- Email: [email protected]
Donor transfer of pulmonary coccidioidomycosis in lung transplantation
306
CASE REPORT TRIPATHY ET AL COCCIDIOIDOMYCOSIS IN LUNG TRANSPLANT
this period, often succumb later to multiple organ system failure. Unexplainably sick thoracic postoperative patients require a high index of suspicion. Rapid diagnostic measures, including computed tomography imaging, and aggressive surgical intervention are typically the only real hope for patient survival.
References 1. Dayal A, Gupta LP, Patawari J, Dave KS. The chest wall gangrene in an infant. Indian J Chest Dis Allied Sci 1979;21: 102– 4. 2. Krol JR, Kwee KW, Thijs LG. Rapidly progressive septic shock, associated with necrotizing fasciitis. Intensive Care Med 1982;8:235–7. 3. Chen YM, Wu MF, Lee PY, Su WJ, Perng RP. Necrotizing fasciitis: is it a fatal complication of tube thoracostomy? Report of three cases. Respir Med 1992;86:249–51. 4. Urschel JD, Horan TA, Unruh HW. Necrotizing chest wall infection. Comp Surg 1993;12:37– 43. 5. Viste A, Vindenes H, Gjerde S. Herniation of the stomach and necrotizing chest wall infection following laparoscopic Nissen fundoplication. Surg Endosc 1997;11:1029–31. 6. Eugster T, Aeberhard P, Reist K, Sakmann K. Streptococcal necrotizing fasciitis with fatal outcome: a case report. Swiss Surg 1997;3:117–20. 7. Hammainen P, Kostiainen S. Postoperative necrotizing chestwall infection. Scand Cardiovasc J 1998;32:243–5. 8. Banwell PE, Pereira J, Powell BWEM. Symmetrical necrotizing chest wall infection following paronychia. J Acc Emerg Med 1998;15:58–9.
Donor Transfer of Pulmonary Coccidioidomycosis in Lung Transplantation
Ann Thorac Surg 2002;73:306-8
L
ung transplant recipients are prone to pulmonary infections, in part because the airways are in direct communication with the environment. Other factors that predispose to airway colonization by microorganisms include the diminished cough reflex and impaired mucociliary clearance in denervated donor lungs [1]. In one review, 81% of lung transplant recipients demonstrated positive fungal sputum cultures after transplantation [1]. Although the presence of Candida and Aspergillus species is common in lung transplant recipients, coccidioidomycosis should also be considered when recipients or donors come from regions where the fungus is endemic (southern California, Arizona, Texas, New Mexico, and Nevada) [2, 3]. A 21-year-old white man underwent bilateral sequential lung transplantation for primary pulmonary hypertension. Serological and skin tests for coccidioidomycosis were negative at the time the patient was first evaluated 2 years previously. The donor was a young healthy female from Arizona who enjoyed hiking in the desert. The preoperative donor chest roentgenogram showed no abnormalities, and the donor lungs had no palpable masses. A 1-cm firm level 4 hilar lymph node, found during organ harvest, was sent for pathologic analysis. Tacrolimus (0.1 mg/h intravenous) and azathioprine (2 mg/kg intravenous) were started postoperatively on day 1, and prednisone was added on day 7. The patient was extubated on the first postoperative day. On day 6, however, he developed fever, progressive respiratory distress, copious thick sputum, and bilateral pulmonary infiltrates on chest roentgenogram (Fig 1). He was reintubated, and bronchoscopic examination revealed thick tan-colored secretions with white plaques lining the bronchus intermedius and left-lower-lobe bronchus. Cy-
Uttam Tripathy, MD, Gordon L. Yung, MBBS, Jolene M. Kriett, MD, Patricia A. Thistlethwaite, MD, David P. Kapelanski, MD, and Stuart W. Jamieson, FRCS Divisions of Cardiothoracic Surgery and Pulmonary and Critical Care Medicine, University of California, San Diego, California
Transplant recipients living in endemic areas are at high risk of aerosol-transmitted fungal infections because of environmental exposure while on immunosuppressive drugs, as well as reactivation of latent infection from either the patient’s or the donor’s organs. The latter may account for early development of coccidioidomycosis after transplantation. We describe a case of pulmonary coccidioidomycosis in a lung transplant recipient who acquired the infection from the donor lung and presented with fulminant pneumonia in the immediate postoperative period. (Ann Thorac Surg 2002;73:306 – 8) © 2002 by The Society of Thoracic Surgeons Accepted for publication March 27, 2001. Address reprint requests to Dr Yung, UCSD Medical Center, 200 W Arbor Dr, San Diego, CA 92103-8373; e-mail: [email protected].
© 2002 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Fig 1. Early postoperative roentgenogram of transplanted lungs. 0003-4975/02/$22.00 PII S0003-4975(01)02723-0
Ann Thorac Surg 2002;73:306-8
Fig 2. Bronchoscopic washings showing intact spherules of Coccidioides immitis (silver stain; ⫻400).
tologic examination of bronchial washings and brushings demonstrated a strong presence of Coccidioides immitis (Fig 2), and the diagnosis was subsequently confirmed by positive cultures from bronchial washings. Fluconazole therapy was started at a dose of 400 mg/d and was increased to 800 mg/d 1 day later. A lumbar puncture was performed to rule out central nervous system involvement. The patient’s condition gradually improved, and he was extubated 3 days later. On day 27, he was discharged from hospital, and he has remained on fluconazole therapy to the present. At 12-month follow-up, the patient remained asymptomatic, with clearance of infiltrates on chest radiograph. Pathologic examination of the donor lymph node was positive for Coccidioides immitis, and no evidence of fungal infection was found in the explanted lungs and multiple lymph nodes taken during surgery. The patient was advised to receive lifelong fluconazole therapy.
Comment Patients living in southwestern parts of the United States have a higher incidence of Coccidioides immitis pulmonary infections because of the endemic nature of this organism in dry climates [4]. Although most cases are self-limiting, the disease can be devastating in immunocompromised patients. Clinical presentation of coccidioidomycosis may vary from asymptomatic disease to chronic illness, and particularly severe forms may manifest in transplant recipients, leading to rapidly progressive fatal disease [5]. Coccidioidal pneumonia in transplant recipients may be caused by airborne infection by spore inhalation (usually in the outdoor setting) or by reactivation of latent infection. When coccidioidomycosis develops in the early postoperative period, the donor lung should be considered as the source of infection. In our patient, the diagnosis of pulmonary coccidioid-
CASE REPORT TRIPATHY ET AL COCCIDIOIDOMYCOSIS IN LUNG TRANSPLANT
307
omycosis was established by clinical symptoms, bronchoscopic and radiographic changes, and pathologic examination of bronchial washings and donor’s lymph node. The early fulminant development of pneumonia while the patient was still hospitalized made an acquired airborne infection less likely. Reactivation of latent infection in the recipient was ruled out by the absence of pathologic findings in both explanted lungs and multiple lymph nodes obtained during surgery. The presence of Coccidioides immitis in the hilar lymph node from the donor suggested that the pathogen was transferred with the donor lung and became reactivated in the presence of immunosuppressive drugs. In our patient, the diagnosis of coccidioidal pneumonia was made from several sources: bronchial washings and brushings and lymph node analysis. However, one study reported that cytologic examinations of bronchial washings provided a diagnosis of coccidioidomycosis in only 42% of human immunodeficiency virus–infected patients who were culture positive for the fungus [6]. Therefore, even though coccidioidal pneumonia is not usually considered in patients presenting with acute respiratory failure in the early postoperative period [7], this diagnosis should be considered when donors originate from endemic areas. Early diagnosis, pulmonary support, and aggressive treatment of this fungal infection in the immunocompromised patient favor a successful outcome. The mortality and morbidity from pulmonary coccidioidomycosis in lung transplant patients is not known because of the low incidence of this infection. However, data from human immunodeficiency virus–infected patients suggest that mortality from coccidioidomycosis exceeds 70% within 1 month of diagnosis [8]. The optimal therapy for coccidioidal pneumonia in lung transplant patients is not known. Fluconazole, given orally or intravenously, would be a reasonable first-line treatment in uncomplicated pulmonary coccidioidomycosis, and the use of amphotericin B is reserved for patients with systemic or central nervous system involvement. The duration of antifungal treatment is unclear. However, because of the potential risks of reactivation, we advised our patient to receive lifelong treatment. Until the true incidence of donor-transmitted coccidioidal disease is established, it is unclear whether routine prophylactic antifungal treatment in patients receiving donor lungs from an endemic fungal area should be undertaken.
References 1. Kanj SS, Welty-Wolf K, Madden J, et al. Fungal infections in lung and heart-lung transplant recipients: report of 9 cases and review of the literature. Medicine 1996;75:142–56. 2. Drutz DJ, Catanzaro A. Coccidioidomycosis (pt 1). Am Rev Respir Dis 1978;117:559– 85. 3. Drutz DJ, Catanzaro A. Coccidioidomycosis (pt 2). Am Rev Respir Dis 1978;117:727–71. 4. Vaz A, Pineda-Roman M, Thomas AR, Carlson RW. Coccidioidomycosis: an update. Hosp Pract (Off Ed) 1998;33:105–15. 5. Kirkland TN, Fierer J. Coccidioidomycosis: a reemerging infectious disease. Emerg Infect Dis 1996;2:192–9. 6. DiTomasso JP, Ampel NM, Sobonya RE, Bloom JW. Broncho-
308
CASE REPORT SEKINE ET AL LUNG TRANSPLANTATION AND TRACHEAL BRONCHUS
scopic diagnosis of pulmonary coccidioidomycosis: comparison of cytology, culture, and transbronchial biopsy. Diagn Microbiol Infect Dis 1994;18:83–7. 7. Houston SH, Sinnott JT. Management of the transplant recipient with pulmonary infection. Infect Dis Clin North Am 1995; 9:965– 85. 8. Fish DG, Ampel NM, Gagliani JN, et al. Coccidioidomycosis: infectious diseases. Medicine 1990;69:384–91.
Bilateral Lung Transplantation Using a Donor With a Tracheal Right Upper Lobe Bronchus Yasuo Sekine, MD, PhD, Stefan Fischer, MD, Marc de Perrot, MD, Andrew F. Pierre, MD, and Shaf Keshavjee, MD Toronto Lung Transplant Program, Division of Thoracic Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
We report on a case of successful bilateral sequential lung transplantation using a donor with the right upper lobe bronchus arising from the trachea. After en-bloc donor lung retrieval, the right bronchial stump was fashioned to create one lumen including the bronchus intermedius and the aberrant right upper lobe bronchus. A carinoplasty was performed in the recipient with resection of a portion of the lateral wall of trachea. The anastomosis was completed using a telescoping technique without any complication. This case demonstrates the possibility of successfully using donor lungs with such anatomic abnormality for transplantation. (Ann Thorac Surg 2002;73:308 –10) © 2002 by The Society of Thoracic Surgeons
A
lthough a significant problem in the early development of clinical lung transplantation, airway complications have thankfully become quite rare. This is likely due to improvements in lung preservation and surgical technique [1]. In general, management of the bronchus for transplantation includes preserving the peribronchial tissue that carries the bronchial blood supply, cutting the donor bronchus short to minimize potentially ischemic airway, and careful surgical handling to minimize trauma to the airway tissues. We describe the application of these principles in the successful performance of a bilateral sequential lung transplant in which the donor had an anomalous takeoff of the right upper lobe bronchus from the trachea. The recipient was a 39-year-old man with cystic fibrosis who cultured negative for the Burkholderia cepacia organ-
Accepted for publication April 26, 2001. Address reprint requests to Dr Keshavjee, Toronto Lung Transplant Program, Division of Thoracic Surgery, Toronto General Hospital, 200 Elizabeth St, EN 10-224, Toronto, Ontario M5G 2C4, Canada; e-mail: [email protected].
© 2002 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Ann Thorac Surg 2002;73:308 –10
ism. He had frequent and refractory pulmonary infections and severely compromised pulmonary function with a forced expiratory volume in 1 second of 19% of predicted. He was listed for bilateral lung transplantation in September 1998. On April 21, 2000, a suitable donor was found. Although chest x-ray films showed bilateral basal segmental atelectasis, the donor had good gas exchange. Prior to retrieval, fiberoptic bronchoscopy was performed and the anomaly of the right upper lobe bronchus was discovered. Essentially, his right upper lobe bronchus arose 1.5 cm proximal to the carina—which was the junction of the left main bronchus with the bronchus intermedius (Fig 1A). After a sternotomy was performed, the lungs were carefully inspected, and no physiological abnormality was found. The lungs were flushed with low potassium dextran solution [1] (Perfadex; Vitrolife AB, Goteborg, Sweden), excised en bloc and stored in cold flush solution for transport to our center. The recipient chest was entered though a bilateral transverse 4th intercostal space thoracosternotomy. Diffuse pleural adhesions were encountered bilaterally and dissected with electrocautery. After a left pneumonectomy, the left lung was implanted in the standard fashion with a telescoping bronchial anastomosis, an end-to-end pulmonary artery anastomosis, and a left atrial anastomosis using an everting horizontal mattress running suture. The right pneumonectomy was then performed. The donor carina, which had been left with the right lung on separation of the left lung, was opened. A large single orifice was fashioned to incorporate the orifice of the aberrant right upper lobe tracheal bronchus and the orifice of the bronchus intermedius. In order to accommodate an anastomosis to this large orifice, a carinoplasty was required in the recipient with resection of 1.5 cm of the right wall of the trachea proximally to the carina. This necessitated division of the azygous vein (Fig 1B). The bronchial anastomosis was performed by telescoping (by about 3 mm) the recipient’s bronchus into the donor airway using a running 4-0 PDS suture (Ethicon, New Brunswick, NJ) for the posterior membranous wall, and eight interrupted horizontal mattress sutures with 4-0 Prolene (Ethicon) for the cartilaginous wall. This tracheobronchial anastomosis was buttressed by peribronchial fatty tissue and donor pericardial tissue. A satisfactory anastomosis was confirmed intraoperatively with fiberoptic bronchoscopy (Fig 1C). The pulmonary artery and left atrial anastomoses were then performed in the usual fashion. The patient’s postoperative course was uneventful. He was extubated on the day following the transplant operation, and the chest tubes were removed within the first week. To facilitate microcirculatory blood flow, we routinely administer intravenous low-dose heparin (100 units per hour) and low molecular weight dextran (Rheomacrodex, Baxter, Dearfield, IL). Due to the unique anatomical considerations, bronchoscopic examinations were performed on postoperative days 7 and 21 to check on the healing of the tracheobronchial anastomosis. At 7 0003-4975/02/$22.00 PII S0003-4975(01)02846-6
CASE REPORT TRIPATHY ET AL COCCIDIOIDOMYCOSIS IN LUNG TRANSPLANT
this period, often succumb later to multiple organ system failure. Unexplainably sick thoracic postoperative patients require a high index of suspicion. Rapid diagnostic measures, including computed tomography imaging, and aggressive surgical intervention are typically the only real hope for patient survival.
References 1. Dayal A, Gupta LP, Patawari J, Dave KS. The chest wall gangrene in an infant. Indian J Chest Dis Allied Sci 1979;21: 102– 4. 2. Krol JR, Kwee KW, Thijs LG. Rapidly progressive septic shock, associated with necrotizing fasciitis. Intensive Care Med 1982;8:235–7. 3. Chen YM, Wu MF, Lee PY, Su WJ, Perng RP. Necrotizing fasciitis: is it a fatal complication of tube thoracostomy? Report of three cases. Respir Med 1992;86:249–51. 4. Urschel JD, Horan TA, Unruh HW. Necrotizing chest wall infection. Comp Surg 1993;12:37– 43. 5. Viste A, Vindenes H, Gjerde S. Herniation of the stomach and necrotizing chest wall infection following laparoscopic Nissen fundoplication. Surg Endosc 1997;11:1029–31. 6. Eugster T, Aeberhard P, Reist K, Sakmann K. Streptococcal necrotizing fasciitis with fatal outcome: a case report. Swiss Surg 1997;3:117–20. 7. Hammainen P, Kostiainen S. Postoperative necrotizing chestwall infection. Scand Cardiovasc J 1998;32:243–5. 8. Banwell PE, Pereira J, Powell BWEM. Symmetrical necrotizing chest wall infection following paronychia. J Acc Emerg Med 1998;15:58–9.
Donor Transfer of Pulmonary Coccidioidomycosis in Lung Transplantation
Ann Thorac Surg 2002;73:306-8
L
ung transplant recipients are prone to pulmonary infections, in part because the airways are in direct communication with the environment. Other factors that predispose to airway colonization by microorganisms include the diminished cough reflex and impaired mucociliary clearance in denervated donor lungs [1]. In one review, 81% of lung transplant recipients demonstrated positive fungal sputum cultures after transplantation [1]. Although the presence of Candida and Aspergillus species is common in lung transplant recipients, coccidioidomycosis should also be considered when recipients or donors come from regions where the fungus is endemic (southern California, Arizona, Texas, New Mexico, and Nevada) [2, 3]. A 21-year-old white man underwent bilateral sequential lung transplantation for primary pulmonary hypertension. Serological and skin tests for coccidioidomycosis were negative at the time the patient was first evaluated 2 years previously. The donor was a young healthy female from Arizona who enjoyed hiking in the desert. The preoperative donor chest roentgenogram showed no abnormalities, and the donor lungs had no palpable masses. A 1-cm firm level 4 hilar lymph node, found during organ harvest, was sent for pathologic analysis. Tacrolimus (0.1 mg/h intravenous) and azathioprine (2 mg/kg intravenous) were started postoperatively on day 1, and prednisone was added on day 7. The patient was extubated on the first postoperative day. On day 6, however, he developed fever, progressive respiratory distress, copious thick sputum, and bilateral pulmonary infiltrates on chest roentgenogram (Fig 1). He was reintubated, and bronchoscopic examination revealed thick tan-colored secretions with white plaques lining the bronchus intermedius and left-lower-lobe bronchus. Cy-
Uttam Tripathy, MD, Gordon L. Yung, MBBS, Jolene M. Kriett, MD, Patricia A. Thistlethwaite, MD, David P. Kapelanski, MD, and Stuart W. Jamieson, FRCS Divisions of Cardiothoracic Surgery and Pulmonary and Critical Care Medicine, University of California, San Diego, California
Transplant recipients living in endemic areas are at high risk of aerosol-transmitted fungal infections because of environmental exposure while on immunosuppressive drugs, as well as reactivation of latent infection from either the patient’s or the donor’s organs. The latter may account for early development of coccidioidomycosis after transplantation. We describe a case of pulmonary coccidioidomycosis in a lung transplant recipient who acquired the infection from the donor lung and presented with fulminant pneumonia in the immediate postoperative period. (Ann Thorac Surg 2002;73:306 – 8) © 2002 by The Society of Thoracic Surgeons Accepted for publication March 27, 2001. Address reprint requests to Dr Yung, UCSD Medical Center, 200 W Arbor Dr, San Diego, CA 92103-8373; e-mail: [email protected].
© 2002 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Fig 1. Early postoperative roentgenogram of transplanted lungs. 0003-4975/02/$22.00 PII S0003-4975(01)02723-0
Ann Thorac Surg 2002;73:306-8
Fig 2. Bronchoscopic washings showing intact spherules of Coccidioides immitis (silver stain; ⫻400).
tologic examination of bronchial washings and brushings demonstrated a strong presence of Coccidioides immitis (Fig 2), and the diagnosis was subsequently confirmed by positive cultures from bronchial washings. Fluconazole therapy was started at a dose of 400 mg/d and was increased to 800 mg/d 1 day later. A lumbar puncture was performed to rule out central nervous system involvement. The patient’s condition gradually improved, and he was extubated 3 days later. On day 27, he was discharged from hospital, and he has remained on fluconazole therapy to the present. At 12-month follow-up, the patient remained asymptomatic, with clearance of infiltrates on chest radiograph. Pathologic examination of the donor lymph node was positive for Coccidioides immitis, and no evidence of fungal infection was found in the explanted lungs and multiple lymph nodes taken during surgery. The patient was advised to receive lifelong fluconazole therapy.
Comment Patients living in southwestern parts of the United States have a higher incidence of Coccidioides immitis pulmonary infections because of the endemic nature of this organism in dry climates [4]. Although most cases are self-limiting, the disease can be devastating in immunocompromised patients. Clinical presentation of coccidioidomycosis may vary from asymptomatic disease to chronic illness, and particularly severe forms may manifest in transplant recipients, leading to rapidly progressive fatal disease [5]. Coccidioidal pneumonia in transplant recipients may be caused by airborne infection by spore inhalation (usually in the outdoor setting) or by reactivation of latent infection. When coccidioidomycosis develops in the early postoperative period, the donor lung should be considered as the source of infection. In our patient, the diagnosis of pulmonary coccidioid-
CASE REPORT TRIPATHY ET AL COCCIDIOIDOMYCOSIS IN LUNG TRANSPLANT
307
omycosis was established by clinical symptoms, bronchoscopic and radiographic changes, and pathologic examination of bronchial washings and donor’s lymph node. The early fulminant development of pneumonia while the patient was still hospitalized made an acquired airborne infection less likely. Reactivation of latent infection in the recipient was ruled out by the absence of pathologic findings in both explanted lungs and multiple lymph nodes obtained during surgery. The presence of Coccidioides immitis in the hilar lymph node from the donor suggested that the pathogen was transferred with the donor lung and became reactivated in the presence of immunosuppressive drugs. In our patient, the diagnosis of coccidioidal pneumonia was made from several sources: bronchial washings and brushings and lymph node analysis. However, one study reported that cytologic examinations of bronchial washings provided a diagnosis of coccidioidomycosis in only 42% of human immunodeficiency virus–infected patients who were culture positive for the fungus [6]. Therefore, even though coccidioidal pneumonia is not usually considered in patients presenting with acute respiratory failure in the early postoperative period [7], this diagnosis should be considered when donors originate from endemic areas. Early diagnosis, pulmonary support, and aggressive treatment of this fungal infection in the immunocompromised patient favor a successful outcome. The mortality and morbidity from pulmonary coccidioidomycosis in lung transplant patients is not known because of the low incidence of this infection. However, data from human immunodeficiency virus–infected patients suggest that mortality from coccidioidomycosis exceeds 70% within 1 month of diagnosis [8]. The optimal therapy for coccidioidal pneumonia in lung transplant patients is not known. Fluconazole, given orally or intravenously, would be a reasonable first-line treatment in uncomplicated pulmonary coccidioidomycosis, and the use of amphotericin B is reserved for patients with systemic or central nervous system involvement. The duration of antifungal treatment is unclear. However, because of the potential risks of reactivation, we advised our patient to receive lifelong treatment. Until the true incidence of donor-transmitted coccidioidal disease is established, it is unclear whether routine prophylactic antifungal treatment in patients receiving donor lungs from an endemic fungal area should be undertaken.
References 1. Kanj SS, Welty-Wolf K, Madden J, et al. Fungal infections in lung and heart-lung transplant recipients: report of 9 cases and review of the literature. Medicine 1996;75:142–56. 2. Drutz DJ, Catanzaro A. Coccidioidomycosis (pt 1). Am Rev Respir Dis 1978;117:559– 85. 3. Drutz DJ, Catanzaro A. Coccidioidomycosis (pt 2). Am Rev Respir Dis 1978;117:727–71. 4. Vaz A, Pineda-Roman M, Thomas AR, Carlson RW. Coccidioidomycosis: an update. Hosp Pract (Off Ed) 1998;33:105–15. 5. Kirkland TN, Fierer J. Coccidioidomycosis: a reemerging infectious disease. Emerg Infect Dis 1996;2:192–9. 6. DiTomasso JP, Ampel NM, Sobonya RE, Bloom JW. Broncho-
308
CASE REPORT SEKINE ET AL LUNG TRANSPLANTATION AND TRACHEAL BRONCHUS
scopic diagnosis of pulmonary coccidioidomycosis: comparison of cytology, culture, and transbronchial biopsy. Diagn Microbiol Infect Dis 1994;18:83–7. 7. Houston SH, Sinnott JT. Management of the transplant recipient with pulmonary infection. Infect Dis Clin North Am 1995; 9:965– 85. 8. Fish DG, Ampel NM, Gagliani JN, et al. Coccidioidomycosis: infectious diseases. Medicine 1990;69:384–91.
Bilateral Lung Transplantation Using a Donor With a Tracheal Right Upper Lobe Bronchus Yasuo Sekine, MD, PhD, Stefan Fischer, MD, Marc de Perrot, MD, Andrew F. Pierre, MD, and Shaf Keshavjee, MD Toronto Lung Transplant Program, Division of Thoracic Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
We report on a case of successful bilateral sequential lung transplantation using a donor with the right upper lobe bronchus arising from the trachea. After en-bloc donor lung retrieval, the right bronchial stump was fashioned to create one lumen including the bronchus intermedius and the aberrant right upper lobe bronchus. A carinoplasty was performed in the recipient with resection of a portion of the lateral wall of trachea. The anastomosis was completed using a telescoping technique without any complication. This case demonstrates the possibility of successfully using donor lungs with such anatomic abnormality for transplantation. (Ann Thorac Surg 2002;73:308 –10) © 2002 by The Society of Thoracic Surgeons
A
lthough a significant problem in the early development of clinical lung transplantation, airway complications have thankfully become quite rare. This is likely due to improvements in lung preservation and surgical technique [1]. In general, management of the bronchus for transplantation includes preserving the peribronchial tissue that carries the bronchial blood supply, cutting the donor bronchus short to minimize potentially ischemic airway, and careful surgical handling to minimize trauma to the airway tissues. We describe the application of these principles in the successful performance of a bilateral sequential lung transplant in which the donor had an anomalous takeoff of the right upper lobe bronchus from the trachea. The recipient was a 39-year-old man with cystic fibrosis who cultured negative for the Burkholderia cepacia organ-
Accepted for publication April 26, 2001. Address reprint requests to Dr Keshavjee, Toronto Lung Transplant Program, Division of Thoracic Surgery, Toronto General Hospital, 200 Elizabeth St, EN 10-224, Toronto, Ontario M5G 2C4, Canada; e-mail: [email protected].
© 2002 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Ann Thorac Surg 2002;73:308 –10
ism. He had frequent and refractory pulmonary infections and severely compromised pulmonary function with a forced expiratory volume in 1 second of 19% of predicted. He was listed for bilateral lung transplantation in September 1998. On April 21, 2000, a suitable donor was found. Although chest x-ray films showed bilateral basal segmental atelectasis, the donor had good gas exchange. Prior to retrieval, fiberoptic bronchoscopy was performed and the anomaly of the right upper lobe bronchus was discovered. Essentially, his right upper lobe bronchus arose 1.5 cm proximal to the carina—which was the junction of the left main bronchus with the bronchus intermedius (Fig 1A). After a sternotomy was performed, the lungs were carefully inspected, and no physiological abnormality was found. The lungs were flushed with low potassium dextran solution [1] (Perfadex; Vitrolife AB, Goteborg, Sweden), excised en bloc and stored in cold flush solution for transport to our center. The recipient chest was entered though a bilateral transverse 4th intercostal space thoracosternotomy. Diffuse pleural adhesions were encountered bilaterally and dissected with electrocautery. After a left pneumonectomy, the left lung was implanted in the standard fashion with a telescoping bronchial anastomosis, an end-to-end pulmonary artery anastomosis, and a left atrial anastomosis using an everting horizontal mattress running suture. The right pneumonectomy was then performed. The donor carina, which had been left with the right lung on separation of the left lung, was opened. A large single orifice was fashioned to incorporate the orifice of the aberrant right upper lobe tracheal bronchus and the orifice of the bronchus intermedius. In order to accommodate an anastomosis to this large orifice, a carinoplasty was required in the recipient with resection of 1.5 cm of the right wall of the trachea proximally to the carina. This necessitated division of the azygous vein (Fig 1B). The bronchial anastomosis was performed by telescoping (by about 3 mm) the recipient’s bronchus into the donor airway using a running 4-0 PDS suture (Ethicon, New Brunswick, NJ) for the posterior membranous wall, and eight interrupted horizontal mattress sutures with 4-0 Prolene (Ethicon) for the cartilaginous wall. This tracheobronchial anastomosis was buttressed by peribronchial fatty tissue and donor pericardial tissue. A satisfactory anastomosis was confirmed intraoperatively with fiberoptic bronchoscopy (Fig 1C). The pulmonary artery and left atrial anastomoses were then performed in the usual fashion. The patient’s postoperative course was uneventful. He was extubated on the day following the transplant operation, and the chest tubes were removed within the first week. To facilitate microcirculatory blood flow, we routinely administer intravenous low-dose heparin (100 units per hour) and low molecular weight dextran (Rheomacrodex, Baxter, Dearfield, IL). Due to the unique anatomical considerations, bronchoscopic examinations were performed on postoperative days 7 and 21 to check on the healing of the tracheobronchial anastomosis. At 7 0003-4975/02/$22.00 PII S0003-4975(01)02846-6