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The Pumpless Extracorporeal Lung Membrane Provides Complete Respiratory Support During Complex Airway Reconstructions Without Inducing Cellular Trauma, Coagulatory and Inflammatory Response
P. Macchiarini, A. Rodriguez, I. Manoli, E. Martinez, D. Sanchez, I. Rovira. Department of General Thoracic Surgery, Barcelona, Spain,
BACKGROUND: Evaluate whether the pumpless extracorporeal lung membrane (iLA, Novalung®, Hechingen, Germany) would provide adequate respiratory support without resulting in systemic morbidity during complex airway reconstruction.
METHODS: Only patients in whom standard or selective intubation with mechanical ventilation was technically or functionally impossible were eligible. Management included larynx mask or orotracheal intubation above the airway defect, arterovenous iLA-femoral vessels attachment to provide extracorporeal gas exchange, apnoic hyperoxygenation, and totally tubeless airway reconstruction. Haptoglobulin, plasmin-antiplasmin complex (PAPc), P-selectin activation (PsA), and IL-6 were measured pre-, intra-, post-iLA, and 72 hrs postoperatively.
RESULTS: Fifteen consecutive patients aged 42±17 years underwent elective (n=7) or emergency (n=8) reconstruction of the airway. Indications were failed supracarinal tracheal resection (n=4), chronic tracheo-esophageal benign fistula (TEF, n=1), post-carinal pneumonectomy anastomotic dehiscence (n=2), lung mass in a 6-months pregnant (n=1), complete loss of the tracheobronchial membraneous wall (n=4), and main carinal perforation (n=3). The iLA was left in place during 185±61 min, diverted 1.70±0.48 L/min of the cardiac output, and provided an arterovenous CO2-removal and O2 transfer of 173±94 and 144±83 mL/min, respectively. The PaO2/FiO2 and PaCO2 remained 314±31 and 40±6 mm Hg, respectively throughout the operations. Surgery were 3 redo-slide tracheoplasties, 1 redo-TEF repair, 2 sleeve lobectomies, 7 main carina reconstructions, and 2 anastomotic stenting and myocutaneous coverages. Three patients required prolonged (9±2 days) iLA support post-operatively. Hospital mortality was 2 (13%) patients. During iLA, there was a significant (p<0.05) increase of haptoglobulin (hemolysis), PAPc (coagulation activation), PsA (platelets activation) but this increase was never above the respective pathological levels, clinically unrelevant, and normalized within 48-hours post-operatively. CONCLUSIONS: The pumpless extracorporeal lung membrane provided a complete intraoperative respiratory support permitting airway reconstruction in patients were standard intubation and mechanical ventilation was impossible, and without inducing significant cellular trauma, coagulatory and inflammatory response.
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