Ann Thorac Surg 2002;73:308-310
© 2002 The Society of Thoracic Surgeons
Case report
Bilateral lung transplantation using a donor with a tracheal right upper lobe bronchus
Yasuo Sekine, MD, PhDa,
Stefan Fischer, MDa,
Marc de Perrot, MDa,
Andrew F. Pierre, MDa,
Shaf Keshavjee, MD*a
a Toronto Lung Transplant Program, Division of Thoracic Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
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: shaf.keshavjee{at}uhn.on.ca
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Abstract
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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.
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Introduction
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Although 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 organism. 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.
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Fig 1. (A) Right upper lobe bronchus (RULB) arising from the trachea approximately 1.5 cm proximal to the carina. (B) The tracheobronchial anastomosis being performed: anastomosis of the membranous part of the tracheobronchial anastomosis. (C) The bronchoscopic appearance of the anastomosis immediately after implantation of the right lung. (D) Bronchoscopic appearance of the airway anastomosis 3 months after transplantation demonstrating satisfactory healing with normal lumenal caliber of the RULB and the RBI. (LMB = left main bronchus; RBI = right bronchus intermedius.)
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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 days, the anastomosis was found to be somewhat dusky, but clearly viable. Subsequent bronchoscopic examination has demonstrated entirely satisfactory healing with a normal lumenal caliber (Fig 1D).
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Comment
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A tracheal bronchus is an aberrant bronchus usually arising from the right lateral wall of trachea within 2 cm above the carina [2]. Its incidence ranges between 0.1% and 5% [2] and some improvisation of airway anastomotic technique is required in order to use the lung for transplantation.
In this case, there were several possible options for the airway anastomosis: en-bloc double lung transplantation with a tracheal anastomosis, left single lung transplantation alone, bilateral transplantation with a left lung and a right middle and lower lobe (following donor lung right upper lobectomy), and bilateral transplantation with a modified right tracheobronchial anastomosis. En-bloc double lung transplantation has a significantly higher airway anastomotic complication rate compared to bilateral sequential lung transplantation [3]. In this patient with cystic fibrosis, a single lung transplant is not a reasonable option due to the risk of infection. Brichon and colleagues have reported on a case of bilateral sequential lung transplantation followed by a right apical segmentectomy for a tracheal bronchus of the right apical segment [4]. However, since the tracheal bronchus was a complete right upper lobe bronchus in our case, a right upper lobectomy would have been required. By examining the orifice created for the anastomosis, we felt that the right lung could be satisfactorily implanted. Although a tracheal anastomosis is potentially at risk of airway ischemia [3], we were careful to avoid disruption of the peritracheal tissue, and the length of bronchial stump was made as short as possible in the donor lung to maximize the benefit of pulmonary-to-bronchial collateral blood supply. The telescoping suture technique and buttressing of peribronchial tissues provided additional security. Magee and colleagues have previously reported on a case of a successful bilateral lung transplantation in a recipient child with a right upper lobe tracheal bronchus [5]. The concept of the tracheo-bronchial anastomosis was similar to ours except that the anomaly was in the recipient. These cases illustrate that this anomaly can be satisfactorily handled when encountered in the donor or in the recipient. Thus, the finding of a tracheal right upper lobe bronchus is not a major obstacle to successful lung transplantation and, with careful technique, these lungs can be safely used to maximize the utilization of donor organs.
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References
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Maccherini M., Keshavjee S.H., Slutsky A.S., Patterson G.A., Edelson J.D. The effect of low-potassium-dextran versus Euro-Collins solution for preservation of isolated type II pneumocytes. Transplantation 1991;52:621-626.[Medline]
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Barat M., Konrad H.R. Tracheal bronchus. Am J Otolaryngol 1987;8:118-122.[Medline]
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Kaiser L.R., Pasque M.K., Trulock E.P., Low D.E., Dresler C.M., Cooper J.D. Bilateral sequential lung transplantation: the procedure of choice for double-lung replacement. Ann Thorac Surg 1991;52:438-446.[Abstract/Free Full Text]
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Brichon P.Y., Blin D., Perez I., et al. Double-lung transplantation using donor lungs with a right tracheal bronchus. Ann Thorac Surg 1992;54:777-778.[Abstract/Free Full Text]
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Magee M.J., Griffith B.P., Armitage J.M. Management of a tracheal bronchus in a pediatric lung transplant recipient. Ann Thorac Surg 1994;58:229-231.[Abstract/Free Full Text]
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Abstract
Introduction
