Pediatric lung transplantation and "lessons from Green Surgery.".

During the past decade, lung transplantation has emerged as the definitive treatment for children with end-stage lung disease. Pediatric transplantation presents unique challenges with respect to diagnostic indications, donor-recipient size disparities, perioperative management, and growth. Lessons from the early development of cardiac surgery at the University of Minnesota (Green Surgical Service) provide a useful model for novel surgical challenges. Since 1990, 25 lung transplantations have been performed at our institution, including 4 heart-lung, 3 single-lung, 17 bilateral-lung, and 1 living-related lobar allograft. Age at transplantation ranged from 7 months to 27 years. The most common indication was cystic fibrosis. Given the limited donor pool, size disparities between donor and recipient were frequent. Excessive donor size was addressed by parenchymal reduction. Accommodation of small donor allografts was facilitated by elective cardiopulmonary bypass and pulmonary vasodilation using inhaled nitric oxide. Epidural anesthesia was routinely used for postoperative pain management and to enhance good pulmonary hygiene. Immunosuppression is presently achieved using cyclosporine, mycophenolate mofetil, and corticosteroids. Monitoring for rejection is accomplished with spirometry and transbronchial biopsies. Bronchial complications in 2 patients required placement of Palmaz stents. The living-related allograft was performed in a previous bone marrow transplant recipient obviating the need for long-term immunosuppression. The potential for growth of mature lung parenchyma postoperatively was studied and verified in a sheep model. Our experience parallels that of other frontiers such as early cardiac surgery in which medical and technologic innovations can be applied in a supportive environment to permit surgical progress.