This is a review article on the main postoperative complications after lung transplantation: airways complications, vascular complications, pleural complications, surgical wound complications, and abdominal complications. Incidence data, severity, and major management regimens are reported. Postoperative complications after lung transplantation result in a significantly increased morbidity and mortality, with early diagnosis and therapy being extremely important.

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The indication of single or double lung transplantation in patients diagnosed pulmonary emphysema is a topic of current debate.

OBJECTIVE:To study the influence of body mass index (BMI) on mortality and postoperative evolution in our 10-year experience as a lung transplant group. METHODS:The study included 256 lung transplants performed between June 1999 and June 2009. BMI was stratified into 4 groups (<20 kg/m2 underweight, 20-25 normal weight, 25-30 overweight, and >30 obese) for posttransplant mortality assessment (chi-square) in relation to age, gender, pathology, and transplant type (logistic regression). Time of mechanical ventilation and length of stay in the intensive care unit and in the hospital were also analyzed (Kruskal-Wallis test). RESULTS:BMI showed a normal distribution with a mean value of 24.8±5 kg/m2 (range, 13-38). Although postoperative mortality was greater in the overweight (23%) and obese (23.7%) groups, it did not reach statistical significance, nor was there a significant increase in the risk of death (odds ratios of 1.06 and 1.17, respectively). Risk of death was independent of BMI and was associated with pathology (lower in emphysema) and transplant type (lower in single lung). There were no significant differences in duration of mechanical ventilation (342 hours in obese patients vs 180 in normal weight; P=.7), length of stay in the intensive care unit (18 days in obese patients vs 14 in normal weight; P=.8), or length of hospital stay of patients that were discharged (37 days in obese patients vs 43 in normal weight; P=.8). CONCLUSIONS:In our experience, BMI is not a risk factor that significantly increases postoperative mortality, probably owing to an adequate selection of recipients and an optimal posttransplant management. However, it must be considered to be a relative contraindication, because it is established in the international guidelines, obliging a correct assessment of patients, especially if there are other comorbidities.

After single lung transplantation for emphysema native lung hyperinflation is a common complication that may cause respiratory failure. Herein we have reported satisfactory bronchoscopic lung volume reduction in a left single-lung transplant recipient with native lung hyperinflation, who suffered from Medical Research Council (MRC) class 3 dyspnea and chest pain. Three endobronchial valves (Zephyr; Emphasys Medical, Redwood, Calif, United States) were placed into the segmental bronchi of the right upper lobe, using videobronchoscopy under general anesthesia. Postoperative chest computed tomography revealed subsegmental atelectasis in that lobe. The clinical benefit was an improved MRC dyspnea class from 3 to 2, which was still present at 4 months after the procedure, although there were no remarkable changes in spirometric parameters.

BACKGROUND:Medical complications after lung transplantation (LT) are frequent despite the advances in management. The objectives of this study were to evaluate the incidence and clinical features of pulmonary embolism (PE) among LT recipients in our center.PATIENTS AND METHODS:We performed a retrospective descriptive study of 280 patients who underwent LT between June 1999 and December 2009.RESULTS:Five patients with PE (1.78%) had undergone single LT due to idiopathic pulmonary fibrosis (IPF). PE developed in the transplanted lung and was bilateral in 2 cases. The only associated risk factor was obesity in 3 patients. The clinical presentation was nonspecific; the most frequent symptom being dyspnea. Computed tomography (CT) angiography and ventilation-perfusion scan were used for diagnosis. Patients underwent treatment with low-molecular weight heparin followed by oral anticoagulation.CONCLUSIONS:Our study showed a low incidence of PE (1.78%), although we focused exclusively on this condition, excluding other entities such as deep vein thrombosis. All PE events occurred in the subpopulation of IPF transplant recipients. Possibly some factors predisposed these patients to PE, although they remain unclear. Because PE can cause significant morbidity in LT recipients, it is important to include PE in the differential diagnosis among LT patients presenting with dyspnea, hypoxia, or clinical deterioration.

Introduction. The major limiting factor for lung transplantation (LT), both worldwide and in Spain, is the number of suitable lung donors. This, together with the increased demand for LT, led us to propose the performance of 2 single lung transplantations simultaneously using the same donor (the "twinning procedure").Objective. The objective of this study was to analyze the outcome of patients who underwent transplantation with this procedure, assessing differences between the first and the second transplant.Patients and Methods. From November 2001. to August 2008, 46 single lung transplantations (SILTS) were performed with 23 donors.Results. The mean ischemia time was 258 minutes (median, 265) for the first transplantation and 312 minutes (median, 320) for the second transplantation. Primary graft dysfunction occurred in 5 patients (24%) in the first group and 9 in the second group (39%; P = .27). The median intubation time was 8 hours for the first and 6.5 hours for the second group. The mean hospital stay was 39 and 31 days, respectively. Postoperative mortality was 2 (8.7%) and 3 (13%) patient, respectively (P = .99). There was no significant difference in the incidence of acute rejection episodes, infections, or chronic rejections. Five-year survival rates were 67.9% for the first and 61.5% for the second (Kaplan-Meier).Conclusions. The performance of 2 SLTs using the same donor and in the same hospital was feasible with adequate planning, permitting better use of donors and reducing waiting list time and mortality. Our results showed no increased risk for recipients of the second transplant in the early postoperative and long-term periods.

Introduction. The indication for single or double lung transplantation in patients diagnosed with pulmonary emphysema is a topic of current debate. Our aim was to analyze the differences in the incidence of perioperative complications, survival, and quality of life between single and double lung transplantations.Materials and Methods. From 1999 to 2008, 223 subjects underwent transplantation in our department, of whom 62 (28%) had a previous diagnosis of pulmonary emphysema. A retrospective study was performed to establish possible differences between group I (single lung) and group 2 (double lung) transplants analyzing overall survival using the Kaplan-Meier method and differences between groups using the log-rank test. Pearson chi-square test was used to compare the frequency of postoperative complications, bronchiolitis obliterans BOS acute rejection episodes, and infections.Results. We included 62 patients who underwent transplantation for emphysema. Cumulative 5-year survival rate, excluding preoperative mortality, was 54% overall, 59% for group 1, and 56% for group 2. No significant differences were observed between the groups (P = .47). The frequency of BOS was 34% in group 1. and 42% in group 2 (P = .52). At least 1 acute rejection episode occurred in 52% of group 1 patients and 51% of group 2 patients (P = .98). Bacterial infections were experienced by 50% of group 1 patients and 54% of group 2 patients (P = .72). Fungal infections affected 10% of group 1 patients and 15% of group 2 patients (P = .71). Intraoperative complications were recorded in 27.6% of group I patients versus 54% of group 2 patients, a difference that was statistically significant (P = .032).Conclusions. The study results supported the decision of our group to consider single lung transplantation the treatment of choice in emphysema, which may be complemented with volume reduction surgery in the native lung or subsequent transplantation of the contralateral lung.

BACKGROUND:Lung transplantation (LTx) has been established as the last treatment option in certain lung diseases. It is not uncommon for complications to occur that require urgent reoperation. The objective of our study was to analyze the characteristics of lung transplant patients who required reoperation in the postoperative period.PATIENTS AND METHODS:We have conducted a retrospective descriptive study of 224 lung transplants from January 1999 to September 2008, excluding retransplants. A subgroup of 16 subjects (7.2%) required reoperations.RESULTS:These 16 individuals had a mean age of 49.38 +/- 14.32 years with 75% men and 25% women. The disease leading to LTx was emphysema in 6 (37.5%), pulmonary fibrosis in 5 (31.3%), pulmonary hypertension in 2 (12.5%) and bronchiectasis, cystic fibrosis, and lymphangioleiomyomatosis in 1 each (6.3%). Preoperatively, 40% were taking corticosteroids. Double lung transplantation was performed in 56.3% and single lung in 43.7%. LTx surgery was prolonged in 68.8% of patients and intraoperative complications were more frequent than in the other patients (P = .041). The causes for reoperation were bleeding in 13 (of these, 5 had severe adhesions and 4 required extracorporeal circulation during LTx); bronchial dehiscence in 1; wall dehiscence in 1; and vascular stenosis in 1. At the end of the study, 62.5% were alive and among the 6 who died, 3 succumbed as a result of the surgery. Most subjects underwent late reoperation after a mean of 16 days from transplantation (range, 1-55). The need for reoperation was not associated with greater perioperative mortality.CONCLUSIONS:The incidence of reoperation in the postoperative period was low in our series. The main cause was bleeding. In more than half of the cases, LTx surgery was prolonged and intraoperative complications were more frequent. The need for reoperation was not associated with greater perioperative mortality.

Primary Graft Dysfunction (PGD) is a severe acute lung injury syndrome after lung transplantation. Outcomes of the severe PGD (grade 3) have not been extensively studied. The purpose of this study was to examine the impact of PGD grade 3 on mortality of lung transplanted patients in the Complexo Hospitalario Universitario Juan Canalejo, La Coruña, Spain.

BACKGROUND:Despite years of experience with lung transplantation, perioperative morbidity rates remain high. The objective of this study was to analyze our series of lung transplant recipients, seeking to identify possible intra- and postoperative risk factors associated with mortality.PATIENTS AND METHODS:We performed a descriptive, retrospective study of 224 consecutive patients undergoing lung transplantation over a period of 112 months; we excluded retransplant procedures. We gathered details of the surgical procedure and postoperative period in the recovery unit. Univariate analysis using the chi-square test identified variables associated with the incidence of mortality.RESULTS:From 1999 to 2008, we performed 224 lung transplants, including 66% in men and 34% in women. Their overall mean age was 49.9 +/- 13.5 years. The conditions that led to transplantation were pulmonary fibrosis (38.4%); chronic obstructive pulmonary disease emphysema (29%); cystic fibrosis (10.7%); bronchiectasis (8.9%); pulmonary hypertension (3.1%); and other diseases (9.9%). A total of 124 (55.4%) patients underwent single and 100 (44.6%) received sequential bilateral lung transplantations. Surgical risk factors were identified in 51.3% of the cases, the most frequent being hemorrhage (25.3%), followed by severe pulmonary hypertension (14.7%) and cardiopulmonary bypass (12.1%). Greater perioperative mortality was detected among patients with surgical risk factors, namely, significantly related to cardiopulmonary bypass, pulmonary hypertension, and air leak. A higher frequency of surgical risk factors was observed among patients with bilateral lung transplantations and longer procedures, but they were not associated with greater perioperative mortality. Reoperation was necessary in 16 patients (7.2%), mainly owing to bleeding, it was not significantly related to mortality risk.CONCLUSIONS:The incidence of surgical risk factors in lung transplantation was high, especially in bilateral lung transplantations and prolonged procedures. Postoperative bleeding requiring reoperation was not frequent and not associated with increased preoperative mortality in our series.

OBJECTIVE:Lung transplant patient survival has significantly improved over the last 2 decades, which has resulted in an increased incidence of malignant disease. We undertook a descriptive, retrospective study of our series of transplant patients.PATIENTS AND METHODS:The study included 129 transplantations from 1999 to 2006. Ten patients (7.75%) developed 11 neoplastic processes during the follow-up period.RESULTS:In these 10 patients with neoformative processes (group 1), 40% were male and 60% female, compared with 62% male and 38% female in the neoplasia-free group (group 2). The overall mean age was 50.5 +/- 15.4 years in group 1 and 48 +/- 14 years in group 2. The neoplasias were: lymphomas (2) and tumors in the urinary tract (2), colon (2), kidney (1), skin (2), breast (1), and native lung (1). The median time from organ transplantation to diagnosis was 21 +/- 16 months. Of the 10 patients in group 1, 60% died, within a median of 9 months after diagnosis. Treatment consisted of surgery in 4 patients, chemotherapy in 5, and chemoradiotherapy in 1. The immunosuppression was changed after cancer diagnosis in 30% of the patients.CONCLUSIONS:Pharmacological immunomodulation caused a higher incidence of malignant disease, in addition to a worse prognosis for these diseases, which demonstrated the importance of adjusting the dose and searching for adequate therapeutic combinations.

BACKGROUND:Invasive fungal infections (IFIs) in patients undergoing lung transplantation (LT) are associated with significant mortality. Previous studies have shown the efficacy of aerosolized amphotericin B deoxycholate and oral fluconazole for antifungal prophylaxis. Evolving data show a potential advantage of prophylaxis with lipid-based formulations of amphotericin B in the prevention of IFIs. We reviewed the incidence of IFIs among patients receiving aerosolized amphotericin B lipid complex (ABLC) in LT.METHODS:We undertook a retrospective review of the results of our antifungal protocol in a cohort of 60 LT patients. We analyzed the efficiency, safety, and tolerability of 50 mg of aerosolized ABLC administered postoperatively for IFI prophylaxis once every 2 days for 2 weeks and then once per week for at least 13 weeks. In addition, these transplanted patients received fluconazole (200 mg/d) during the first 21 days posttransplant. The prophylaxis-related efficiency and safety were quantified for IFIs and adverse events (AEs) for 6 months after study drug initiation.RESULTS:Prophylaxis was efficient in 59 (98.3%) patients. Only one patient developed a possible IFI, due to Aspergillus fumigatus. Four patients presented nausea and vomiting as an AE, although aerosolized amphotericin B was ongoing.CONCLUSIONS:Nebulized ABLC was effective, safe, and well tolerated for the prophylaxis of aspergillosis in lung transplant patients during the early posttransplant period.

OBJECTIVE:This study compared the incidence of acute or chronic rejection and adverse events in lung transplant patients receiving induction basiliximab versus controls not receiving treatment.MATERIALS AND METHODS:Basiliximab was administered to 15 patients with impaired renal function, advanced age, or high surgical risk, (group I). The mean age was 48.9 years; nine were double-lung and six single-lung grafts. They were compared to 13 lung transplants performed in 2001 (mean age 43.6 years, 11 double lung and two single lung [group II]).RESULTS:The incidence of acute rejection was 13.3% in group I versus 38.5% in group II (P = .19, OR 4.06), with chronic rejection in 20% and 38.5% of cases, respectively (P = .4, OR 2.5). No significant differences were observed in the incidence of infections or malignancies. Nor were there any direct adverse events due to the administration of the drug. The estimated 2-year survival was 80% for group I and 54% for group II (P = .14).CONCLUSIONS:Basiliximab has a trend to reduce the rate of acute and chronic rejection in lung transplant recipients, with no increased incidence of infections or malignancies. The 2-year survival for patients treated with basiliximab was better than the control group, despite including high risk transplant patients.

BACKGROUND:Basiliximab is a chimeric anti-interleukin-2 monoclonal antibody that has shown safety and efficacy in the prophylaxis of acute organ rejection in renal, liver, heart, and kidney-pancreas transplantation (Tx). The aim of this study was to present our initial experience with the use of Basiliximab in lung Tx.METHODS:Basiliximab (2 doses of 20 mg on day 0 and day 4) was administered to 16 patients treated with cyclosporine, azathioprine, and steroids between September 13, 2001 and August 26, 2003, including 12 men and 4 women patients with a mean age of 56.5 years (range, 19-69). The indication for use in transplantations were: reduced renal function (n = 14), post-Tx acute renal failure (n = 1) and steroid-resistant acute rejection (n = 1). Eight double-lung and eight single-lung Tx were performed for emphysema (n = 6), idiopathic pulmonary fibrosis (n = 7), silicosis (n = 2), and cystic fibrosis retransplantation (n = 1).RESULTS:The incidence of acute rejection was 16.6% (2 patients). Infections included cytomegalovirus (CMV) 33.3% (n = 4), bacterial 16.6% (n = 2), and fungal 8.3% (n = 1). Two patients died in the postoperative period and another at 3 months. There was no reaction to the medicine, and no malignancies or Bronchiolitis Obliterans Syndrome (BOS) during a follow-up period of more than 1 year in 10 patients.CONCLUSION:Basiliximab appeared to reduce the incidence of acute organ rejection and showed a good safety profile in terms of infections and adverse events.