Search

OBJECTIVE To report the results of lung volume reduction surgery (LVRS) for severe emphysema in Australia. SETTING A tertiary teaching hospital. DESIGN A prospective study of a consecutive case series. PARTICIPANTS 20 patients (mean age, 56 years) with severe emphysema--mean forced expiratory volume in one second (FEV1), 0.72 L (28% of predicted) and severe gas trapping (mean residual volume, 286% of predicted). INTERVENTION Bilateral apical LVRS was performed via a median sternotomy with a linear stapler; bovine pericardial strips were used to reinforce the staple line. RESULTS There was a 95% survival, and a mean (range) inpatient stay of 17 (8-45) days. No complications occurred in nine patients; a further six patients had only minor complications. Five patients had major complications (sputum retention requiring reintubation, persistent air leak requiring reoperation, duodenal perforation, and epidural haemorrhage); one patient died from multiorgan failure at 28 days. Intercostal drainage was left in situ for a mean of eight days. The results of FEV1, Medical Research Council (MRC) Dyspnoea Score and six-minute walk test improved in more than 90% of patients. FEV1 improved an average of 0.35 L (54% over baseline) (P < 0.001). Mean MRC Dyspnoea Score decreased from 3.4 to 2.1 (P < 0.001). Mean distance for the six-minute walk test increased from 306 to 431 metres (P < 0.001). CONCLUSION Our experience confirms that LVRS produces worthwhile early outcomes for a subgroup of patients with severe emphysema. The clinical, economic and ethical questions raised by this new therapy will need to be assessed.

OBJECTIVE To report the first "domino-donor" operation performed in Australia; review the results of the first five combined procedures at the Alfred Hospital; and discuss the advantages of the procedure and its place in transplantation. PATIENTS AND OUTCOME The first domino-donor was a 25-year-old man with cystic fibrosis and pulmonary hypertension, receiving a heart-lung transplant, whose heart was transplanted into a 20-year-old woman with end-stage cardiomyopathy. The cardiac recipient's initial course was satisfactory, but at eight months she developed severe rejection, with failure of the donor heart, and required retransplantation. Subsequently four further combined procedures were performed. All 10 patients are alive and well. Four patients have had cytomegalovirus infection but without major complications. Improved function of the donor right ventricle has been observed when the ventricle is working against a lower resistance. CONCLUSIONS Four advantages of the domino procedure are evident: an increased pool of donor allografts; the use of a heart with an hypertrophied ("prepared") right ventricle; absence of the adverse effects of brain-death in the live donor; and improved ability to match the donor and recipient before the operation.