Viéctor Calvo

Lung transplantation has become a valid therapeutic option for patients with pulmonary fibrosis in terminal stage, and the number of such interventions has increased exponentially in recent years. We undertook a retrospective study of 46 pulmonary fibrosis patients who received lung transplants from 1992 through 2002 with the aim of describing the most common intra- and early postoperative complications in the recovery unit. We also aimed to analyze the impact of each complication on mortality during the study period. The most frequent complications during surgery were reperfusion syndrome (47.5%), hemodynamic instability (41%), arrhythmias (23.9%), and pulmonary hypertension (15%), with exitus secondary to reperfusion syndrome. The most common postoperative complications were infection (56.5%), reimplantation response (45.7%), and kidney failure (19.6%). Overall mortality during the study period was 23.9%. The following complications were statistically significant in the univariate analysis of the relation with mortality: reperfusion syndrome (p=0.039), reimplantation response (p=0.039), kidney failure (p=0.013), rejection (p=0.016), and sepsis (p<0.001). The only complication that remained significant in the multivariate analysis was sepsis (p<0.001). In spite of the considerable progress made, intra- and postoperative complications continue to be a real threat for the transplanted lung patient. Sepsis was the strongest predictor of poor prognosis in the early recovery period.

Mechanical ventilation before lung transplantation has been identified as a risk factor for early death after surgery. However, several studies have reported patient series in which ventilation assistance was given preoperatively without increasing the rates of postoperative complications and death, apart from increasing time of postoperative intubation. The present retrospective analysis of the postoperative course of patients who had been mechanically ventilated before transplantation encompasses a period of 5 years in our hospital. Eight transplants (7 double- and 1 single-lung procedures) were performed. Six patients (75%) required extracorporeal oxygenation during surgery. Three patients (37.5%) died within 30 days of receiving the transplanted lung. The mean time of intubation after the operation was 10.3 days and the mean stay in the postoperative recovery and intensive care unit was 27.5 days. The most common postoperative complications were respiratory colonization (100%), with infection in 3 patients, and reimplantation injury (50%). Pretransplant mechanical ventilation was associated with high risk in the patient series we report; however, the survival rate observed suggest that such patients should be considered acceptable candidates to receive grafts if indicated.

The specific cell type in primary lung cancer (LC) has important consequences, both for treatment and prognosis. Our objective has been to evaluate the degree of accuracy of several preoperative techniques in the LC diagnosis. We have studied 442 diagnostic techniques realized in 360 patients who underwent thoracotomy for LC in our hospital (1988-1994). Twelve sputum cytologies, 93 transthoracic needle biopsies (TNB), 73 bronchial aspirated cytologies, 30 bronchial brushing, 205 bronchial biopsies (BB) and 29 transbronchial biopsies were included. In each case the cellular type of LC, obtained through these techniques, was compared with the result derived from the study of surgical piece (reference diagnosis). To calculate the degree of concordance between both diagnoses we used the kappa coefficient (K). The overall concordance between the cellular type observed in the different preoperative techniques and the definitive result obtained by thoracotomy was 0.61. The worst test was TNB (K = 0.41). Sputum cytology and BB presented a good histopathological precision (K = 0.75 and 0.70 respectively). The rest of techniques showed moderate results. On the different histologies, the best result was obtained in squamous carcinoma (K = 0.68) and the worst in undifferentiated large cell carcinoma (LCC) (K = 0.39). Small-cell lung cancer only showed a moderate concordance (K = 0.58). The coexistence and coincidence of two or more tests with the same cellular type were associated with a higher proportion of accuracy (0.97 vs 0.73; p = 0.00002; odds ratio: 12.02). The preoperative histopathological diagnoses should be interpreted with caution, especially those obtained by TNB and those where it is implied the LCC. In these two circumstances and in cases in which the knowledge of the cellular type have relevance, we think that the initial diagnosis should be reinforced with a second result. The precision of the preoperative diagnoses in small-cell lung cancer must be reevaluated.