[ISPHLT-SY4-5] Split lung transplantation for small children: Bilateral segmental lung transplantation using split adult living-donor lower lobe
Donor shortage has been a persistent problem in pediatric lung transplantation. As a solution to donor shortage, living-donor lobar lung transplantation (LDLLT) has still been a realistic therapeutic option in Japan. However, because an adult lower lobe may be too large to fit into the chest cavity of small children, standard LDLLT using lower lobe graft may be difficult for small pediatric patients. To overcome this problem, split lung transplantation using adult living-donor lower lobe was performed on 3 children at our institution. In this study, we describe our experience of split lung transplantation for small children. Three children aged 1 to 4 years with idiopathic pulmonary fibrosis underwent split lung transplantation using adult living-donor lower lobe between August 2014 and December 2018. All 3 children were mechanically ventilated with 80 to 100％ oxygen concentration before transplantation. The right or left lower lobe was donated from one recipient parent. In the donor operation, the lower lobe of the donor was split into the superior and basal segmental grafts in vivo. Cold flushing and graft preservation were performed ex vivo. In the recipient operation, the superior and basal segmental grafts were implanted into the right and left chest cavities in place of the whole lungs of the recipient, respectively. The superior segment was transplanted without changing its direction, and the segmental vein was anastomosed to the recipient´s lower pulmonary vein. The basal segments were rotated 180 degrees horizontally and 90 degrees vertically, and then the segmental vein was attached to the recipient´s upper pulmonary vein. After split lung transplantation, two patients necessitated delayed chest closure due to size mismatch. One patient died due to legionellosis 66 days after transplantation, whereas two patients recovered without requiring oxygen inhalation in the acute phase. In the chronic phase, one patient required lung re-transplantation due to pulmonary hypertension 75 months after transplantation, whereas the other patient was still surviving 40 months after transplantation. Split lung transplantation using adult living-donor lower lobe might offer a bridge to lung re-transplantation for small children. Pediatric recipients who underwent split lung transplantation should be cautiously followed for future re-transplantation.