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J Thorac Cardiovasc Surg 1995;109:817
© 1995 Mosby, Inc.

LETTERS TO THE EDITOR

Airway complications after lung transplantation: Is there a left-sided predilection?

Division of Cardiothoracic Surgery
C700 PUH, UMPC
200 Lothrop St.
Pittsburgh, PA 15213-2582

Reply to the Editor:

The suggestion by Dr. Takao and his group that the bronchial mucosal blood flow is reduced in the left main-stem bronchus relative to the right is fascinating and a significant contribution. Since the publication of our article, titled "Anastomotic Pitfalls in Lung Transplantation," we have accrued additional patients from whom to draw conclusions.

A total of 133 patients have undergone single (SLT) or double (DLT) lung transplantation (61 SLT, 72 DLT) and have survived 1 to 50 months. Of these, 15 patients (6 SLT, 9 DLT; 11%) have had significant bronchial anastomotic complications. The method of lung transplantation and suture of or wrapping of anastomoses were not significant risk factors. Patients underwent 41 procedures (range one to nine per patient) involving insertion of 23 silicone rubber stents (range one to five per patient). Sixteen of 23 stents required adjustment because of distal migration and obstruction of the upper lobe. Among DLT recipients, left-sided problems were significantly more common than right (7 versus 2; p = 0.0117); two patients had bilateral problems. Strictures in five patients were debrided with the neodymium-yttrium-aluminum-garnet laser on 12 occasions. Stents placed in four patients who died were functioning well at the time of death. Among the 11 survivors, three patients had temporary stents (6 to 15 days); two are well (7 months and 2 years) and one has a stable 40% stenosis. Five patients received long-term stents (160 to 507 days); four are well (4 to 10 months) and one required repeat stenting at 3 months. Three patients were managed with laser debridement alone. Five patients were discharged after transplantation only after stenting for symptomatic relief. ¹

On the basis of these data, it would appear that the left main-stem bronchial anastomosis is at greater risk of abnormal healing, and Takao's finding of a reduced blood flow may indeed have significance. Because all bronchi are trimmed to within 5 to 10 mm of the upper lobe branch, it is not likely that length of donor bronchus is the cause for the higher prevalence on the left for stenosis or dehiscence. It would be of additional interest if the group at Papworth Hospital could perform these studies on bronchial mucosal blood flow during the operation as opposed to later in the course, when effects of reduced blood flow may be more significant. It would be important if revascularization of bronchial arteries could be shown to increase bronchial mucosal blood flow to near normal. It would also be of interest to know what impact the now rarely performed omental or pericardial fat wrap might have on blood flow. This group is to be congratulated for their pioneering efforts in this area, and we look forward to limiting the risk of bronchial anastomotic pitfalls based on surgical maneuvers backed up by objective data such as bronchial mucosal blood flow.

References

1. Keenan RJ, Landreneau RJ, Ferson PF, Hardesty RL, Griffith BP. Endoscopic management of airway complications after lung transplantation. Chest 1993;104:2:129S.
   

This Article Alert me when this article is cited Alert me if a correction is posted 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 Author home page(s): Bartley P. Griffith Robert J. Keenan Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Griffith, B. P. Articles by Keenan, R. J. Search for Related Content PubMed PubMed Citation Articles by Griffith, B. P. Articles by Keenan, R. J.