Effect of surgical exposure on outcomes in bilateral lung transplantation: Insight from the international multicenter extracorporeal life support in lung transplantation registry
Year: 2026
Type: article
Study design: Observational Study
Abstract: BACKGROUND: Surgical access for bilateral lung transplantation (BLTx), including clamshell, sternotomy, and isolated bilateral thoracotomies (IBT), may influence perioperative outcomes. We analyzed the international ECLS Registry to assess the impact of access type on perioperative outcomes and graft survival. METHODS: Adult BLTx performed from January 2016 to August 2024 across 12 centers was reviewed. Patients were grouped as being transplanted through clamshell (n = 451, 37.6%), IBT (n = 624, 52.0%), or sternotomy (n = 125, 10.4%). Three 1:1 propensity score-matched comparisons were performed: clamshell vs IBT, clamshell vs sternotomy, and IBT vs sternotomy. RESULTS: Before matching, baseline characteristics differed significantly across surgical approaches, including BMI (25.2 vs 23.6 vs 24.3 kg/m², p < 0.001), diabetes (19.3% vs 14.9% vs 16.8%, p < 0.001), pulmonary hypertension (4.2% vs 4.8% vs 5.6%, p < 0.001), and intraoperative extracorporeal life support (ECLS) use (p < 0.001). After matching, IBT patients showed longer ischemic times (p< 0.001) but less intraoperative ECLS use, shorter ventilation and ICU stays (p < 0.001), lower reintubation (p = 0.021 vs clamshell; p = 0.045 vs sternotomy), fewer reoperations for bleeding (p = 0.190 vs clamshell; p = 0.018 vs sternotomy), and lower transfusion needs (p< 0.001). At 1 year, IBT was associated with higher pulmonary function and improved unadjusted graft survival than clamshell patients (1-year: 91% vs 86%; 3-year: 74% vs 63%; 5-year: 51% vs 49%; p = 0.007). CONCLUSION: Surgical access in BLTx affects perioperative morbidity and recovery. IBT was associated with improved early/intermediate graft survival compared with clamshell incision, although the absolute difference was attenuated at 5 years. Incision choice should be tailored to patient profile, procedural demands, and institutional expertise.
Authors: Nunzio Davide de Manna, Sophie Kruszona, Andres Leon-Pena, Ramiro Fernandez, Uma Ramamurthy, Matthew Hartwig, Kamrouz Ghadimi, Nathaniel B. Langer, Asishana A. Osho, Mohammed Kashem, Yoshida Toyoda, Amir Emtiazjoo, Mindaugas Rackauskas, Laurens J. Ceulemans, Cedric Vanluyten, Stephen Huddleston, Subramaniam Kathirvel, Silvana Crowley Carrasco, Pablo G. Sanchez, Jawad Salman, Khalil Aburahma, Dirk Van Raemdonck, Gabriel Loor, Fabio Ius
Institutions: Medizinische Hochschule Hannover, Baylor College of Medicine, Duke Medical Center, Massachusetts General Hospital, Temple University, University of Florida, Universitair Ziekenhuis Leuven, University of Minnesota, University of Pittsburgh, Hospital Universitario Puerta de Hierro Majadahonda, University of Chicago, University of Chicago Medical Center
Language: English
Subfield: Surgery
Field: Medicine
Domain: Health Sciences
Open Access status: hybrid
Estimated APC paid: $3,606
Funder: Baylor College of Medicine
OpenAlex ID: W7171615986