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Ann Thorac Surg 2001;71:993-994
© 2001 The Society of Thoracic Surgeons
a Department of Pulmonary & Critical Care Medicine, The Cleveland Clinic Foundation, Cleveland, OH 44195, USA
Over the past 20 years, lung transplantation has become standard therapy for a variety of end-stage lung diseases. With experience, better immunosuppression, and prophylaxis, there has been gradual improvement in survival; yet, lung transplantation lags behind improvement with other solid organs. Airway complications are unique to lung transplantation; they may not always be preventable but are often treatable. Their recognition and proper management would certainly palliate symptoms and could improve survival.
Herrera and associates describe their experience with this procedure and raise several important issues. First, despite surgical innovations and experience, airway complications do occur, as much as 25% of the time. Interestingly the type of anastomosis (end-to-end vs telescoping), need for cardiopulmonary bypass, rejection, or use of steroids do not appear to have an impact on the outcome, whereas the benefits of muscle or pericardial wrap remain unknown in the study. Second, the authors substantiate the previously believed and documented risk factors of aspergillus colonization or infection. The presence of this organism should be actively sought before, during, and after the procedure. Reported high complication rates make the argument against prophylactic use of aerosolized amphotericine-B difficult. This is of even greater concern in patients with cystic fibrosis who are not only more likely to be colonized, but also have allergic bronchopulmonary aspergillosis. The study does not clearly state how many of their patients had cystic fibrosis. Finally, the treatment of airway complications remains challenging and depends on its characteristics. The suture granulomas can be easily treated with laser photoresections, whereas the concentric strictures can be palliated with electrosurgery and balloon bronchoplasty. Self-expanding metallic stents add a new facet to the management of bronchomalacia and the dehiscence. Newer-generation metallic stents may further simplify their use and related complications.
Heart-lung transplantation is too much a price to pay to prevent the complications, yet bronchial artery anastomosis to reduce another risk factor of mucosal necrosis may be appealing if the rate of such complications remains this high.
I agree with the authors that a high degree of vigilance should be practiced perioperatively to detect aspergillus colonization and infection in the lung transplant recipients. Prophylactic use of aerosolized amphotericine-B is appropriate. Patients should be closely followed for early detection of airway complication in the immediate postoperative period.
Related Article
Ann. Thorac. Surg. 2001 71: 989-993.
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