| In 1983, Cooper performed the right lung transplantation for a patient with end stage cystic fibrosis and firstly achieved long term survival. From then on, lung transplantation has become the sole hope for patients with end stage pulmonary disease. In recent 20 years, lung transplantation has been performed in a certain scale overseas. Up to September, 2004, there were about 18 hospitals which have performed lung transplantation, with totally 30 cases of single lung transplantation in our country. There are about 8 hospitals that have got long term survival. The lung function is ameliorated and living quality increases significantly after lung transplantation. Along with the development of lung transplantation, the contradiction of demand and supply of donor lung are increasing. The shortage of donor lung restricts the development of lung transplantation seriously, especially for the children. The other organs in most children patients with primary puhnonary hypertension or Eisenmenger's syndrome with end congenital heart disease have normal functions. It is more satisfactory to perform the operation repairing the abnormalities and lung transplantation simultaneously. In most cases, the adult cadaver lung is not suit forchildren. At the same time, children donor lung are very scarce and the quality is not guaranteed, either. In order to solve the problem of donor lung shortage, living lobar lung donor vas investigated to increase the donor sources, and the relative's living lung donors are the major source of donor lung in children lung transplantation. This work has been developed for years overseas whereas it is still blank in our country, and the data overseas are not sure whether it suit for the population in our country or not. In order to explore the applicability of riving donor lobar lung transplantation to promote this technique, to stimulate the living lobar lung transplantation, to provide related anatomic data, the accelerate the development lobar lung transplantation in our country, we performed this study, in which anatomic measurement of adult and children lung were done and several porcine lung transplantation experiment were performed.Chapter one: The clinical applied anatomic study of lobar lungtransplantation in adultObjective: Lung transplantation is the best way to treat pediatric end-stage lung disease. The shortage of lung donor is the most obstacles to pediatric lung transplantation. Since the pediatric thorax is smaller, the suitable cadaver lung donor can not be found easily. Today pediatric living lobar lung transplantation has already been done in several foreign clinics, but it has not been done in our country. The foreign data probably do not fit Chinese people. Applied anatomy of adult lobar lung was studied and we hope to offer valuable anatomic data for Chinese living lobar lung transplantation.Methods: 40 adult cadavers (80 lungs) fixed by formalin were involved in this study, out of which 26 were male and 14 were female. The average cadaver lengthwas 168cm. A median sternotomy was done and the heart-lung block was excised. After lung was dissected, diameters and lengths of main bronchi, lobar bronchia, lobar arteries, and lobar veins were measured. We specially observed the structure of inferior lobar lung, artery of the middle, lingua lobar lung, and relationship between bronchia of middle lobe and superior segmental bronchia of inferior lobar.Results: Superior lobe of right lung: length of superior lobar bronchia 11.20±3.62 mm, external diameter 10.84±3.47 mm, volume 342 cm3 (male), 287cm3(female); superior lobar artery had one branch (5%, 2/40), two branches (25%, 10/40), three branches (70%, 28/40). The first branch was 13.02±3.60 mm in length and 8.8±2.20 mm in diameter. The length of right middle lobe artery was 15.40±2.21 mm and the external diameter was 7.16±1.03 mm; right middle lobar artery had one (47.5%, 19/40) or two (52.5%, 21/40) branches. The first branch was 10.52±2.60 mm in length and 8.30±2.30 mm in diameter; the volume of the right middle lobe was 160 cm3 in male, 147cm3 in female. Inferior lobe of right lung: length a of bronchia of right inferior lobe was 6.28±1.81mm, external diameter was 11.22±2.33 mm; length b of bronchia of right inferior lobe was 18.26±2.75 mm, external diameter 11.22±2.33 mm; volume of right inferior lobar lung was 438 cm3 in male, 387cm3 in female; length a of right inferior lobar artery was 5.5±1.50 mm, diameter 11.34±2.60 mm. Length of right inferior lobe is 9.52±1.13 mm, diameterll.34±2.60 mm. The length of left superior bronchia was 12.71±3.15 mm and external diameter was 12.37±1.62 mm. The volume of left superior lobe was 384 cm3 in male, 323 cm3 in female. Left superior lobar artery had 3 branches (20%, 8/40) or 4 branches (80%, 32/40). The length of the first branch was 8.40±1.32 mm and diameter was 6.16±1.26 mm. The length of left inferior lobar bronchus was 7.82±2.97 mm and external diameter was 11.84±3.15 mm. The volume of left inferior lobe was 460 cm3 in male and 404 cm3 in female. The length of left inferior lobar artery was 4.6±1.00 mm and the diameter was11.15±1.47 mm. The length b of left inferior lobar artery was 13.36±2.80 mm and the diameter was 11.15±1.47 mm. The percentage of cases in which the opening of middle lobar bronchia was higher than superior segmental bronchi of inferior lobe was 62.5%(25/40); The percentage of cases in which the openings of middle and superior segmental bronchi of inferior lobe was at the same level was 25% (10/40); The percentage of cases in which the opening of middle lobar bronchia was lower than that of superior segmental bronchi of inferior lobe was 12.5% (5/40). The percentage of cases in which right middle lobar artery had one branch which open at same level with superior segmental artery of inferior lobe was 20%(8/40); The percentage of cases in which right middle lobar artery open higher or lower than superior segmental artery of inferior lobe was 22.5% (9/40), 5% (2/40) respectively. The percentage of cases in which right middle lobar artery had two branches one of which open higher than superior segmental artery of inferior lobe and another lower was 32.5%(13/40). The percentage of cases in which one of two branches opened higher than superior segmental artery of inferior lobe and another was at the same level was 15%(6/40); The percentage of cases in which both of two branches opened lower than superior segmental artery of inferior lobe and another at same level was 5%(2/40). The percentage of cases in which left lingual segmental artery opened higher or lower than superior segmental artery of inferior lobe was 10%(4/40), 80%(32/40) respectively; the percentage of cases in which left lingual segmental artery opened at the same level with the superior segmental artery of inferior lobe was 10%(4/40).Conclusion: 1. In the light of anatomy, adult can be a donor for pediatric living lobar lung transplantation. Adult inferior lobes are more suitable, but left superior lobes are not because of the anatomy of the superior lobar artery. Right superior lobe can also be used for pediatric lung transplantation if lobar artery has one branch.Right middle lobe is not suitable because of its too small volume.2. If the opening of middle lobar bronchus is too low, middle stem bronchus can be cut off above the opening of middle lobar bronchus and transplant middle lobar bronchus to the proximal part. If the resection of the artery of middle lobe or lingual lobe that is too low which will do harm to the blood supply in this area, auto-transplantation is suggested. Middle lobar bronchus and segmental artery of middle or lingual lobe auto-transplantation, and reconstruction pulmonary artery using auto-graft pericardium patch are first put forward in this study.Chapter two: The clinical applied anatomic study of lung lobetransplantation in childrenObjective: Lung transplantation is the best way to treat pediatric end-stage lung disease. The shortage of lung donor is a great obstacle to pediatric lung transplantation. To explore the feasibility of pediatric living lobar lung transplantation, the clinical applied anatomic study was performed to offer anatomic evidence of pediatric living lobar lung transplantation.Methods: 30 pediatric cadavers (60 lungs) fixed by formalin were involved in this study, out of which 19 were male and 11 were female. They were divided into three groups according to cadaver length. Group A: 10 cases, length 90-109cm; group B: 10 cases, length 110-129cm; group C: 10 cases, length 130~150cm. The age was calculated according to the cadaver length which was 3-5 years, 6-8 years, 9-13 years, respectively. A median sternotomy was made and the heart-lung block was excised. After lung was dissected, the external and internal diameters of the left and right main bronchi were measured. Both length and internal diameter of pulmonary artery and pulmonary veins were also measured. The lung volume was measured as well.Results: The external diameters of pediatric main bronchi of group A, B, C were8.82±0.87 mm in the left side, 8.82±0.87 mm in the right side; 9.78± 0.58 mm in the left side, 10.55±0.78 mm in the right side; 11.82+1.25 mm in the left side 12.05+0.87mm in the right side, respectively. Compared with adult inferior lobar bronchus of the same side in external diameters (left side 11.84±3.15mm, right side 11.22±2.33 mm respectively), Group C matched most (P>0.05); there was significant difference of the bronchus of the external diameters between Group A and adult and between group B and adult (p<0.05). Compared in diameter, there was no significant difference between the pediatric pulmonary artery in children and the inferior lobar artery of the same side in adult (P >0.05). There was significant difference of volume between the pediatric lung in group A (left side 278 +46cm3,right side 347 +32cm3) and the same side of inferior lung in adult (right inferior lobar lung of male 439±53cm3, right inferior lobar lung of female 387±32cm3, left inferior lobar lung of male 460±51cm3 , left inferior lobar lung of female 404± 33cm3, respectively); but there was no significant difference of volume between the pediatric lung in group B(left side 408+68cm3, right side 507+48 cm3) and the same side of inferior lung in adult and between group C (left side 484 + 74cm3,right side 572 ±5 lcm3).Conclusion: According to the anatomic data measured, Group C matches adult's lobe most, so it is most suitable for lung transplantation. Group B matched adult's lobe a little least, so when lung transplantation is suggested, attention should be paid to optimize the technique. Group A does not match adult's lobe, so it is not suitable for living lobar lung transplantation.Chapter three: The experimental study of porcine lobar lungtransplantation under normothermic cardiopulmonary bypassObjective: Along with the improvement of technology and research of lung transplantation, promotion of life quality and survival time after operation, moreorgans are needed and shortage of organ has seriously restricted the development of lung transplantation. Although living donor lungs have been used internationally for years, it has not been developed in our country. In our study, we investigated the operative skills of animal lobar lung transplantation based on the anatomic materials to promote the lobar lung transplantation in our country.Methods: Three adult local lean pigs were chosen as donors, weighing 65, 68 and 70kg, respectively and three infant pigs as recipients, weighing 30, 33 and 35kg, respectively. The operations of donor and recipient were performed simultaneously. The animals were anaesthetized with ketamine, and pancuronium Bromide was used to maintain the muscle in relaxed state. Trachea intubations were performed through an incision in the neck and it was connected to ventilator for mechanical breath support. The jugular vein was separated and the vein catheter was inserted into the vein for the measurement of the blood pressure and fluid infusion. The systemic arterial pressure was monitored through a catheter in the carotid artery. After thoracotomy, the double lungs were removed from young pig, at the same time, the double lower lobes of the adult lungs were harvested, and then they were transplanted into the thoracic cavity of the young pig. The relationship of right middle lobe artery and the right superior segmental artery, the lingual segmental artery and the left superior segmental artery in the left lower lung lobe were observed. The anatomies of middle lobe artery or lingual segmental artery with pulmonary artery nub were simulated in the isolated adult pig lungs. The pericardial patch was use to repair the pulmonary artery nub defect. The anastomosis of right lung middle bronchus and the bronchial stem were also performed.Results: The anastomosis of the donor's pulmonary artery and the pulmonary vein with the recipient's pulmonary artery, the atria wall were achieved successfully, but there were some difficulties in the bronchial anasomosis. Two recipient pigs hadresumed to spontaneous breath without the ventilator after transplantation. One died in the experimental stage.Conclusion: 1. It is feasible to anastomize middle lobar artery with itself inter lobar artery according to the anatomic data and laboratorial research, but it is difficult to perform the autograft transplantation of middle bronchus.2. It is very important that the relationship between the superior segmental bronchus in the lower lobe and the lingual segmental bronchus, the superior segmental artery of the lower lobe and the lingual segmental artery, the middle lobe artery and the lingual segmental artery. It is crucial to protect the remaining donor lung function; autograft transplantation should be done to maintain the integrity of the donor lung structure when needed.3. In children, lung transplantation should be performed with beating heart under normothermic cardiopulmonary bypass. With the support of normothermic cardiopulmonary bypass and the beating heart, it will be beneficial for the heart and general system, especially for the immunity system, which has less bad effect on immunity system than that with hypothermic cardiopulmonary bypass. Further study is needed in this aspect.
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