=4 x 10(5) cells/cm2, and incubated for 60 min. These parameters are compatible with an operating room vascular procedure.

Critical ischemia due to extensive femoropopliteal occlusive disease often leads to amputation in patients in whom an autologuous vein is unavailable for reconstruction. The purpose of this nonrandomized prospective study is to evaluate the usefulness of cryopreserved venous allografts (CPVA) as an arterial substitute in these cases. Between October 1990 and March 1993, long bypass to a tibial or a foot artery using a CPVA was performed in 25 consecutive patients with ulcerations or gangrene. There were 19 women and six men with a mean age of 72 years (range: 51-90). The indication for allograft reconstruction was absence (17 cases) or unsuitability (eight cases) of an autologous vein graft. Greater saphenous vein allografts were harvested from multiple organ donors and frozen at -80 degrees C with 12% dimethylsulfoxide (DMSO). Sixteen patients had undergone one or more previous unsuccessful limb salvage attempts. The plantar arch was absent or incomplete in 16 patients (64%). Patients were followed up prospectively for a mean of 21 months (range: 3-32). One patient died early (32 days) and three patients died late with patent bypasses. Cumulative survival rate was 77% at 1 year and 72% at 2 years. Cumulative secondary patency rate (Kaplan-Meier) was 88% at 1 month, 72% at 6 months, and 52% at 1 year. The cumulative limb salvage rate was 78% at 2 years. When an autologous vein is unavailable, long bypass using a CPVA is a simple, quick, minimally traumatic, economical, and effective method to achieve limb salvage in patients with severe distal arterial occlusive disease. However, CPVA causes immunoreaction and there is a risk of proximal postanastomotic stenosis. Doppler ultrasound surveillance of a subcutaneous graft allows accurate assessment and repair of the abnormalities with no increase in mortality or morbidity.

Surgery for pulmonary emphysema, with the exception of lung transplantation, is limited at present to resection of the emphysematous areas. The resection of a unique bulla within an otherwise healthy parenchyma can be indicated in case of complications but rarely in asymptomatic patients. When the bullae are large (i.e. volume greater than one-third of the hemithorax) in a patient suffering from diffuse emphysema, bullectomy is the ideal indication, Mortality varies from 0 to 10%, essentially due to infection or acute respiratory failure. In most patients, the subjective improvement in terms of dyspnea and the objective improvement as measured by spirometry remains significative up to 5 years after surgery, Inversely, surgical resection is classically considered to be contraindicated in patients with small poorly-limited bullae. Recent data would however question this idea since subjective and objective improvement after reduction of the lung volume is still present 1 year after surgery in most patients, even those with severe obstruction, The mechanism is probably related to increased elastic recoil, Even if only temporary improvement can be achieved for a few years, the persisting course of emphysema would suggest that volume reduction should always be entertained as an alternative before lung transplantation.

Surgery for pulmonary emphysema, with the exception of lung transplantation, is limited at present to resection of the emphysematous areas. The resection of a unique bulla within an otherwise healthy parenchyma can be indicated in case of complications but rarely in asymptomatic patients. When the bullae are large (i.e. volume greater than one-third of the hemithorax) in a patient suffering from diffuse emphysema, bullectomy is the ideal indication. Mortality varies from 0 to 10%, essentially due to infection or acute respiratory failure. In most patients, the subjective improvement in terms of dyspnea and the objective improvement as measured by spirometry remains significative up to 5 years after surgery. Inversely, surgical resection is classically considered to be contraindicated in patients with small poorly-limited bullae. Recent data would however question this idea since subjective and objective improvement after reduction of the lung volume is still present 1 year after surgery in most patients, even those with severe obstruction. The mechanism is probably related to increased elastic recoil. Even if only temporary improvement can be achieved for a few years, the persisting course of emphysema would suggest that volume reduction should always be entertained as an alternative before lung transplantation.

Recovery of shed blood is part of the allogenic blood saving policy of particular importance even though the risk of viral infection via transfusion has been considerably reduced. Blood transfusion requirements in vascular surgery are discussed together with alternatives to allogenic transfusion. Differed withdrawal of autologous blood can involve pre-operative autologous plasmapheresis and cytapheresis. Per-operative haemodilution is another variant of pre-operative isovolemic haemodilution and erythrocytapheresis. Recovery of shed blood can be done with or without lavage. Technical and pharmacologic measurements complete the method. Simultaneous use of different techniques can be useful. Recovery is particularly interesting in highly haemorhagic vascular procedures or those which must be done quite rapidly. Care must be taken to avoid the "recovery syndrome". Improvement in material will assure safety.

Le chirurgien thoracique n’est pas accoutume aux contraintes de la chirurgie de « confort » ou il existe une quasi-obligation de resultat. La diffusion, grâce a la video-thoracoscopie, de la sympathectomie thoracique pour hyperhidrose primitive des membres superieurs est une illustration de cette obligation. Pour satisfaire cet imperatif, la simplicite du geste operatoire ne doit pas occulter les aleas du protocole therapeutique qui peuvent etre a l’origine d’un resultat incomplet de l’intervention ou de la survenue d’un prejudice inattendu. L’hyperhidrose primitive des membres superieurs est un probleme fonctionnel dont il ne faut pas sous-estimer le retentissement social et psycho-affectif, des cas de suicide ayant ete rapportes [1]. Les patients atteints d’hyperhidrose se heurtent a une double difficulte. La premiere est la meconnaissance des praticiens a l’egard des possibilites therapeutiques de cette affection. La seconde est la mauvaise reputation du recours chirurgical dans cette indication. Cette mauvaise reputation n’est pas liee aux echecs de la sympathectomie qui sont tres rares mais a la morbidite des voies d’abord de la chirurgie directe a « ciel ouvert » [2, 3]. Avant l’avenement de la video-chirurgie, de nombreuses voies d’abord ont ete proposees pour realiser une sympathectomie thoracique haute sans qu’aucune n’ait fait l’unanimite. La voie axillaire passant dans le deuxieme ou le troisieme espace intercostal etait cependant la plus couramment utilisee et la moins morbide mais elle ne permettait pas de traiter sans risque les deux cotes dans le meme temps operatoire [4]. Grâce au developpement de la video-chirurgie, la sympathectomie endoscopique transthoracique s’est progressivement imposee comme le traitement de reference des hyperhidroses severes des membres superieurs. Le geste est simple et permet de traiter dans le meme temps operatoire les deux cotes au prix d’une voie d’abord esthetique et non delabrante. La mortalite est nulle, la morbidite est faible, le protocole therapeutique est de courte duree et les resultats immediats et a long terme sont excellents [1, 5-9].

The surgical approach to affections of the chest wall and pleura, still the predominant indications for thoracic surgery, has greatly changed since the advent of thoracoscopic procedures, and is emphasized in this second part of a two-part review, together with other indications for mediastinal tumours. Indicated after lung exeresis or emergency chest surgery, protective chest wall reconstruction with muscular flaps is no longer an exceptional operation. Inversely, thoracic surgery for infectious complications have become less frequent, unusually limited to well established procedures for tuberculosis surgery, treatment of bronchial fistula or mediastinal supperations. The chest cavity is well adapted to new techniques of thoracoscopy and video-assisted thoracic surgery both for diagnosis and treatment. Indications for pleuroscopy have taken on a completely new aspect since 1989. These techniques are used for pericardial fenestration, thoracic sympathectomy for dyshidrosis, vagotomy, splanchnicectomy, chylothorax, spinal affections, empyema and trauma surgery. These new techniques have also had an impact on treatment of spontaneous pneumothorax. For tumour surgery, thoracoscopy has made possible a more adapted strategy currently based on an initial needle biopsy, with limited thoracoscopic exeresis and ultimate treatment depending upon the pathology report. Immediate thoracoscopy without prior biopsy appears excessive. Video-assisted thoracosurgery is also used for most malignant mediastinal tumour which, due to advances in chemotherapy surgery have transformed the prognosis of a large number of mediastinal tumours.

Les premiers essais cliniques d'endothelialisation de protheses vasculaires n'ont pas confirme les bons resultats observes chez l'animal. L'utilisation de protocoles d'endothelialisation differents pourrait, au moins en partie, expliquer cette discordance. Le but de notre etude a ete d'etudier la faisabilite et l'efficacite d'une technique d'endothelialisation en deux temps autorisant, comme chez l'animal, un ensemencement per-operatoire a haute densite. Notre protocole d'endothelialisation comporte, dans un premier temps, un prelevement veineux autologue sous anesthesie locale permettant l'isolement enzymatique des cellules endotheliales puis leur culture in vitro. Dans un deuxieme temps, la revascularisation est realisee. En per-operatoire, la prothese est precoagulee avec du sang total ou du plasma autologue pendant 30 mn puis les cellules sont ensemencees a tres forte densite et incubees pendant 45 mn. Entre Mai 1988 et Juin 1993, 32 malades etaient eligibles pour notre etude. Chez 11 malades, le protocole n'a pu etre mene a son terme pour plusieurs raisons: un infarctus pre-operatoire, 9 echecs d'isolement et/ou de culture des cellules et une culture contaminee. Vingt et un malades (18 hommes, trois femmes) d'un âge moyen de 62 ans (38-78 ans) ont eu un pontage femoro-poplite sus-articulaire avec une prothese en PTFE de 7 mm endothelialisee. L'indication chirurgicale etait 20 fois une claudication intermittente et une fois une ischemie de repos. La surface moyenne du prelevement veineux a ete de 10,5 ± 3,5 cm 2 . La duree moyenne de la culture in vitro a ete de 23,5 ± 8,5 jours. La densite cellulaire moyenne d'ensemencement a ete de 2,9 ± 0,8 x 105 cellules/cm 2 de prothese. Aucun evenement critique n'est survenu pendant la periode post-operatoire precoce (30 jours). Au cours du suivi, deux malades sont decedes (deuxieme et trente-sixieme mois) de cause intercurrente avec un pontage permeable, un malade a eu un abces du triangle de Scarpa conduisant a l'ablation de la prothese (75 jours) et trois pontages se sont occlus respectivement aux troisieme, dixieme et cinquante-troisieme mois post-operatoires. Le suivi moyen des 20 malades ayant survecu plus de trois mois a l'intervention a ete de 42 ± 15 mois. La permeabilite primaire cumulee (Kaplan-Meier) etait de 95 ± 10 % a trois mois, 89 ± 13 % a 10 et 48 mois et 67 ± 39 % a 53 et 76 mois. La technique d'endothelialisation en deux temps que nous preconisons a ete realisable chez 69 % des malades ne necessitant pas une revascularisation urgente et n'a pas aggrave la mortalite - morbidite peri-operatoire. Les resultats sur la permeabilite des pontages femoro-poplites sus-articulaires en PTFE realises pour claudication intermittente sont encourageants

Progress over the last 40 years has greatly reduced morbidity and mortality in the constantly changing field of thoracic surgery. The first part of this review focuses on current indications and limitations in lung surgery.Technical procedures for pneumonectomy, lobectomy, bronchial resection and conservative surgery are well established. Although major respiratory or cardiac failure still limit indications bronchogenic cancer extension is no longer a contraindication. Exeresis after 70 years of age is not an exception.Surgery for non-small cell lung cancer has given promising results with a 5-year survival rate of 60-80% for patients in stage I and II. For stage III, two recent comparative studies have demonstrated the effectiveness of preoperative adjuvant chemotherapy which should logically be proposed with or without radiotherapy in patients with resectable tumours. Surgical removal of lung metastases and mesotheliomas has also made considerable progress. Unfortunately, except for therapeutic trials, exeresis of small cell lung cancer does not provide any beneficial effect and cannot be proposed.Indications for surgery in patients with chronic obstructive pulmonary disease however has been quite successful and now goes beyond classical exeresis of large compressive bullae. In many situations patients with diffuse emphysema can benefit from surgical reduction in lung volume before proposing transplantation.Lung transplantation is indicated for pulmonary fibrosis, pulmonary vascular disease and obstructive lung pulmonary disease with an overall survival rate of 50% at 5 years and 43% at 6 years. The rate of successful bilateral lung transplantation for cystic fibrosis remains to be determined.

The surgical approach to affections of the chest wall and pleura, still the predominant indications for thoracic surgery, has greatly changed since the advent of thoracoscopic procedures, and is emphasized in this second part of a two-part review, together with other indications for mediastinal tumours.Indicated after lung exeresis or emergency chest surgery, protective chest wall reconstruction with muscular flaps is no longer an exceptional operation. Inversely, thoracic surgery for infectious complications have become less frequent, unusually limited to well established procedures for tuberculosis surgery, treatment of bronchial fistula or mediastinal supperations.The chest cavity is well adapted to new techniques of thoracoscopy and video-assisted thoracic surgery both for diagnosis and treatment. Indications for pleuroscopy have taken on a completely new aspect since 1989. These techniques are used for pericardial fenestration, thoracic sympathectomy for dyshidrosis, vagotomy, splanchnicectomy, chylothorax, spinal affections, empyema and trauma surgery. These new techniques have also had an impact on treatment of spontaneous pneumothorax. For tumour surgery, thoracoscopy has made possible a more adapted strategy currently based on an initial needle biopsy, with limited thoracoscopic exeresis and ultimate treatment depending upon the pathology report. Immediate thoracoscopy without prior biopsy appears excessive. Video-assisted thoracosurgery is also used for most malignant mediastinal tumour which, due to advances in chemotherapy surgery have transformed the prognosis of a large number of mediastinal tumours.

The feasibility and the good immediate acceptability of unilateral lung transplants in the patients with obstructive respiratory problems have recently been demonstrated and since the initial reports, some hundreds of lung transplants have been performed ill various parts of the world for this indication. Nevertheless, few results of respiratory function are currently available in the medium term. We report these ina series of 20 patients with severe obstruction who were given single lung transplants. The actual probability of survival for 1 and 2 years was 75 and 70% respectively with 4 peri-operative deaths and 2 later deaths. In the 16 survivors of more than 6 months, in relation to the pre-operative values, a significant improvement was observed 3 months after the graft in the FEV1 which rose from 17+/-6 to 53+/-13% of the predicted values. The PaO2 rose from 52+/-10 to 81+/-3 mmHg. The distance covered on the six minute walking test went from 99+/-84 m before the graft to 587+/-147 m 6 months after the operation. In addition to the improved distance, the lung function was stable in a group of patients as the months went by, although there was a fall in the respiratory function in others with the appearance of the syndrome of bronchiolitis obliterans or in 2 patients with bronchial complications. The four patients with severe deterioration in the graft function were re-transplanted with a good clinical result in three of them, the fourth dying in the immediate post operative period. We conclude that single lung transplant represents an effective treatment both in the short and medium term in patients with chronic airflow obstruction.

We studied the characteristics of the pulmonary reimplantation response (PRR) in single-lung transplantation (SLT), and detailed the occurrence, evolution, prognosis and risk factors of this complication. Forty single-lung transplant recipients were studied. Twenty four patients developed hypoxaemia and allograft infiltrates consistent with the PRR. In 40% of the cases hypoxaemia was severe, precluding weaning and requiring prolonged mechanical ventilation with high fractional inspiratory oxygen (FIO2). The mean duration of ventilation was 7 days (range 1-19 days). Clearing of the chest radiographs was progressive, with complete resolution between 6 and 21 days. In all cases, the pulmonary arterial wedge pressure was normal (6 +/- 2 mmHg) suggesting low pressure oedema. Sampling of the pulmonary oedema fluid revealed that the ratio of protein concentration in oedema fluid to that in serum exceeded 0.5. In patients with severe PRR (40% of cases) clinical, radiographic and haemodynamic abnormalities were identical to adult respiratory distress syndrome (ARDS), but the prognosis was more favourable with no death directly related to PRR in our patients. The mean duration of graft ischaemia of the oedematous grafts (241 +/- 103 min) was significantly longer than that of nonoedematous grafts (155 +/- 71 min). These date suggest that prolongation of graft ischaemia increased the incidence of PRR.

Pulmonary reimplantation response in single-lung transplantation. Ch. Sleiman, H. Mal, M. Fournier, J-P. Duchatelle, P. Icard, O. Groussard, G. Jebrak, J-L. Mollo, O. Raffy, C. Roue, M. Kitzis, B. Andreassian, R. Pariente. ERS Journals Ltd 1995. ABSTRACT: We studied the characteristics of the pulmonary reimplantation response (PRR) in single-lung transplantation (SLT), and detailed the occurrence, evolution, prognosis and risk factors of this complication. Forty single-lung transplant recipients were studied. Twenty four patients devel- oped hypoxaemia and allograft infiltrates consistent with the PRR. In 40% of the cases hypoxaemia was severe, precluding weaning and requiring prolonged mechanical ventilation with high fractional inspiratory oxygen (FIO2). The mean duration of ventilation was 7 days (range 1-19 days). Clearing of the chest radiographs was progressive, with complete resolution between 6 and 21 days. In all cases, the pulmonary arterial wedge pressure was normal (6±2 mmHg) suggest- ing low pressure oedema. Sampling of the pulmonary oedema fluid revealed that the ratio of protein concentration in oedema fluid to that in serum exceeded 0.5. In patients with severe PRR (40% of cases) clinical, radiographic and haemody- namic abnormalities were identical to adult respiratory distress syndrome (ARDS), but the prognosis was more favourable with no death directly related to PRR in our patients. The mean duration of graft ischaemia of the oedematous grafts (241 ±103 min) was significantly longer than that of nonoedematous grafts (155±71 min). These date suggest that prolongation of graft ischaemia increased the incidence of PRR.

Early clinical trials using endothelial cells seeded vascular grafts failed to confirm the successful results observed in animals. Differences in seeding methods could at least partially account for this failure. The purpose of the present study was to ascertain the feasibility and intraoperative efficacy of a two-stage technique that allowed high-density seeding as in animals. The first stage of the technique consists of harvesting an autologous vein specimen under local anesthesia followed by enzymatic isolation and in vitro culture of endothelial cells. The second stage is vascular repair. During the procedure the prosthesis is precoated with autologous whole blood or plasma for 30 minutes and seeded at high density with endothelial cells incubated for 45 minutes. Between May 1988 and June 1993, 32 patients were enrolled in this study. In 11 of them, however, the technique could not be completed for various reasons including preoperative infarction in one case, failure to achieve isolation and/or cell cultures in nine cases, and contamination of cell culture in one case. Twenty-one patients (18 men and 3 women) whose mean age was 62 years (range 38 to 78) underwent above-knee femoropopliteal bypass using an endothelial cell seeded polytetrafluoroethylene graft (7 mm). The indication for surgery was intermittent claudication in 20 patients and rest pain in one. The mean size of the vein specimen was 10.5 +/- 3.5 cm2. The mean duration of in vitro cell culture was 23.5 +/- 8.5 days. The mean density of seeding was 2.9 +/- 0.8 x 105 cells/cm2 prosthesis. No major complications were encountered during the immediate postoperative period (30 days). During follow-up two patients with patent bypasses died of intercurrent causes at 2 and 36 months, respectively, one patient had an abscess in the femoral triangle that required removal of the prosthesis (75 days), and three patients presented with bypass failure (2 occlusions and 1 thromboembolic complication) at 3, 10, and 53 months, respectively. Mean follow-up in the 20 patients surviving at 3 months was 42 +/- 15 months. Cumulative primary patency (Kaplan-Meier analysis) was 95% (+/- 10) at 3 months, 89% (+/- 13) at 10 and 48 months, and 67% (+/- 39) at 53 and 76 months. The two-stage seeding technique described herein was feasible in 69% of patients not requiring emergency reconstruction and did not increase perioperative morbidity and mortality. Bypass patency in patients who underwent above-knee femoropopliteal bypass for intermittent claudication was promising.

Bronchiolitis obliterans is an anatomical lesion with multiple aetiologies. In the lung transplant patient the pure forms of bronchiolitis obliterans are probably the consequence of a process of chronic rejection; in fact necropsy tissue or lungs removed which have been transplanted show that the lesions of bronchiolitis obliterans are often associated with parenchymal disorders, vascular and proximal bronchial disease, which are sequelae of phenomena of rejection or infection. The effect of bronchiolitis obliterans on lung function is constant; this may appear progressively or in stages. Increasing immunosuppressive treatment may arrest the progress. This rarely occurs and the development of respiratory failure tends to be the rule. It is exceptional to achieve the diagnosis of bronchiolitis obliterans from the examination of a transbronchial biopsy. It is a combination of features, both clinical and respiratory function, negative bacteriology and virological investigations as well as the absence of any efficacy of conventional treatment for rejection which leads to the diagnosis. In certain cases the question of a pulmonary re-transplantation is raised.

The immunohistochemical profile of mucosal lymphocytes was investigated in the central airways of lung transplant recipients. Bronchial and transbronchial biopsies (BB and TBB, respectively) and bronchoalveolar lavage for culture of bacteria and viruses were performed during a fibroscopic procedure in patients without evidence of chronic rejection, 3 to 10 mo after surgery. Analysis was restricted to samples without concurrent airway infection: 23 pairs of BB and TBB from 18 transplant recipients were analyzed. An immunohistochemical technique was used to identify and score mucosal cells that reacted with monoclonal antibodies against CD4, CD8, CD45-Ro (memory T-cells), and HLA-DR molecules. The same procedure was applied in nine nonsmoking control subjects (NS group). Data from transplant recipients were allocated to R+ (n = 11) or R- groups (n = 12), depending on the presence or absence of histologic evidence of acute rejection on TBB. A statistically significant depletion of every immunoreactive cell subset was observed in the R+ and the R- groups, but not in the NS group. Conversely, no significant difference for either score of immunoreactive cells were found between R+ and R- groups. The immunosuppressive regimen is suspected to play to play a major role in this depletion of bronchial mucosal T-cells. The acute lung rejection process does not appear to affect concurrently the immunohistochemical profile of immunoreactive cells in the bronchial mucosa.