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J Thorac Cardiovasc Surg 1994;107:1476-1480
© 1994 Mosby, Inc.

CARDIAC AND PULMONARY REPLACEMENT

Surgical treatment of airway complications after lung transplantation

Hannover, Germany

From the Division of Thoracic and Cardiovascular Surgery, Department of Radiology, ^a and the Department of Pneumonology, ^b Hannover Medical School, Hannover, Germany.

Received for publication July 30, 1993. Accepted for publication Nov. 24, 1993 Address for reprints: H.-J. Schäfers, MD, Division of Thoracic and Cardiovascular Surgery, Medical School Hannover, 30623 Hannover, Germany.

Abstract

The treatment of dehiscence or stenosis of the bronchus after lung transplantation has to date consisted of endobronchial stenting or balloon dilation. Operative intervention has been limited to retransplantation with all its limitations. In our series of 121 anastomoses at risk, severe bronchial stenosis occurred in 11 (9%). In five instances the airway complications were treated surgically: two patients underwent retransplantation, one patient had a bilobectomy, and two required sleeve resection of the stenotic segment. All these procedures successfully removed the stenosis. This experience demonstrates that options other than bronchial anastomotic stenting and dilation may be successfully used to overcome posttransplantation anastomotic complications. Conventional resections may result in superior long-term graft function compared with retransplantation, avoiding the immunologically adverse effects of the latter procedure. (J THORAC CARDIOVASC SURG 1994;107:1476-80)

Bronchial complications continue to occur after lung transplantation despite advances in operative technique and organ preservation. ^1,2 Ischemia of the graft airway may lead to tissue necrosis with bronchomalacia, granulation tissue, stricture formation, or even dehiscence with subsequent vascular erosion. Endobronchial stents may provide airway patency for prolonged periods. ¹ In extensive lesions, however, adequate placement of endobronchial stents may be difficult. In addition, dislodgment of the stent or its occlusion by secretions may occur. Retransplantation has occasionally been done for this indication, ^3,4 but the overall results of this approach have not been satisfactory. ³ As long-term results of lung transplantation continue to improve, a more stable and definite treatment of airway complications has become necessary. We report a series of five cases in which airway complications were treated surgically by retransplantation or resection.

PATIENTS AND METHODS

Between October 1988 and May 1993, 78 patients underwent either unilateral or bilateral pulmonary transplantation in our unit. Bronchial complications necessitating intervention were observed in eight patients. In three of these, endobronchial stenting with a rigid bronchoscope ¹ was sufficient for long-term maintenance of the graft airway. The remaining five patients were ultimately treated by surgical means. Two required retransplantation, whereas three required resection because of distal airway necrosis or complex stenosis extending into the lobar bronchi, or both conditions. These patients are listed in Table I. Four patients had had bilateral lung transplantation for emphysema (n = 2) or cystic fibrosis (n = 2); in one patient unilateral lung transplantation had been done for idiopathic pulmonary fibrosis. The details of our preservation methods and technique of transplantation have been previously reported. ^5,6

The indications for reintervention are summarized in Table I. Extensive bronchial necrosis and erosion of the pulmonary artery resulted in emergency retransplantation in one patient (case 2).

In the remaining four patients, bronchial ischemia resulted in a limited dehiscence (n = 1) or partial thickness necrosis of the bronchial wall (n = 3). Initially, standard treatment with observation followed by balloon dilation for central airway stenosis was used. Two patients had silicone stent placement in an attempt to maintain airway patency. Despite these efforts, progressive distal airway stenosis occurred, necessitating a more aggressive approach (Fig. 1).

View larger version (86K): [in this window] [in a new window]   Fig. 1. Three-dimensional reconstruction of preoperative spiral computed tomography with visualization of central airways (case 4). There is a moderate, relatively long stenosis in the distal left main bronchus. Upper lobe bronchus is occluded; normal airway dimensions are observed in lingular and apical bronchi. Lower lobe bronchus appears normal.

For the unilateral approach (that is, resection; cases 3, 4, and 5) a posterolateral thoracotomy in the fifth intercostal space was used. Anesthesia was maintained by one-lung ventilation with the use of a left-sided double-lumen endotracheal tube. Intermittent ventilation of the graft had to be used in the unilateral transplant (case 4) until the graft pulmonary artery could be occluded. The airways were dissected, and in one patient a lower bilobectomy was done. In two patients a sleeve resection of the stenotic airways was done, sparing all pulmonary parenchyma in one patient and sacrificing only one pulmonary segment in the other. In all patients abundant arterial collateral blood supply of the graft bronchus was encountered. After lobe resection the bronchial stump was closed with interrupted absorbable sutures (3-0 Vicryl, Ethicon, Hamburg, Germany). Reconstruction of the airway after sleeve resection was done with standard techniques with interrupted absorbable sutures (PDS, Ethicon). In one of these two cases (case 4), an end-to-end anastomosis was performed between the lower lobe and main bronchus. The upper lobe bronchus was then anastomosed end to side into the lower lobe bronchus (Fig. 2). In the other case, a neocarina was constructed between distal intermediate and upper lobe bronchi; this was then anastomosed to the main bronchus in an end-to-end-fashion. Immunosuppression was continued after the intervention as given preoperatively, including the administration of corticosteroids.

View larger version (36K): [in this window] [in a new window]   Fig. 2. Operative approach (case 4). Stenotic segment consisting of left mainand proximal upper and lower lobe bronchi is resected. Reconstruction is achieved by anastomosing lower lobe and main bronchi (end to end). Upper lobe airway is connected to lower lobe (end to side).

All patients survived reoperation. The two patients who underwent retransplantation required mechanical ventilatory assistance for 7 and 8 days, respectively. They were discharged on day 35 and day 68 after retransplantation, respectively. The three patients who underwent pulmonary resection were extubated after 12, 26, and 28 hours. They were discharged from the hospital after a mean of 23 days.

All patients are alive at this time. The patients who underwent retransplantation, however, are functionally limited by obliterative bronchiolitis 12 and 20 months, respectively, after the intervention. All three patients who underwent resection are alive and well with stable airways and good pulmonary function after a follow-up of 10, 12, and 16 months (Fig. 3).

View larger version (71K): [in this window] [in a new window]   Fig. 3. Postoperative three-dimensional reconstruction of spiral computed tomography (case 4). Mild narrowing is noted at site of anastomosis between left main and left lower lobe bronchi. Superior segment of lower lobe has been resected; all remaining segmental bronchi are patent.

Despite substantial advances in operative technique and graft preservation, airway complications continue to be significant sequelae of lung transplantation. ^1,2 Along with bronchomalacia, bronchial ischemia, dehiscence, and granulation tissue lead to formation of stenotic airway segments. Temporary airway patency can be achieved by balloon dilation with a rigid or fiberoptic bronchoscope. ⁷ Placement of endobronchial stents has resulted in long-term airway patency if the stenosis is confined to the main bronchus. ¹ If, however, the stenosis is located close to a lobar orifice, placement of these stents may be difficult without obstruction of the distal airways. A stenosis that extends into the lobar bronchi is even more difficult to treat by endobronchial stents. So far only one case has been published in which stenting of an upper lobe bronchus was done, ⁸ and the patient ultimately underwent retransplantation. In addition to technical difficulties, placement of stents in intermediate or lobar bronchi may result in an increased incidence of stent occlusion because of inadequate clearing of secretions.

Significant necrosis of the graft airways can occur up to the point of anastomotic dehiscence with subsequent bronchopleural fistula, mediastinitis, or erosion of vascular structures. ⁹ If necrosis is strictly confined to the graft main bronchus, resection of the necrotic segment and repeated anastomosis using more distal airways may be attempted. ¹⁰ More commonly, the distal airways may be nonviable or of questionable viability. In these instances retransplantation remains the only option. ^3,4 Airway necrosis has been an indication for retransplantation in two reports ^3,4; as yet we are not aware of detailed results in this subgroup.

The cases presented here show that besides retransplantation the application of the principles of pulmonary surgery including bronchoplastic procedures represents a valid alternative to endobronchial stenting. A large number of arterial collateral vessels were encountered during reoperation when a minimum of 6 months had elapsed since the initial transplant procedure (cases 1, 3, 4, and 5), which indicates that the risk of ischemic anastomotic complications should not be higher than in normal bronchoplastic operations.

Because clinical and experimental evidence has indicated a beneficial effect of corticosteroids on bronchial healing, ^11-13 postoperative immunosuppression should not be considered a risk factor for anastomotic complications. Spiral computed tomography with three-dimensional reconstruction appears to be a helpful tool in defining the airway anatomy and pathologic condition before the decision for resection. ¹⁴

Anesthetic management during reoperative procedures may be difficult after single lung transplantation because of a significant ventilation-perfusion mismatch. This can be avoided by intermittent ventilation of the graft or by restricting arterial inflow to the transplanted lung up to the point of occlusion of the pulmonary artery. If this is not sufficient, the use of extracorporeal circulation must be considered.

The present limited experience does not allow us to predict whether the surgical approach may replace bronchial stenting. We currently believe that endoscopic interventions (dilation, stents) should be used within the first few months after transplantation. In the long-term, however, resection may be the better option for restoring airway function. Because stent-related complications (dislodgment, occlusion by secretions) are avoided, resection of stenotic airway segments appears to be an alternative to endobronchial stenting for airway stenosis in lung transplantation. In view of the poor results of retransplantation ³ and the recognized fact that the immunologic fate and overall prognosis of second transplants are inferior to those of primary procedures, ¹⁵ the value of this approach may be questionable. Resection of stenotic airways avoids the potential early and late (including immunologic) complications of retransplantation and in our view should be attempted primarily.

References

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2. Patterson GA, Todd TR, Cooper JD, Pearson FG, Winton TL, Maurer J. Airway complications after double lung transplantation. J THORAC CARDIOVASC SURG 1990;99:14-21. [Abstract]
   
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10. Kirk AJB, Conacher ID, Corris PA, Ashcroft T, Dark JH. Successful surgical management of bronchial dehiscence after single-lung transplantation. Ann Thorac Surg 1990;49:147-9. [Abstract]
    
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13. Inui K, Schäfers HJ, Aoki M, et al. Bronchial circulation after experimental lung transplantation. J THORAC CARDIOVASC SURG 1993;105:474-9. [Abstract]
    
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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Schäfers, H.-J. Articles by Borst, H. G. Search for Related Content PubMed PubMed Citation Articles by Schäfers, H.-J. Articles by Borst, H. G.