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Early Surgical Management of Bronchial Dehiscence After Single-Lung Transplantation: A Case Report
Early Surgical Management of Bronchial Dehiscence After Single-Lung Transplantation: A Case Report Anna Muñoz Fosa,*, Francisco Cerezo Madueñoa, Javier Cosanob, Javier Redelb, Javier González Garcíaa, David Povedaa, Eloísa Ruíza, Paula Moreno Casadoa, Javier Algar Algara, Antonio Álvarez Kindelana, Carlos Baamonde Labordaa, and Ángel Salvatierra Velázqueza a Division of Thoracic Surgery and Lung Transplantation, Reina Sofia University Hospital, Córdoba, Spain; and the bDivision of Interventional Pneumology, Reina Sofia University Hospital, Córdoba, Spain
ABSTRACT Anastomotic airway complications after lung transplantation affect up to 20% of patients. Bronchial stenosis is the most frequent complication, while dehiscence of bronchial anastomosis is a rarely seen complication, with report incidences between 1% and 10%. Despite its low incidence, dehiscence of bronchial anastomoses remains a disastrous complication in the posttransplantation period without a well-established management protocol. We present a challenging case of complete bronchial dehiscence after unilateral lung transplantation in a patient with interstitial lung fibrosis (ILF) that occurred on postoperative day 10. The dehiscence was diagnosed early and the patient’s status was stable for repeat thoracotomy, therefore, an early surgical approach was preferable to conservative management or bronchoscopy. Aggressive early surgical management in a stable patient allows for complete debridement with removal of the detritus that impedes correct anastomosis healing and permits the removal of microbial vegetations with successful results.
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UNG transplantation has the potential to improve the survival and quality of life of patients with advanced lung disease. Anastomotic airway complications, including the dehiscence of the bronchial anastomosis, are a severe cause of mortality after lung transplantation [1]. Dehiscence is a rarely seen complication, with report incidences between 1% and 10% [1,2]. The main reason for this is the relative ischemia at the site of the bronchial anastomosis, which relies on retrograde blood flow through the pulmonary circulation. Low cardiac output, hypotension, and low level of oxygenation predispose the area to ischemia. The use of steroids and immunosuppression are also thought to be implicated in the dehiscence of bronchial anastomosis [2]. Key aspects to successful treatment of this type of bronchial complication are an early diagnosis and an early intervention. Bronchial dehiscence can be identified on surveillance bronchoscopy, but also should be suspected in patients with prolonged air leaks, spontaneous pneumothorax, failure to wean, or sepsis. Chest radiographs are unreliable in the diagnosis of a dehiscence. Computed ª 2020 Elsevier Inc. All rights reserved. 230 Park Avenue, New York, NY 10169
Transplantation Proceedings, XX, 1e3 (2020)
tomography (CT) can detect defects in the bronchial wall, bronchial narrowing, or extraluminal air. Although peribronchial air can be seen after transplantation, the addition of bronchial wall abnormalities should increase suspicion for an anastomotic defect. Several studies have shown that chest CT has a high sensitivity and specificity for detecting dehiscence, but bronchoscopy remains the gold standard. We describe a case of bronchial dehiscence that was successfully managed by early surgical intervention. CASE REPORT We present a 60-year-old male patient with end-stage respiratory failure secondary to interstitial lung fibrosis (ILF) who underwent unilateral right lung transplantation. The donor lung was extracted from a 32-year-old female donor diagnosed with brain death
*Address correspondence to Anna Muñoz Fos, Division of Thoracic Surgery and Lung Transplantation, University of Córdoba; 14004, Menendez Pidal Avenue, 14004, Córdoba, Spain. Tel: þ34 957 736 174. E-mail: [email protected] 0041-1345/20 https://doi.org/10.1016/j.transproceed.2019.09.021
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MUÑOZ FOS, CEREZO MADUEÑO, COSANO ET AL
Fig 1. (A, B) Bronchoscopic view of anastomosis: partial dehiscence with necrotic adherent membranes. (C) Bronchoscopic view in the operating field which shows a complete dehiscence. (D) Chest radiography after the second thoracotomy, which shows a complete reexpansion. (E, F) Bronchoscopic view of anastomosis after 10 days of the rethoracotomy: excellent macroscopic aspect just with a discrete stenosis (< 30%). MDS classification (macroscopic, bronchial diameter, and suture appearance): M0 D0 S0. (oxygenation index of 416) after 9 days in the intensive care unit (ICU). Right lung transplantation began with a posterolateral thoracotomy incision. Right pneumonectomy was carried out without incidence, the bronchus was anastomosed end-to-end with a 1-running 4-0 polydioxanone (PDS) suture. No extracorporeal circulation was needed during the transplantation. Total ischemic time was 300 minutes. At the end of the surgery, the patient developed a right ventricular dysfunction, which was managed with levosimendan, nitric
oxide, and noradrenalin (0.7 mg/kg per minute) because of hemodynamic instability. Despite this, cardiac function improved and the patient could be extubated 48 hours after surgery with hemodynamic improvement. No air leak was observed during this time. The patient received immunosuppression with tacrolimus, mycophenolate, and deflazacort; in addition, he received induction immunosuppression therapy with basiliximab [1]. Clindamycin and ceftazidime was administrated as postoperative antibiotic therapy.
BRONCHIAL DEHISCENCE AFTER LUNG TRANSPLANT On postoperative day 10, the patient was noted to have a discrete air leak (150 mL per minute) seen through the digital thorax collector connected to the chest tube. A few hour later, the air leak increased to 300 mL per minute, and a chest radiograph revealed a discrete pneumothorax. On postoperative day 11, the air leak increased considerably, reaching values of 1000 mL to 3000 mL per minute, so we decided to carry out an early bronchoscopy looking for a possible anastomosis air leak. Bronchoscopy revealed a partial dehiscence of the anastomosis with necrotic adherent membranes (Fig 1A and B). The patient’s status was excellent; therefore, we choose early surgical management. In the operating room, a complete dehiscence could be seen (Fig 1C). We performed a complete debridement of the necrotic segment resecting both bronchial margins, after which we performed a reanastomosis of both donor and receptor main bronchus using interrupted (mattress and 8-figure) 4-0 PDS sutures. The patient was extubated 48 hours after the second surgery. No air leak was registered and chest radiography revealed a complete expansion of lungs, with no evidence of pneumothorax. After 8 days in the ICU, he was transferred to his hospital room. The postoperative bronchoscopy revealed an excellent a well-formed anastomosis, with only discrete stenosis (< 30%). Per the endoscopic grading system for macroscopic central airway complications after lung transplantation, the MDS (for macroscopic, bronchial diameter, and suture appearance) classification for this patient was M0 D0 S0 [3]. The patient was discharged home after 93 days. Discharge was delayed because of an episode of pneumonia secondary to bronchoaspiration noted after a surveillance bronchoscopy. The pneumonia was managed successfully with conventional antibiotic therapy. No other complications occurred.
DISCUSSION
Bronchial dehiscence remains a disastrous complication in the posttransplantation period. It can occur early after transplantation, is extremely difficult to treat, and is associated with high mortality. A key aspect of the treatment is early diagnosis and intervention which can be done via either a surgical [4] or bronchoscopic [5] approach. Bronchoscopy techniques that have previously been tried include cyanoacrylate glue, growth factors, and autologous platelet-derived growth factors; however, these techniques do not fully resolve the dehiscence. An uncovered, self-expanding metal stent can
3
be placed temporarily to allow healing of the defect. It is deployed across the dehiscence and serves as a scaffolding for the exuberant growth of granulation tissue. A challenge of this technique is precise placement and removal, as there is the potential to extend the injury. Furthermore, there is a tendency for stenosis or malacia to occur at or distal to the site of prior dehiscence. Therefore, we prefer employing bronchoscopic techniques when the patient is not clinically stable enough for rethoracotomy. The surgical approach consists of rethoracotomy with complete debridement of the necrotic segment and the creation of a second anastomosis. This approach allows for complete removal of the detritus that impedes anastomosis healing and permits removal of microbial vegetations with successful results. CONCLUSIONS
The surgical approach is the most effective option to correct bronchial dehiscence if the patient is medically stable and early diagnosis is achieved. We employ the bronchoscopic approach when the patient is not stable enough for rethoracotomy or when, because of late diagnosis, rethoracotomy is technically impossible due to extensive adhesions. REFERENCES [1] Kshettry VR, Kroshus TJ, Hertz MI, Hunter DW, Shumway SJ, Bolman RM. Early and late airway complications after lung transplantation: incidence and management. Ann Thorac Surg 1997;63:1576e83. [2] Frye L, Machuzak M. Airway complications after lung transplantation. Clin Chest Med 2017;38:693e706. [3] Dutau H, Vandemoortele T, Laroumagne S, Gomez C, Boussaud V, Cavailles A, et al. A new endoscopic standardized grading system for macroscopic central airway complications following lung transplantation: the MDS classification. Eur J Cardiothorac Surg 2013;45:e33e8. [4] Krahenbuhl SM, Gonzalez M, Aubert JD, Tamm M, Ris HB, Krueger T, et al. Management of bilateral necrotizing bronchial dehiscence after a double lung transplantation. J Thorac Cardiovasc Surg 2018;156:e29e31. [5] Bottero S, Meucci D, Trozzi M, Carotti A. Dehiscence of bronchial anastomosis after lung transplantation: a successful unconventional treatment. Ann Thorac Surg 2018;106:e81e3.
ABSTRACT Anastomotic airway complications after lung transplantation affect up to 20% of patients. Bronchial stenosis is the most frequent complication, while dehiscence of bronchial anastomosis is a rarely seen complication, with report incidences between 1% and 10%. Despite its low incidence, dehiscence of bronchial anastomoses remains a disastrous complication in the posttransplantation period without a well-established management protocol. We present a challenging case of complete bronchial dehiscence after unilateral lung transplantation in a patient with interstitial lung fibrosis (ILF) that occurred on postoperative day 10. The dehiscence was diagnosed early and the patient’s status was stable for repeat thoracotomy, therefore, an early surgical approach was preferable to conservative management or bronchoscopy. Aggressive early surgical management in a stable patient allows for complete debridement with removal of the detritus that impedes correct anastomosis healing and permits the removal of microbial vegetations with successful results.
L
UNG transplantation has the potential to improve the survival and quality of life of patients with advanced lung disease. Anastomotic airway complications, including the dehiscence of the bronchial anastomosis, are a severe cause of mortality after lung transplantation [1]. Dehiscence is a rarely seen complication, with report incidences between 1% and 10% [1,2]. The main reason for this is the relative ischemia at the site of the bronchial anastomosis, which relies on retrograde blood flow through the pulmonary circulation. Low cardiac output, hypotension, and low level of oxygenation predispose the area to ischemia. The use of steroids and immunosuppression are also thought to be implicated in the dehiscence of bronchial anastomosis [2]. Key aspects to successful treatment of this type of bronchial complication are an early diagnosis and an early intervention. Bronchial dehiscence can be identified on surveillance bronchoscopy, but also should be suspected in patients with prolonged air leaks, spontaneous pneumothorax, failure to wean, or sepsis. Chest radiographs are unreliable in the diagnosis of a dehiscence. Computed ª 2020 Elsevier Inc. All rights reserved. 230 Park Avenue, New York, NY 10169
Transplantation Proceedings, XX, 1e3 (2020)
tomography (CT) can detect defects in the bronchial wall, bronchial narrowing, or extraluminal air. Although peribronchial air can be seen after transplantation, the addition of bronchial wall abnormalities should increase suspicion for an anastomotic defect. Several studies have shown that chest CT has a high sensitivity and specificity for detecting dehiscence, but bronchoscopy remains the gold standard. We describe a case of bronchial dehiscence that was successfully managed by early surgical intervention. CASE REPORT We present a 60-year-old male patient with end-stage respiratory failure secondary to interstitial lung fibrosis (ILF) who underwent unilateral right lung transplantation. The donor lung was extracted from a 32-year-old female donor diagnosed with brain death
*Address correspondence to Anna Muñoz Fos, Division of Thoracic Surgery and Lung Transplantation, University of Córdoba; 14004, Menendez Pidal Avenue, 14004, Córdoba, Spain. Tel: þ34 957 736 174. E-mail: [email protected] 0041-1345/20 https://doi.org/10.1016/j.transproceed.2019.09.021
1
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MUÑOZ FOS, CEREZO MADUEÑO, COSANO ET AL
Fig 1. (A, B) Bronchoscopic view of anastomosis: partial dehiscence with necrotic adherent membranes. (C) Bronchoscopic view in the operating field which shows a complete dehiscence. (D) Chest radiography after the second thoracotomy, which shows a complete reexpansion. (E, F) Bronchoscopic view of anastomosis after 10 days of the rethoracotomy: excellent macroscopic aspect just with a discrete stenosis (< 30%). MDS classification (macroscopic, bronchial diameter, and suture appearance): M0 D0 S0. (oxygenation index of 416) after 9 days in the intensive care unit (ICU). Right lung transplantation began with a posterolateral thoracotomy incision. Right pneumonectomy was carried out without incidence, the bronchus was anastomosed end-to-end with a 1-running 4-0 polydioxanone (PDS) suture. No extracorporeal circulation was needed during the transplantation. Total ischemic time was 300 minutes. At the end of the surgery, the patient developed a right ventricular dysfunction, which was managed with levosimendan, nitric
oxide, and noradrenalin (0.7 mg/kg per minute) because of hemodynamic instability. Despite this, cardiac function improved and the patient could be extubated 48 hours after surgery with hemodynamic improvement. No air leak was observed during this time. The patient received immunosuppression with tacrolimus, mycophenolate, and deflazacort; in addition, he received induction immunosuppression therapy with basiliximab [1]. Clindamycin and ceftazidime was administrated as postoperative antibiotic therapy.
BRONCHIAL DEHISCENCE AFTER LUNG TRANSPLANT On postoperative day 10, the patient was noted to have a discrete air leak (150 mL per minute) seen through the digital thorax collector connected to the chest tube. A few hour later, the air leak increased to 300 mL per minute, and a chest radiograph revealed a discrete pneumothorax. On postoperative day 11, the air leak increased considerably, reaching values of 1000 mL to 3000 mL per minute, so we decided to carry out an early bronchoscopy looking for a possible anastomosis air leak. Bronchoscopy revealed a partial dehiscence of the anastomosis with necrotic adherent membranes (Fig 1A and B). The patient’s status was excellent; therefore, we choose early surgical management. In the operating room, a complete dehiscence could be seen (Fig 1C). We performed a complete debridement of the necrotic segment resecting both bronchial margins, after which we performed a reanastomosis of both donor and receptor main bronchus using interrupted (mattress and 8-figure) 4-0 PDS sutures. The patient was extubated 48 hours after the second surgery. No air leak was registered and chest radiography revealed a complete expansion of lungs, with no evidence of pneumothorax. After 8 days in the ICU, he was transferred to his hospital room. The postoperative bronchoscopy revealed an excellent a well-formed anastomosis, with only discrete stenosis (< 30%). Per the endoscopic grading system for macroscopic central airway complications after lung transplantation, the MDS (for macroscopic, bronchial diameter, and suture appearance) classification for this patient was M0 D0 S0 [3]. The patient was discharged home after 93 days. Discharge was delayed because of an episode of pneumonia secondary to bronchoaspiration noted after a surveillance bronchoscopy. The pneumonia was managed successfully with conventional antibiotic therapy. No other complications occurred.
DISCUSSION
Bronchial dehiscence remains a disastrous complication in the posttransplantation period. It can occur early after transplantation, is extremely difficult to treat, and is associated with high mortality. A key aspect of the treatment is early diagnosis and intervention which can be done via either a surgical [4] or bronchoscopic [5] approach. Bronchoscopy techniques that have previously been tried include cyanoacrylate glue, growth factors, and autologous platelet-derived growth factors; however, these techniques do not fully resolve the dehiscence. An uncovered, self-expanding metal stent can
3
be placed temporarily to allow healing of the defect. It is deployed across the dehiscence and serves as a scaffolding for the exuberant growth of granulation tissue. A challenge of this technique is precise placement and removal, as there is the potential to extend the injury. Furthermore, there is a tendency for stenosis or malacia to occur at or distal to the site of prior dehiscence. Therefore, we prefer employing bronchoscopic techniques when the patient is not clinically stable enough for rethoracotomy. The surgical approach consists of rethoracotomy with complete debridement of the necrotic segment and the creation of a second anastomosis. This approach allows for complete removal of the detritus that impedes anastomosis healing and permits removal of microbial vegetations with successful results. CONCLUSIONS
The surgical approach is the most effective option to correct bronchial dehiscence if the patient is medically stable and early diagnosis is achieved. We employ the bronchoscopic approach when the patient is not stable enough for rethoracotomy or when, because of late diagnosis, rethoracotomy is technically impossible due to extensive adhesions. REFERENCES [1] Kshettry VR, Kroshus TJ, Hertz MI, Hunter DW, Shumway SJ, Bolman RM. Early and late airway complications after lung transplantation: incidence and management. Ann Thorac Surg 1997;63:1576e83. [2] Frye L, Machuzak M. Airway complications after lung transplantation. Clin Chest Med 2017;38:693e706. [3] Dutau H, Vandemoortele T, Laroumagne S, Gomez C, Boussaud V, Cavailles A, et al. A new endoscopic standardized grading system for macroscopic central airway complications following lung transplantation: the MDS classification. Eur J Cardiothorac Surg 2013;45:e33e8. [4] Krahenbuhl SM, Gonzalez M, Aubert JD, Tamm M, Ris HB, Krueger T, et al. Management of bilateral necrotizing bronchial dehiscence after a double lung transplantation. J Thorac Cardiovasc Surg 2018;156:e29e31. [5] Bottero S, Meucci D, Trozzi M, Carotti A. Dehiscence of bronchial anastomosis after lung transplantation: a successful unconventional treatment. Ann Thorac Surg 2018;106:e81e3.