Ann Thorac Surg 2003;76:2075-2076
© 2003 The Society of Thoracic Surgeons
Case report
Bronchial sleeve resection for posttransplant stricture
E. Carter Paulson, BSa,
Sunil Singhal, MDa,
John C. Kucharczuk, MDa,
Daniel H. Sterman, MDb,
Larry R. Kaiser, MDa,
M. Blair Marshall, MDa*
a Section of Thoracic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
b Pulmonary, Allergy, and Critical Care Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
Accepted for publication April 29, 2003.
* Address reprint requests to Dr Marshall, Section of Thoracic Surgery, Hospital of the University of Pennsylvania, 3400 Spruce St, 6 Silverstein Pavilion, Philadelphia, PA 19104-4227, USA
e-mail: blair.marshall{at}uphs.upenn.edu
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Abstract
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Nonanastomotic bronchial stenosis is a rare complication of lung transplantation. We report a case of a bilateral lung transplant recipient who experienced recalcitrant stenosis of the bronchus intermedius. All attempts at conservative management failed, and the stricture was successfully treated by a parenchymal-sparing segmental sleeve resection. Although rare, this is an important technique in the management of this difficult problem.
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Introduction
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Lung transplantation, despite its increasing success, carries a significant risk of postoperative airway complications. Because of several modifications in patient selection, surgical technique, and postoperative management, the prevalence of postoperative complications has decreased during the past several years [1]. Airway complications in transplant recipients most often involve the anastomosis. Distal airway strictures have been reported but are exceedingly rare. Frequently, these complications can be managed with nonoperative techniques. Surgical treatment is used as a last resort. We describe a patient with a recalcitrant stricture of the bronchus intermedius who failed conservative treatment. We performed a parenchymal-sparing sleeve resection of the bronchus intermedius.
A 53-year-old woman with 
1-antitrypsin deficiency underwent lung volume reduction surgery in October 1996. Her pulmonary function continued to deteriorate, and she underwent double lung transplantation in February 2001. Six weeks later, a radiograph demonstrated middle lobe consolidation, and stenosis of the right bronchus intermedius was noted during bronchoscopy (Fig 1). During the subsequent year, the patient required repeat balloon dilatations, laser ablation, and stenting of the stricture to manage this problem.
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Fig 1. Bronchoscopic view showing stenosis of the bronchus intermedius (A) and the right upper lobe takeoff (B).
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One year later, at bronchoscopy, complete obstruction of the bronchus intermedius was seen. During an attempt at dilation, the bronchoscope traversed the wall of the bronchus intermedius. The scope was removed, an urgent computed tomographic scan was obtained, and the patient was administered antibiotics. She recovered from this without incident and was referred for surgical management.
Given the refractory nature of this obstruction, surgical resection was the only therapeutic option. At the time of evaluation, the extent of the stricture was uncertain. The patient was counseled on the possibilities of a number of pulmonary resections that might be necessary to treat this problem, including lobectomy and bilobectomy.
Rigid bronchoscopy was performed, but the obstruction was complete beyond the takeoff of the right upper lobe. Attempts were made to pass a wire through the strictured area but were unsuccessful. A posterolateral thoracotomy was performed, and the latissimus dorsi muscle flap was harvested. A muscle flap was chosen for prophylactic protection of the bronchial anastomosis in this high-risk immunocompromised patient. The lung was mobilized in its entirety. After extensive dissection, the previous anastomosis, the right upper lobe bronchus, and the area of stricture were identified. The bronchus was divided just distal to the right upper lobe takeoff and then proximal to the superior segmental bronchus. The superior segmental and basilar segmental bronchi were of normal caliber. After sleeve resection of the bronchus intermedius, an anastomosis was constructed using a 4-0 Prolene suture (Ethicon, Somerville, NJ) in a running fashion. Because the patient was on long-term immunosuppression, the muscle was transposed into the chest and brought through the fissure. The pedicle was split to decrease its bulk and wrapped around the anastomosis. The patient's postoperative course was unremarkable, and she was discharged on postoperative day six (Fig 2).
On follow-up, she is doing well 6 months after surgery.
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Fig 2. Chest roentgenogram revealing normal lung fields with the latissimus dorsi coursing through the fissure.
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Comment
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Airway complications have plagued the field of lung transplantation. Although anastomotic dehiscence was the most common airway complication, it has been replaced by anastomotic stenosis [2, 3]. Numerous studies report airway complication rates of 5% to 16% after lung transplantation. These complications include stenosis, granulation tissue, infection, bronchomalacia, and dehiscence [1, 3, 4]. Most airway complications, including stenosis, occur at the level of the bronchial anastomosis. In our patient, the stenosis occurred at the bronchus intermedius distal to the right-sided anastomosis, which is a rare site of airway complication. Hasegawa and colleagues [5] reported that among 246 lung transplantations, distal stenosis developed in only 6 patients (2.5%).
Several factors may predispose lung transplant patients to the development of stenosis distal to the anastomosis. We suspect ischemic injury, rejection, and bronchial trauma may all play a role. Bronchial complications have been ascribed to ischemia resulting from the loss of bronchial artery circulation. Although one would expect ischemia to be greatest at the anastomosis, the distal donor airway is also at risk.
Hasegawa and colleagues [5] reported a series of patients with segmental nonanastomotic stricture after lung transplantation. In these patients, there was a higher grade of acute cellular rejection in patients with distal bronchial stenosis, suggesting rejection as a mediator of distal stenosis. Airway inflammation from acute cellular rejection has been shown to result in complete luminal obliteration, further supporting the mechanism of rejection as a factor in the development of posttransplant nonanastomotic stricture [6].
The traditional treatment of bronchial stenosis is well described. Balloon dilatation, laser therapy, and stenting are often effective in combination. Other therapies, including electrocautery, argon plasma coagulation, photodynamic therapy, and cryotherapy, have been reported. Besides the therapeutic nature of these interventions, the granulation tissue and trauma associated with these manipulations may inadvertently enhance the intractable nature of these strictures. In general, conservative treatment is used to treat airway stenosis with good outcomes of up to at least 4 years [1, 3, 4]. In one report from Washington University (n = 229), 17 of 18 post–lung transplant patients who developed stenosis were successfully treated with a combination of dilatation, lasers, and stenting [3]. Similarly, a University of Minnesota paper (n = 127) reported successful conservative treatment in 17 of 19 patients with posttransplant stenosis [4].
Occasionally, conservative treatment fails to relieve the stenosis. Surgical treatment is reserved for these rare cases. Reconstruction of the bronchial anastomosis has been described [1]. Prophylactic use of pedicled flaps in the management of high-risk bronchial anastomoses may prevent postoperative airway complications [7]. Retransplantation, a drastic option, has also been used as a successful treatment [1]. For our patient, a parenchymal-sparing sleeve resection of the bronchus intermedius was possible and allowed for maximal preservation of pulmonary function. In lung transplant patients, if the anatomy permits, parenchymal-sparing sleeve resection is feasible and should be the surgical technique of choice for isolated nonanastomotic segmental stenosis.
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References
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- Meyers B.F., Patterson G.A. Lung transplantation. In: Pearson L.H., ed. Thoracic Surgery. New York: Churchill Livingstone, 2002:1085-1114.
- DeMeo D.L., Ginns L.C. Lung transplantation at the turn of the century. Annu Rev Med 2001;52:185-201.[Medline]
- Date H., Trulock E.P., Arcici J.M., Sundaresan S., Copper J.D., Patterson G.A. Improved airway healing after lung transplantation. J Thorac Cardiovasc Surg 1995;110:1424-1431.[Abstract/Free Full Text]
- Kshettry V.R., Kroshus T.J., Hertz M.I., Hunter D.W., Shumway S.J., Bolman R.M. Early and late airway complications after lung transplantation: incidence and management. Ann Thorac Surg 1997;63:1576-1583.[Abstract/Free Full Text]
- Hasegawa T., Iacono A.T., Orons P.D., Yousen S.A. Segmental nonanastomotic bronchial stenosis after lung transplantation. Ann Thorac Surg 2000;69:1020-1024.[Abstract/Free Full Text]
- Neuringer I.P., Mannon R.B., Coffman T.M., et al. Immune cells in a mouse airway model of obliterative bronchiolitis. Am J Respir Cell Mol Biol 1998;19:379-386.[Abstract/Free Full Text]
- Cerfolio R.J. The incidence, etiology, and prevention of postresectional bronchopleural fistula. Semin Thorac Cardiovasc Surg 2001;1:3-7.
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Abstract
Introduction
