Safety and early outcomes of nighttime lung transplantation with a surgical multidisciplinary team in a low-volume center

Introduction

Lung transplantation (LTx) performed in high-volume centers has been consistently associated with lower complication rates, reduced healthcare costs, and more favorable survival outcomes. These benefits are primarily attributed to accumulated surgical expertise, the adoption of standardized care protocols, and a heightened capacity to recognize and manage complications effectively (1-5). More recently, multidisciplinary team (MDT) care models have demonstrated both cost-effectiveness and significant improvements in surgical outcomes, including in LTx (6-8). Notably, the integration of a surgical MDT may exert a synergistic impact, supporting favorable outcomes even in low-volume centers (9,10).

Surgical procedures conducted during nighttime hours have been associated with higher rates of intraoperative adverse events and postoperative complications compared to those performed during the day (11,12). This issue is particularly pertinent in LTx, where the timing of donor organ availability is often unpredictable, and minimizing graft ischemic time is critical. Furthermore, the complex coordination required among multiple procurement and transplant teams frequently necessitates nighttime procedures (13). Previous investigations on nighttime LTx have predominantly focused on high-volume centers. While these studies suggest an association between nighttime operations and increased early postoperative complications, evidence regarding long-term survival remains inconclusive (13,14). In addition, the impact of nighttime transplantation on outcomes in low-volume centers remains poorly described. Given that nighttime LTx is often unavoidable in many countries due to logistical and donor-related constraints, this knowledge gap presents a significant concern. Accordingly, we conducted this retrospective study to assess the outcomes of LTx performed in a low-volume center employing a multidisciplinary surgical team approach, with particular attention to procedures conducted at night. We also aimed to identify potential strategies for optimizing clinical outcomes in this challenging context. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-856/rc).

Methods

Patients

Ethics approval for this investigation was granted from the Chang Gung Medical Foundation Institutional Review Board (IRB No. 202401711B0) on November 13, 2024. The requirement for informed consent was waived due to the retrospective nature of the study. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Between December 2016 and September 2023, 72 patients underwent LTx at Chang Gung Memorial Hospital (Linkou, Taiwan). After excluding patients who underwent single-LTx, a total of 70 double-lung transplant recipients were included in the study. All patients were followed up through monthly outpatient evaluations post-discharge, with no instances of loss to follow-up throughout the study period.

LTx team

The LTx team operated within an MDT framework, comprising general thoracic surgeons, cardiac surgeons, pulmonologists, intensivists, anesthesiologists, pathologists, infectious disease specialists, social workers, and psychologists. During the LTx procedures, the surgical MDT included thoracic surgeons, cardiac surgeons, and anesthesiologists. Thoracic surgeons were responsible for donor lung procurement, recipient pneumonectomy, and bronchial anastomoses. Cardiac surgeons performed vascular anastomoses—including the pulmonary artery and left atrial cuff—and provided intraoperative hemodynamic support via extracorporeal life support (ECLS) or cardiopulmonary bypass. Anesthesiologists played a critical role in maintaining adequate anesthesia, managing ventilation and oxygenation, and conducting continuous hemodynamic monitoring and support. At our center, the core surgical MDT comprised six thoracic surgeons, three cardiac surgeons, and four anesthesiologists.

Data collection

Collected recipient variables included demographic information [age, sex, body mass index (BMI)], primary indication for LTx (e.g., emphysema, pulmonary fibrosis, bronchiectasis, primary pulmonary arterial hypertension, or other conditions), presence of comorbidities, history of thoracic surgery, duration on the transplant waitlist, glycated hemoglobin (HbA1c) levels, mean pulmonary artery pressure, requirement for pre-transplant assisted ventilation, Lung Allocation Score (LAS), and results of lung function tests both before and after transplantation. Additional data encompassed surgical outcomes, short-term postoperative results, and long-term survival. Donor variables comprised demographic characteristics (age, sex, BMI), cause of brain death, smoking history, HbA1c levels, and optimal pre-retrieval arterial blood gas parameters, including the arterial oxygen partial pressure to fractional inspired oxygen ratio (PaO₂/FiO₂).

Patient stratification by surgical timing

All transplanted patients were stratified into two groups according to the timing of the surgical incision: daytime (8:00 AM to 8:00 PM) and nighttime (8:00 PM to 8:00 AM). This time-based division was selected to reflect the institution’s staffing model, wherein full surgical, anesthetic, and support teams are available during standard daytime hours (8:00 AM to 5:00 PM), with extended in-house coverage maintained until 8:00 PM. Procedures initiated after 8:00 PM are performed by on-call teams operating with reduced staffing levels and limited support resources. This classification was intended to capture not only the temporal aspect of surgery but also potential differences in team availability and perioperative care conditions that could affect clinical outcomes.

Surgical metrics and early outcomes

The surgical metrics analyzed in this study included total operative time, ischemic time, total anastomosis time, the use and duration of ECLS, the need for postoperative extracorporeal membrane oxygenation (ECMO) support, intraoperative blood loss, and the requirement for leukocyte-reduced packed red blood cell transfusions. Short-term post-transplant outcomes comprised the incidence of grade 3 primary graft dysfunction (PGD) at 6, 24, 48, and 72 hours after reperfusion, as defined by the International Society for Heart and Lung Transplantation (ISHLT) criteria (15), in addition to the occurrence of postoperative surgical and medical complications, in-hospital mortality, duration of intensive care unit (ICU) stay, and total length of hospital stay. Long-term outcomes were also assessed, including forced expiratory volume in the first second (FEV₁) recovery at 1 year, as well as 1-year and 3-year survival rates.

Statistical analysis

Categorical variables are reported as counts and percentages, with group comparisons performed with the Chi-squared test as appropriate based on sample size. Continuous variables are summarized as medians with interquartile ranges (IQR) and compared using the non-parametric Mann-Whitney U test. Survival differences between daytime and nighttime groups were assessed using the log-rank test. Analyses were performed using SPSS, version 26 (IBM, Armonk, NY, USA), with all tests two-sided at a 5% level of significance.

Results

Recipient characteristics

Among the 70 patients who underwent double LTx, 43 (61.4%) belonged to the daytime group and 27 (38.6%) to the nighttime group (Figure 1). The median procedure start time was 1:00 PM for daytime surgeries and 4:00 AM for nighttime procedures. Table 1 summarizes recipient characteristics and operative parameters based on the timing of transplantation. Emphysema was the most common indication for bilateral LTx (41%), followed by pulmonary fibrosis (29%) and bronchiectasis (9%). No significant differences were observed between the two groups regarding age, sex, BMI comorbidities, surgical indication, preoperative cardiopulmonary function, or LAS. The overall median follow-up duration was 40 months (IQR, 18–56 months), with a median follow-up of 42 months (IQR, 14–70 months) in the nighttime group and 40 months (IQR, 19–61 months) in the daytime group.

Figure 1 Flow diagram illustrating study design and cohort selection.

Donor characteristics

We subsequently compared donor characteristics between the daytime and nighttime groups. There were no significant differences between the groups in terms of donor age, sex, BMI, HbA1c concentrations, or PaO₂/FiO₂ ratio (Table 2).

Surgical metrics

Key surgical metrics are presented in Table 3. The median total operative time was comparable between the two groups at 520 minutes (P=0.61). For the first lung, the median ischemic time for the entire cohort was 349 minutes (IQR, 285–431 minutes). The nighttime group demonstrated a 1-hour longer median ischemic time [390 minutes (IQR, 304–422 minutes)], although this difference was not statistically significant (P=0.36). For the second lung, the overall median ischemic time was 456 minutes (IQR, 399–536 minutes), with the nighttime group experiencing a 53-minute longer median ischemic time [505 minutes (IQR, 412–546 minutes)]; however, this difference similarly did not reach statistical significance (P=0.27). The only statistically significant difference was observed in total anastomosis time, with the nighttime group having a median anastomosis time of 119 minutes (IQR, 105–132 minutes) compared to 109 minutes (IQR, 103–121 minutes) in the daytime group (P=0.04; Figure 2). ECLS was utilized in 53% of bilateral LTx procedures, with a moderately higher utilization rate in the daytime group (58%) versus the nighttime group (44%); however, this difference was not statistically significant (P=0.31). The median duration of intraoperative ECLS was approximately 5 hours [327 minutes (IQR, 202–369 minutes)]. Nighttime procedures demonstrated a 1-hour longer median ECLS duration [307 minutes (IQR, 230–536 minutes)] compared to daytime operations [243 minutes (IQR, 199–357 minutes)], although this difference did not reach statistical significance (P=0.15). Prolonged ECMO support was required in 14.3% of patients, comprising six recipients of veno-arterial ECMO and four of veno-venous ECMO. There was no significant difference between groups in the need for prolonged ECMO support (P=0.33). Intraoperative blood loss was comparable between groups, with both daytime and nighttime surgeries having a median volume of 850 mL (P=0.62). However, nighttime surgeries required a higher median number of leukocyte-poor packed red blood cell transfusions [6 units (IQR, 4–10 units)] compared to daytime procedures.

Figure 2 Bar chart illustrating the distribution of lung transplantation procedures according to surgical timing. Superimposed line graphs (daytime: blue; nighttime: red) display the median anastomotic duration for each hourly interval of surgical initiation. The nighttime group demonstrated a significantly longer anastomotic time compared to the daytime group (P=0.04).

Early outcomes

Short-term surgical outcomes following LTx were generally comparable between the daytime and nighttime groups (Table 4). The median duration of mechanical ventilation across the entire cohort was 59 hours (IQR, 37–116 hours), with no significant difference between the daytime group [60 hours (IQR, 40–122 hours)] and the nighttime group [56 hours (IQR, 34–102 hours); P=0.98]. Grade 3 PGD within the first 72 hours post-transplant occurred in 49% of patients overall, with comparable rates in the daytime (51%) and nighttime (44%) groups (P=0.58). The incidence of pulmonary embolism was low, occurring in 4% of the total cohort—specifically, in two patients (5%) from the daytime group and one (4%) from the nighttime group.

Post-transplant pneumonia developed in 10% of recipients, with similar distribution between the groups: 12% in the daytime cohort and 7% in the nighttime cohort (P=0.57). Severe postoperative complications requiring surgical intervention (Clavien-Dindo grade III–V) were reported in 40% of patients overall, affecting 37% of patients in the daytime group and 44% in the nighttime group (P=0.31) (Tables S1,S2). In-hospital mortality was low, with three deaths recorded in the entire cohort—two patients (5%) in the daytime group and one (4%) in the nighttime group. Post-transplant care duration was similar between groups, with a median ICU stay of 9 days (IQR, 7–12 days) for daytime procedures and 8 days (IQR, 7–13 days) for nighttime procedures (P=0.61). Similarly, the total length of hospitalization showed no significant difference, with a median stay of 40 days for the overall cohort (P=0.76). The median follow-up duration was 3.9 years. Overall survival rates at 1 and 3 years were 91% and 79.5%, respectively. No statistically significant differences in survival were observed between groups (1-year: 93% vs. 89%, P=0.62; 3-year: 79% vs. 89%, P=0.12) (Figure 3). Pulmonary function recovery—defined as achieving a FEV₁ greater than 80% of predicted within 1 year—was observed in 44% of the study population. Although the daytime group demonstrated a slightly higher rate of recovery (47%) compared to the nighttime group (41%), this difference was not statistically significant (P=0.32) (Tables S3,S4).

Figure 3 Kaplan-Meier survival curves depicting 3-year survival rates of lung transplant recipients, stratified by surgical timing. No statistically significant differences in survival were noted between the daytime (79%) and nighttime (89%) groups (P=0.12).

Discussion

Center volume has been widely recognized as a key determinant of outcomes following LTx, with higher-volume institutions typically achieving more favorable results (1-4). Interestingly, even within these centers, nighttime procedures have been associated with increased complication rates (13). However, the implementation of standardized protocols and the involvement of experienced MDTs have enabled some low-volume centers to attain outcomes comparable to those of larger programs (9,10). In this study, we demonstrated that, through a well-coordinated surgical MDT approach, our low-volume center achieved results comparable to those reported by high-volume institutions. Although nighttime transplantation was associated with longer anastomosis times, this did not negatively impact postoperative outcomes, underscoring the critical role of effective team-based care in mitigating the challenges of nighttime surgery.

Annual LTx volumes exceeding 33 cases have been linked to reduced in-hospital mortality and more favorable 1- and 5-year survival rates (1,2,4). These positive outcomes are largely attributed to the adoption of standardized perioperative pathways and robust critical care infrastructure within integrated transplant programs (1,4). Such integration is typically supported by a MDT including general thoracic surgeons, pulmonologists, anesthesiologists, pharmacists, social workers, physical therapists, and nutritionists (7). The inclusion of a dedicated surgical MDT—comprising both thoracic and cardiac surgeons—has further been shown to enhance outcomes even in low-volume centers (9,10). A retrospective analysis of 2,844 patients from high-volume centers based on the Scientific Registry of Transplant Recipients (SRTR) database reported 1- and 3-year survival rates of 81.2% and 68.9%, respectively (5). By comparison, our cohort, managed by a surgical MDT in a low-volume setting, achieved superior 1-year (91%) and comparable 3-year (79.5%) survival outcomes.

Nighttime surgery is often unavoidable due to the urgent and time-sensitive nature of many medical procedures. Nevertheless, accumulating evidence suggests that operations performed during nighttime hours are associated with less favorable clinical outcomes compared to those conducted during the day (16). For example, nighttime orthopedic procedures have been linked to an increased incidence of unplanned reoperations and removal of hardware due to postoperative complications (17). Similarly, nighttime colorectal surgeries have shown higher rates of anastomotic leakage, with surgical timing identified as an independent risk factor (18). Multiple factors likely contribute to the elevated complication rates observed at night, including physician fatigue due to extended work hours or sleep deprivation, increased frequency of provider handovers, and the limited availability of senior clinical staff during night shifts (11,12).

In organ transplantation, the necessity of nighttime operations is driven by the unpredictable timing of donor organ availability, the imperative to limit total ischemic time, logistical coordination among transplant teams at different sites, and restricted access to operating rooms in donor hospitals (13,19,20). Despite these constraints, the impact of surgical timing on transplant outcomes remains controversial. In kidney transplantation, nighttime surgery has been associated with higher rates of wound complications, although differences in overall survival remain statistically nonsignificant (20-22). Liver transplantation studies have yielded mixed results: Lonze et al. (19) reported higher early mortality following nighttime procedures, whereas Becker et al. (23) found no detrimental effect of surgical timing. Importantly, neither study showed a significant difference in overall survival between daytime and nighttime liver transplants (19,23).

In LTx, nighttime procedures have traditionally been associated with increased rates of airway dehiscence and major postoperative complications (13,14). However, more recent single-center studies have challenged this view, showing no difference in survival while, paradoxically, reporting a higher incidence of airway complications during daytime operations (24). It is important to note that most of these studies were performed in high-volume centers. According to UNOS data, the proportion of LTx performed in high-volume institutions has increased significantly over time, from 30.9% to 67% (1,4). Nonetheless, a substantial number of transplants still take place at low-volume centers. In Taiwan, for instance, the annual case volume at each authorized hospital remains below ten, largely due to persistently low organ donation rates (25). In light of these trends, evaluating the impact of nighttime LTx in low-volume settings remains especially relevant.

Given the potential risks associated with nighttime transplantation, several strategies have been proposed to optimize outcomes. Kim et al. (26) reported that postponing LTx procedures until after 6:00 AM—when cross-clamp times would otherwise fall between 1:30 AM and 5:00 AM—yielded comparable rates of complications and 3-year survival at a high-volume center. Recent advancements in organ preservation—most notably, ex vivo lung perfusion (EVLP) and controlled hypothermic storage (CHS) —offer potential solutions for delaying transplantation until daytime hours (27-29). With EVLP, total ischemic times exceeding 12 hours have not been associated with increased in-hospital, 90-day, or 1-year mortality (28). Likewise, CHS has allowed for ischemic times up to 15 hours without a rise in early mortality or major postoperative complications (29). Nevertheless, the high costs and complex logistics associated with both EVLP and CHS may limit their feasibility, particularly in low-volume centers. These preservation strategies were not employed in our cohort.

The collaborative integration of general thoracic and cardiac surgeons within a surgical MDT has demonstrated synergistic benefits in managing complex LTx cases (10). Moreover, the MDT model has been shown to shorten the learning curve and improve early outcomes in centers with low surgical volumes (9). At our center, a dedicated surgical MDT was established in December 2016, comprising general thoracic surgeons, cardiac surgeons, anesthesiologists, perfusionists, and operating room staff. This team-based structure facilitates shared surgical responsibilities, thereby reducing physician fatigue during prolonged procedures. Additionally, the presence of specialized anesthesiologists and surgical personnel during night shifts minimizes intraoperative handovers and maintains procedural consistency. Although nighttime LTx was associated with longer anastomosis times in our cohort, it did not adversely impact postoperative complications or survival, underscoring the effectiveness of a coordinated MDT approach in overcoming the risks typically associated with nighttime surgery.

Our study has several limitations that must be acknowledged. First, because the data were obtained from a single center in Taiwan, generalizability to other low-volume LTx centers may be limited. Second, the definition of daytime and nighttime procedures was based on local scheduling logistics rather than clinically relevant intraoperative timepoints such as cross-clamp or reperfusion timing. Third, the small sample size inherent to low-volume centers may have limited the statistical power to detect meaningful differences, and precluded detailed subgroup analyses. Future multicenter studies with larger cohorts are warranted to validate these findings. Finally, extended follow-up is essential to fully assess long-term graft function and recipient survival outcomes.

Conclusions

Despite the inherent complexity of LTx, our low-volume center achieved comparable short-term outcomes between daytime and nighttime procedures through the consistent involvement of a surgical MDT. These findings indicate that a well-coordinated surgical MDT may help mitigate the risks typically associated with nighttime transplantation. This team-based approach could serve as a model for emerging LTx programs, supporting the safe and effective implementation of LTx in resource-limited or developing centers.

Acknowledgments

We gratefully acknowledge the collaboration and dedication of our multidisciplinary lung transplantation team. The expertise and steadfast commitment of each team member were integral to the successful execution of this complex procedure, irrespective of the time of day. Their collective efforts were essential in achieving the favorable clinical outcomes reported in this study.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-856/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-856/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-856/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-856/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Ethics approval for this investigation was granted from the Chang Gung Medical Foundation Institutional Review Board (IRB No. 202401711B0) on November 13, 2024. The requirement for informed consent was waived due to the retrospective nature of the study. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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