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Anastomotic Airway Complications after Lung Transplantation.

Cho EN, Haam SJ, Kim SY, Chang YS, Paik HC - Yonsei Med. J. (2015)

Bottom Line: Five others were found to have stenosis at the bronchus intermedius, distal to the anastomosis site.Three of these patients showed improvement after ballooning or bronchoplasty.By serial surveillance via FBS after LTx, we detected anastomotic airway complications in 42.9% of cases, which were successfully managed with improved clinical outcomes.

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.

ABSTRACT

Purpose: Anastomotic airway complications are a major cause of morbidity and mortality after lung transplantation (LTx). In this study, the authors identified types and clinical outcomes of airway complications after LTx.

Materials and methods: All bronchial anastomotic complications were analyzed in a total of 94 LTx cases involving 90 recipients who underwent surgery between July 2006 and May 2014. Fifteen LTx cases (14 recipients) with incomplete medical records for fiberoptic bronchoscopy (FBS) and three cases underwent heart-lung transplantation (HLT) were excluded. Postoperative FBS at 24-48 hours, 1, 3, 6, and 12 months, and then yearly after the transplantation were performed.

Results: A total of 76 LTx cases (75 recipients) were analyzed. The mean age of the recipients was 49.55 years (range, 18-71 years), and 38 (49.4%) were male. Twenty-one out of 76 cases (27.6%) experienced early anastomotic complications, and 12 (15.8%) presented late anastomotic complications. The early anastomotic airway complications presented in various forms: stenosis, 1 case; narrowing, 1; necrosis & dehiscence, 3; fistula, 4; granulation, 10; and infection, 2. Late complications almost entirely presented in the form of bronchial stenosis; five recipients showed stenosis at the anastomosis site, and one of them showed improvement after ballooning. Five others were found to have stenosis at the bronchus intermedius, distal to the anastomosis site. Three of these patients showed improvement after ballooning or bronchoplasty.

Conclusion: By serial surveillance via FBS after LTx, we detected anastomotic airway complications in 42.9% of cases, which were successfully managed with improved clinical outcomes.

No MeSH data available.


Related in: MedlinePlus

Representative photographs of early anastomotic airway complications. (A) A case of early airway complication presenting fistula at anastomosis site. No specific findings at the anastomosis site were detected by immediate post-op bronchoscope. At POD#12, fistula at the proximal portion of the right upper lobe bronchus was detected and re-suture was performed. Follow-up bronchoscope performed at POD#90 revealed stenosis of right upper lobe bronchus. (B) Another case of early airway complication showing fungal infection at anastomotic sites. Exophytic granulation tissues with 30% luminal narrowing at both anastomosis sites were identified at POD#18. Bronchoscopic biopsy and culture study revealed the granulation from A. fumigatus infection. After treatment with antifungal agents, the granulations were disappeared but there were minimal stenosis on a follow-up study at POD#60. POD, postoperative day.
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Figure 2: Representative photographs of early anastomotic airway complications. (A) A case of early airway complication presenting fistula at anastomosis site. No specific findings at the anastomosis site were detected by immediate post-op bronchoscope. At POD#12, fistula at the proximal portion of the right upper lobe bronchus was detected and re-suture was performed. Follow-up bronchoscope performed at POD#90 revealed stenosis of right upper lobe bronchus. (B) Another case of early airway complication showing fungal infection at anastomotic sites. Exophytic granulation tissues with 30% luminal narrowing at both anastomosis sites were identified at POD#18. Bronchoscopic biopsy and culture study revealed the granulation from A. fumigatus infection. After treatment with antifungal agents, the granulations were disappeared but there were minimal stenosis on a follow-up study at POD#60. POD, postoperative day.

Mentions: Early anastomotic airway complications were defined as complications that developed within 3 months of LTx. Among 76 LTx recipients, 21 experienced early anastomotic airway complications, and the median time of detection for these complications was 26 days after transplantation. Early anastomotic complications presented in various forms: stenosis (one case), narrowing (one case), necrosis & dehiscence (three cases), fistula (four cases), granulation (ten cases), and infection (two cases) (Table 2). Stenosis was diagnosed by visual estimation. Five recipients, who experienced granulation and necrosis at anastomosis sites, respectively showed improvement with antibiotics and antiviral agents without endoscopic intervention. However, other forms of early anastomotic airway complications such as fistula, stenosis, and dehiscence required specific interventions. All four recipients who presented with a fistula 10-38 detection days after LTx underwent resuture or surgical repair, and three patients showed improvement on follow-up bronchoscopy. One recipient with a fistula that had developed at the proximal portion of the right upper lobe bronchus at postoperative day (POD) #12 underwent emergency open thoracotomy and surgical re-suture. After the re-suture, follow-up bronchoscopy revealed stenosis of the right upper lobe bronchus (Fig. 2A). Fungal infection at anastomosis sites was another form of early airway complication. Bronchoscopy, performed on an LTx recipient who experienced gradually aggravating dyspnea and rhonchi, revealed luminal narrowing with exophytic granulation tissues at both anastomosis sites. A biopsy was performed at the granulation and confirmed Aspergillus fumigatus infection. After treatment with antifungal agents, the granulation sites healed, and minimal stenosis developed as a sequela on a follow-up study after 2 months (Fig. 2B). Dehiscence at the anastomosis site was one of the most disastrous complications that developed without prodromal symptoms. One recipient experienced sudden and rapid clinical deterioration with shock. Emergency bronchoscopy was performed and dehiscence at both anastomosis sites was identified. Despite intensive medical care, the recipient died before surgical intervention was initiated.


Anastomotic Airway Complications after Lung Transplantation.

Cho EN, Haam SJ, Kim SY, Chang YS, Paik HC - Yonsei Med. J. (2015)

Representative photographs of early anastomotic airway complications. (A) A case of early airway complication presenting fistula at anastomosis site. No specific findings at the anastomosis site were detected by immediate post-op bronchoscope. At POD#12, fistula at the proximal portion of the right upper lobe bronchus was detected and re-suture was performed. Follow-up bronchoscope performed at POD#90 revealed stenosis of right upper lobe bronchus. (B) Another case of early airway complication showing fungal infection at anastomotic sites. Exophytic granulation tissues with 30% luminal narrowing at both anastomosis sites were identified at POD#18. Bronchoscopic biopsy and culture study revealed the granulation from A. fumigatus infection. After treatment with antifungal agents, the granulations were disappeared but there were minimal stenosis on a follow-up study at POD#60. POD, postoperative day.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4541669&req=5

Figure 2: Representative photographs of early anastomotic airway complications. (A) A case of early airway complication presenting fistula at anastomosis site. No specific findings at the anastomosis site were detected by immediate post-op bronchoscope. At POD#12, fistula at the proximal portion of the right upper lobe bronchus was detected and re-suture was performed. Follow-up bronchoscope performed at POD#90 revealed stenosis of right upper lobe bronchus. (B) Another case of early airway complication showing fungal infection at anastomotic sites. Exophytic granulation tissues with 30% luminal narrowing at both anastomosis sites were identified at POD#18. Bronchoscopic biopsy and culture study revealed the granulation from A. fumigatus infection. After treatment with antifungal agents, the granulations were disappeared but there were minimal stenosis on a follow-up study at POD#60. POD, postoperative day.
Mentions: Early anastomotic airway complications were defined as complications that developed within 3 months of LTx. Among 76 LTx recipients, 21 experienced early anastomotic airway complications, and the median time of detection for these complications was 26 days after transplantation. Early anastomotic complications presented in various forms: stenosis (one case), narrowing (one case), necrosis & dehiscence (three cases), fistula (four cases), granulation (ten cases), and infection (two cases) (Table 2). Stenosis was diagnosed by visual estimation. Five recipients, who experienced granulation and necrosis at anastomosis sites, respectively showed improvement with antibiotics and antiviral agents without endoscopic intervention. However, other forms of early anastomotic airway complications such as fistula, stenosis, and dehiscence required specific interventions. All four recipients who presented with a fistula 10-38 detection days after LTx underwent resuture or surgical repair, and three patients showed improvement on follow-up bronchoscopy. One recipient with a fistula that had developed at the proximal portion of the right upper lobe bronchus at postoperative day (POD) #12 underwent emergency open thoracotomy and surgical re-suture. After the re-suture, follow-up bronchoscopy revealed stenosis of the right upper lobe bronchus (Fig. 2A). Fungal infection at anastomosis sites was another form of early airway complication. Bronchoscopy, performed on an LTx recipient who experienced gradually aggravating dyspnea and rhonchi, revealed luminal narrowing with exophytic granulation tissues at both anastomosis sites. A biopsy was performed at the granulation and confirmed Aspergillus fumigatus infection. After treatment with antifungal agents, the granulation sites healed, and minimal stenosis developed as a sequela on a follow-up study after 2 months (Fig. 2B). Dehiscence at the anastomosis site was one of the most disastrous complications that developed without prodromal symptoms. One recipient experienced sudden and rapid clinical deterioration with shock. Emergency bronchoscopy was performed and dehiscence at both anastomosis sites was identified. Despite intensive medical care, the recipient died before surgical intervention was initiated.

Bottom Line: Five others were found to have stenosis at the bronchus intermedius, distal to the anastomosis site.Three of these patients showed improvement after ballooning or bronchoplasty.By serial surveillance via FBS after LTx, we detected anastomotic airway complications in 42.9% of cases, which were successfully managed with improved clinical outcomes.

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.

ABSTRACT

Purpose: Anastomotic airway complications are a major cause of morbidity and mortality after lung transplantation (LTx). In this study, the authors identified types and clinical outcomes of airway complications after LTx.

Materials and methods: All bronchial anastomotic complications were analyzed in a total of 94 LTx cases involving 90 recipients who underwent surgery between July 2006 and May 2014. Fifteen LTx cases (14 recipients) with incomplete medical records for fiberoptic bronchoscopy (FBS) and three cases underwent heart-lung transplantation (HLT) were excluded. Postoperative FBS at 24-48 hours, 1, 3, 6, and 12 months, and then yearly after the transplantation were performed.

Results: A total of 76 LTx cases (75 recipients) were analyzed. The mean age of the recipients was 49.55 years (range, 18-71 years), and 38 (49.4%) were male. Twenty-one out of 76 cases (27.6%) experienced early anastomotic complications, and 12 (15.8%) presented late anastomotic complications. The early anastomotic airway complications presented in various forms: stenosis, 1 case; narrowing, 1; necrosis & dehiscence, 3; fistula, 4; granulation, 10; and infection, 2. Late complications almost entirely presented in the form of bronchial stenosis; five recipients showed stenosis at the anastomosis site, and one of them showed improvement after ballooning. Five others were found to have stenosis at the bronchus intermedius, distal to the anastomosis site. Three of these patients showed improvement after ballooning or bronchoplasty.

Conclusion: By serial surveillance via FBS after LTx, we detected anastomotic airway complications in 42.9% of cases, which were successfully managed with improved clinical outcomes.

No MeSH data available.


Related in: MedlinePlus