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Ann Thorac Surg 2001;72:2109-2111
© 2001 The Society of Thoracic Surgeons

Case report

Endoscopic repair of bronchial dehiscence after lung transplantation

James D. Maloney, MD*a, Tracey L. Weigel, MDa, Robert B. Love, MDa

a Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA

Accepted for publication March 1, 2001.

* Address reprint requests to Dr Maloney, Department of Surgery, University of Wisconsin, 600 Highland Ave, H/410, Madison, WI 53792, USA
e-mail: jdmalone{at}facstaff.wisc.edu


   Abstract
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 Abstract
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We report a case of bronchial dehiscence after right single lung transplantation and describe a novel means of management: bronchoscopic closure of the defect with alpha-cyanoacrylate glue.


   Introduction
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The Achilles heel of lung transplantation has been the bronchial or tracheal anastomosis. Anastomotic dehiscence continues to adversely affect lung transplant morbidity and mortality. Lethal airway complications occur in approximately 2% of patients [1]. Nonlethal dehiscence may often be managed conservatively with tube drainage, but can result in airway stenosis [2, 3]. We describe the closure of a lung transplant bronchial anastomotic dehiscence by endoscopically applied cyanoacrylate glue.

A 48-year-old woman underwent right single lung transplantation for chronic obstructive pulmonary disease. A standard telescoped anastomosis was used without omental buttressing or bronchial artery revascularization. Immunosuppressive therapy, including methylprednisolone, cyclosporine, and azathioprine, was initiated postoperatively. The postoperative course for this patient was complicated. She suffered from acute graft dysfunction and prolonged intubation. On the 14th postoperative day the patient was noted to have an increasing air leak. Bronchoscopic evaluation demonstrated a dehiscence at the posterior aspect of the anastomosis. At the time that the dehiscence was found there was no clinical evidence of mediastinal or pleural infection from leakage of bronchial secretions. Plain radiographs demonstrated pneumomediastinum and pneumothorax without pleural effusion.

We elected to repair the defect by application of alpha-cyanoacrylate glue using a flexible Pentax FB19TX bronchoscope. Using a TB syringe, the glue was directed at the defect through a Wang needle sheath with the biopsy needle removed (Fig 1). Three sequential applications of the glue were performed under direct visualization during this therapeutic bronchoscopy. The patient’s pulmonary status improved and the air leak was notably diminished after the procedure. The right chest tube was removed 2 days later. The patient was weaned from the ventilator and transferred to general care on the 23rd postoperative day.



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  		Fig 1. Cyanoacrylate glue applied to posterior dehiscence. Adhesive is directed at the defect with a Wang needle sheath under bronchoscopic guidance.

 
At 3 weeks after application of the cyanoacrylate, the bronchial anastomosis was widely patent. The glue was noted to be intact posteriorly, and the area surrounding the glue visualized. The patient was discharged home 2 months after transplantation. Bronchoscopy was performed at 2-month to 3-month intervals after discharge. At 7 months postoperatively the glue was removed by endoscopic debridement without complication. At 18 months the bronchial anastomosis appeared well healed without evidence of stenosis (Fig 2).



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  		Fig 2. Endoscopic photograph of bronchial anastomosis 18 months after application of cyanoacrylate glue (arrow).

 

   Comment
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Airway complications have been a major source of morbidity and mortality in lung transplantation. Many factors including ischemia, immunosuppression, infection, rejection, and inadequate preservation may increase the risk of anastomotic complications. Ischemia is thought to be one of the foremost variables affecting the rate of dehiscence [2–4]. Additionally, prolonged ventilator support may increase the risk of airway complications [1]. Innovative techniques such as telescoped anastomoses, buttressing anastomoses with omentum or other well-vascularized tissue, and more recently direct bronchial artery revascularization have been proposed to reduce complication rates [4]. The risk of lethal airway complications is estimated at approximately 2%. Nonlethal dehiscences occur more frequently. In a large series by Date and associates [1], bronchial dehiscence required clinical intervention in 12.8% of patients undergoing lung transplantation. In the last 76 patients undergoing transplantation the authors decreased the airway complication rate to 4% [1]. These complications still occur, however, and can lead to bronchial stenosis, which remains a considerable cause of morbidity [3]. Endoscopic therapies such as dilation, stenting, and laser ablation for stenosis secondary to dehiscence have been described. However, multiple, repeated dilatations are often required to maintain an adequate lumen [2, 3]. No primary bronchoscopic therapy for repair of the bronchial dehiscence after lung transplantation has been reported in the literature.

Cyanoacrylate glue has been used effectively for repair of bronchopleural fistulas after pulmonary resections and lung volume reduction surgical procedures. Intraoperative use of the adhesive in conjunction with surgical repair has been reported [5]. Scappaticci and colleagues [6] reported an 83% success rate for endoscopic closure of postoperative bronchopleural fistula with cyanoacrylate glue. Some authors [7] have recommended intraoperative application of monomeric n-butyl-2-cyanoacrylic tissue adhesive prophylactically to reduce the incidence of bronchopleural fistula. This has not been reported in the lung transplant population.

The combination of prolonged ventilatory support and acute graft dysfunction increased the risk of dehiscence in this patient. Ultimately, prevention of airway complications by minimizing risk factors was our goal. It was our intent to use the cyanoacrylate glue to seal the dehiscence, thus improving pulmonary function; to decrease the leak of bronchial secretions into the pleural and mediastinal space; and to limit or avoid secondary stenosis. It is not without risk to place a foreign body within the bronchus in an immunocompromised population with high risk of infection. Further study is needed to determine the role of cyanoacrylate glue in bronchial anastomotic dehiscence after lung transplantation, the appropriate timing for removal of the glue, and its associated infectious risks.


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 References
 

  1. Date H., Trulock E., Arcidi J., et al. Improved airway healing after lung transplantation. J Thorac Cardiovasc Surg 1995;110:1424-1432.[Abstract/Free Full Text]
  2. Schafers H.J., Haydock D.A., Cooper J.D. The prevalence and management of bronchial anastomotic complications in lung transplant. J Thorac Cardiovasc Surg 1991;101:1044-1052.[Abstract]
  3. Shennib H., Massard G. Airway complications in lung transplantation. Ann Thorac Surg 1994;57:506-511.[Abstract/Free Full Text]
  4. Anderson M.B., Kriet J.M., Harrel J., et al. Lung and heart-lung transplantation, techniques for bronchial anastomosis. J Heart Lung Transplant 1995;14:1090-1094.[Medline]
  5. Horsley W.S., Miller J.I. Management of the uncontrollable pulmonary air leak with cyanoacrylate glue. Ann Thorac Surg 1997;63:1492-1493.[Abstract/Free Full Text]
  6. Scappaticci E., Ardissone F., Ruffini E., Baldi S., Mancuso M. Postoperative bronchopleural fistula: endoscopic closure in 12 patients. Ann Thorac Surg 1994;57:119-122.[Abstract/Free Full Text]
  7. Sabanathan A., Sabanathan S., Shah R., Richardson J. Tissue adhesive in bronchial closure. Ann Thorac Surg 1997;63:899-900.[Free Full Text]



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This Article
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Tracey L. Weigel
Robert B. Love
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