===::::::== -====:.
clinical investigations
----4~III.~-----------
Endoscopic Management of Bronchial Stenosis after Double Lung Transplantation *
Henri G. Colt, M.D., F.C.C.R;t julius R janssen, M.D.;+ [ean-Francois Duman, M.D., F.C.C.R;§ and Michel] Noirclerc, M.D.II Double lung transplantation with bilateral bronchial sutures is an increasingly popular therapeutic alternative for endstage, bilateral, septic pulmonary disease; however, surgical outcome has been hampered by mechanical complications at the level of the airway anastomoses. In our institution, therefore, the protocol for surveillance includes frequent flexible fiberoptic and rigid bronchoscopy under general anesthesia in all patients. Since 1988, there were 24 double lung transplantations (mean age, 19 yr) performed at the University of Marseille Hospitals using bilateral sutures without omental wrapping. Nineteen patients had cystic fibrosis; of the ten individuals (53 percent) with cystic fibrosis who ultimately developed bronchial stenosis, six required therapeutic endoscopic intervention including dilatation or Nd:YAG laser resection. Five patients required
endobronchial silicone stents, Statistically significant risk factors for postsurgical airway narrowing included young age (mean, 14.3 yr vs 24.0 yr in patients without stenosis) and prolonged mechanical ventilation prior to transplant (all five patients ventilated before surgery developed stenosis). Results of interventional bronchoscopy were good, and an excellent level of physical activity was maintained in most patients. A team familiar with all aspects of therapeutic bronchoscopy is essential to ensure proper management of airway complications in patients after lung transplantation. (Chest 1992; 102:10-16)
Double lung transplantation (DLT) is increasingly accepted for selected patients with end-stage pulmonary disease and satisfactory cardiac function. Despite improvements in surgical technique, postoperative care, and immunosuppression, complications still occur. These usually include infection, obliterative bronchiolitis, and graft rejection. In addition, the newly transplanted lungs may be subject to tracheal or bronchial suture dehiscence. Surgical techniques of lung transplantation have been hampered by poor vascularization of the airway anastomoses because of lost continuity between pulmonary, coronary, and bronchial circulations. Ischemia at the level of the tracheal anastomosis prompted operators to use vas-
cularized omentum to protect the suture site.' We2 and then others-" have advocated bilateral bronchial sutures. Regardless of the surgical technique employed, close endoscopic surveillance of airway sutures is essential. In addition, bronchoscopy after lung transplantation permits diagnostic and therapeutic intervention. Clinical deterioration, pulmonary function abnormalities, or abnormal chest roentgenographic findings often require transbronchial biopsy (TBB) or bronchoalveolar lavage (BAL) to confirm a diagnosis of graft rejection, obliterative bronchiolitis, or opportunistic infections." Bronchoscopic laser resection may be required to remove granulomas which form around suture sites and may be subsequent to prolonged airway injury from inflammation, infection, repeatedly traumatic suctioning, or bronchial devascularization. When bronchial stenosis occurs, insertion of an endobronchial stent may be desirable." At the University Hospitals of Marseille, France, bronchoscopic examinations are performed in all patients with lung and heart-lung transplants at regular intervals after surgery and when clinically indicated. Since 1988, there were 24 DLTs performed using bilateral bronchial anastomoses without omental wrapping. We report our experience with bronchial stenosis in ten patients and describe our current management strat-
*Fn)m the Departments of Laser and Thoracic Endoscopy and of Thoracic Surgery, Marseille Lung Transplant Group, Hopital Sainte Marguerite, CIIU Sud, Marseille, France. tAssistant, Centre Laser et Service d'Endoscopie Thoracique. Currently Assistant Professor of Medicine, Pulmonary Division, University of California San Diego Medical Center. tVisiting Scholar, CHU Sud de Marseille (funded by Astra and De Drie Lichten, the Netherlands). §Chief, Centre Laser et Service d'Endoscopie Thoracique. \IProfessor of Thoracic Surgery. Supported in part by a grant from the Association Francaise de Lutte contre la Mucoviscidose. Manuscript received June 12; revision accepted October 8. Re'Jrint requests: Dr: Dumon, Association REEL, Hopital Ste Marguerite, 270 Bid de Ste Alarguerite , Marseille, France 13009
10
= =
=
DLT double lung transplantation; LMB left main bronchus; RB rigid bronchoscopy; RMB right main bronchus; TBB transbronchial biopsy
=
=
Endoscopic Management of BronchialStenosis (Colt at 81)
egy for mechanical airway problems after transplantation.
omental wrapping.' The recipients bronchi were divided beyond the second cartilaginous ring. Extramucosal bronchial anastomoses were performed with single, nonabsorbable, monofilament running sutures. The right lung was transplanted first. The recipient's trachea and the donors bronchi were hardly dissected, in order to maximally preserve peribronchiolar vascularization. Peribronchial tissue of the donors lungs was subsequently stitched over the bronchial anastomoses. Bilateral sequential reimplantation was performed in ten patients through separate thoracotomies or transverse thoracotomy In this case, bronchial anastomoses were extrahilar. The left bronchial anastomosis was performed 1 em or less proximal to the orifice of the left upper lobe bronchus.
MATERIALS AND METHODS
lbtients Twenty-four patients (10 male and 14 female patients) ranging in age from 7 to 55 yr (mean, 19± 10 yr) underwent DLTwith bilateral bronchial sutures between September 1988 and February 1991. Nineteen had cystic 6brosis (CF), one had bronchiolitis obliterans, one hadsilicosis, one had emphysema, one bad bronchiectasis, and one had immotile cilia syndrome. Criteria for selection of donors and recipients and for the surgical procedure have been described elsewhere." Indications are examined for recipients on a case-bycase basis. Mismatching of the donors and recipients cytomegalovirus (CMV) serology is accepted. Age and donor-recipient thoracic perimeters are taken into consideration to match the donors and recipients thoracic volumes. Transplantation is considered even after tracheotomy, thoracotomy, or prolonged mechanical ventilation, and in high-risk patients with severe underlying illness, chronic infection, or terminal respiratory distress.
lbstoperative Management Antibiotic prophylaxis consisted of broad-spectrum and narrowspectrum antibiotics based on sensitivity patterns determined during the immediate preoperative period. Oral Ruconazole (2 mg! kWday) and acyclovir (BOO to 31'000 mg/m 2) were also administered. Acute lung rejection was treated with pulsed intravenous therapy with methylprednisolone (15 mglkg/day) for three days. Patients were initially managed in the intensive care unit. Because of suspected interference with bronchial healing, high-dose corticosteroids were avoided as much as possible in the first 14 days after operation.
SurgicalTechnique The donors heart-lung block was harvested, with separation of the heart after explanation. Special care was taken to leave tissue surrounding the bronchi intact. Lung preservation was achieved with cold Euro-Collins solution pulmonoplegia and prostaglandin E •. In the recipient, bilateral pneumonectomies were performed through a median sternotomy or after transverse thoracotomy En bloc transplantation of both lungs was performed in 14 patients using a modification of the Toronto procedure':" consisting of bilateral, end-to-end, main-stem bronchial anastomoses without
Bnmchoscopic Suroeillance Flexible 6beroptic bronchoscopy (FOB) was performed in the 6rst ten days after surgery and when indicated by clinical deterioration or suspicion of lung rejection. If patients were transportable or if they were discharged from the intensive care unit, bronchoscopy was performed at the Thoracic Endoscopy and Laser Center of Saint Marguerite Hospital. Because our protocol for surveillance
Table 1-BronchoBcopic InteroentionB in Ten lbtienta with BronchitJl Steraolia No. of Interventions
nosis*
Locationt
First Day Stenosis Diagnosed
No. of FOBs
No. of RBs
Dilatation Only
Laser Only
Bronchial Stent
1, F, 18
CF
L
13
7
31
4
6
16
2, F,9
CF
L
5
3
0
0
0
3,M,22
CF
L
44
5
10
0
4, F, 13
CF
L
294
5
4
0
5, F, 10
OB
R+L
13
3
7
6,F,9
CF
L
21
7
7, F,7
CF
R+L
73
8, F, 18
CF
L
9, M, 15
CF
10, M, 22
CF
Patient, Sex, Age (yr)
Diag-
Immediate Results*
Final Outcome§
0
Unsatisfactory NA
3
Excellent
Alive, day 625 Died, day 35 Died, day 360
0
0
NA
0
0
2
Excellent
14
1
0
2
Good
4
23
11
2
4
Unsatisfactory
7
14
0
0
0
0
NA
L
22
6
7
0
0
0
NA
R+L
136
6
6
1
0
0
Good
60
102
17
9
27
Total
Alive, day 369 Alive, day 254 Alive, day 387 Died, day 446 Died, day 45 Alive, day 236 Alive, day271
Ultimate Cause of Death** NA Lung rejection OB; failure of retransplantation NA NA NA Failure of surgical reanastomosis Suture dehiscence NA NA
*OB = obliterative bronchiolitis. tMain bronchial suture left (L) or right (R). *NA = not applicable. 'Outcome as of March 1, 1991. CHEST I 102 I 1 I JUL'(, 1992
11
also includes monthly bronchoscopy, most inte-rventions consist of riJ,(id hrondlOsmpy (RB) und er J,(e'll'ral anesthesia. Procedures were videotape-d , and color photographs of abnormal ith -s were ohtained. Afh'r intnhation and inspection with the- riJ,(id bronchoscope . a Hexible filll'ropti
clinical investigations
----4~III.~-----------
Endoscopic Management of Bronchial Stenosis after Double Lung Transplantation *
Henri G. Colt, M.D., F.C.C.R;t julius R janssen, M.D.;+ [ean-Francois Duman, M.D., F.C.C.R;§ and Michel] Noirclerc, M.D.II Double lung transplantation with bilateral bronchial sutures is an increasingly popular therapeutic alternative for endstage, bilateral, septic pulmonary disease; however, surgical outcome has been hampered by mechanical complications at the level of the airway anastomoses. In our institution, therefore, the protocol for surveillance includes frequent flexible fiberoptic and rigid bronchoscopy under general anesthesia in all patients. Since 1988, there were 24 double lung transplantations (mean age, 19 yr) performed at the University of Marseille Hospitals using bilateral sutures without omental wrapping. Nineteen patients had cystic fibrosis; of the ten individuals (53 percent) with cystic fibrosis who ultimately developed bronchial stenosis, six required therapeutic endoscopic intervention including dilatation or Nd:YAG laser resection. Five patients required
endobronchial silicone stents, Statistically significant risk factors for postsurgical airway narrowing included young age (mean, 14.3 yr vs 24.0 yr in patients without stenosis) and prolonged mechanical ventilation prior to transplant (all five patients ventilated before surgery developed stenosis). Results of interventional bronchoscopy were good, and an excellent level of physical activity was maintained in most patients. A team familiar with all aspects of therapeutic bronchoscopy is essential to ensure proper management of airway complications in patients after lung transplantation. (Chest 1992; 102:10-16)
Double lung transplantation (DLT) is increasingly accepted for selected patients with end-stage pulmonary disease and satisfactory cardiac function. Despite improvements in surgical technique, postoperative care, and immunosuppression, complications still occur. These usually include infection, obliterative bronchiolitis, and graft rejection. In addition, the newly transplanted lungs may be subject to tracheal or bronchial suture dehiscence. Surgical techniques of lung transplantation have been hampered by poor vascularization of the airway anastomoses because of lost continuity between pulmonary, coronary, and bronchial circulations. Ischemia at the level of the tracheal anastomosis prompted operators to use vas-
cularized omentum to protect the suture site.' We2 and then others-" have advocated bilateral bronchial sutures. Regardless of the surgical technique employed, close endoscopic surveillance of airway sutures is essential. In addition, bronchoscopy after lung transplantation permits diagnostic and therapeutic intervention. Clinical deterioration, pulmonary function abnormalities, or abnormal chest roentgenographic findings often require transbronchial biopsy (TBB) or bronchoalveolar lavage (BAL) to confirm a diagnosis of graft rejection, obliterative bronchiolitis, or opportunistic infections." Bronchoscopic laser resection may be required to remove granulomas which form around suture sites and may be subsequent to prolonged airway injury from inflammation, infection, repeatedly traumatic suctioning, or bronchial devascularization. When bronchial stenosis occurs, insertion of an endobronchial stent may be desirable." At the University Hospitals of Marseille, France, bronchoscopic examinations are performed in all patients with lung and heart-lung transplants at regular intervals after surgery and when clinically indicated. Since 1988, there were 24 DLTs performed using bilateral bronchial anastomoses without omental wrapping. We report our experience with bronchial stenosis in ten patients and describe our current management strat-
*Fn)m the Departments of Laser and Thoracic Endoscopy and of Thoracic Surgery, Marseille Lung Transplant Group, Hopital Sainte Marguerite, CIIU Sud, Marseille, France. tAssistant, Centre Laser et Service d'Endoscopie Thoracique. Currently Assistant Professor of Medicine, Pulmonary Division, University of California San Diego Medical Center. tVisiting Scholar, CHU Sud de Marseille (funded by Astra and De Drie Lichten, the Netherlands). §Chief, Centre Laser et Service d'Endoscopie Thoracique. \IProfessor of Thoracic Surgery. Supported in part by a grant from the Association Francaise de Lutte contre la Mucoviscidose. Manuscript received June 12; revision accepted October 8. Re'Jrint requests: Dr: Dumon, Association REEL, Hopital Ste Marguerite, 270 Bid de Ste Alarguerite , Marseille, France 13009
10
= =
=
DLT double lung transplantation; LMB left main bronchus; RB rigid bronchoscopy; RMB right main bronchus; TBB transbronchial biopsy
=
=
Endoscopic Management of BronchialStenosis (Colt at 81)
egy for mechanical airway problems after transplantation.
omental wrapping.' The recipients bronchi were divided beyond the second cartilaginous ring. Extramucosal bronchial anastomoses were performed with single, nonabsorbable, monofilament running sutures. The right lung was transplanted first. The recipient's trachea and the donors bronchi were hardly dissected, in order to maximally preserve peribronchiolar vascularization. Peribronchial tissue of the donors lungs was subsequently stitched over the bronchial anastomoses. Bilateral sequential reimplantation was performed in ten patients through separate thoracotomies or transverse thoracotomy In this case, bronchial anastomoses were extrahilar. The left bronchial anastomosis was performed 1 em or less proximal to the orifice of the left upper lobe bronchus.
MATERIALS AND METHODS
lbtients Twenty-four patients (10 male and 14 female patients) ranging in age from 7 to 55 yr (mean, 19± 10 yr) underwent DLTwith bilateral bronchial sutures between September 1988 and February 1991. Nineteen had cystic 6brosis (CF), one had bronchiolitis obliterans, one hadsilicosis, one had emphysema, one bad bronchiectasis, and one had immotile cilia syndrome. Criteria for selection of donors and recipients and for the surgical procedure have been described elsewhere." Indications are examined for recipients on a case-bycase basis. Mismatching of the donors and recipients cytomegalovirus (CMV) serology is accepted. Age and donor-recipient thoracic perimeters are taken into consideration to match the donors and recipients thoracic volumes. Transplantation is considered even after tracheotomy, thoracotomy, or prolonged mechanical ventilation, and in high-risk patients with severe underlying illness, chronic infection, or terminal respiratory distress.
lbstoperative Management Antibiotic prophylaxis consisted of broad-spectrum and narrowspectrum antibiotics based on sensitivity patterns determined during the immediate preoperative period. Oral Ruconazole (2 mg! kWday) and acyclovir (BOO to 31'000 mg/m 2) were also administered. Acute lung rejection was treated with pulsed intravenous therapy with methylprednisolone (15 mglkg/day) for three days. Patients were initially managed in the intensive care unit. Because of suspected interference with bronchial healing, high-dose corticosteroids were avoided as much as possible in the first 14 days after operation.
SurgicalTechnique The donors heart-lung block was harvested, with separation of the heart after explanation. Special care was taken to leave tissue surrounding the bronchi intact. Lung preservation was achieved with cold Euro-Collins solution pulmonoplegia and prostaglandin E •. In the recipient, bilateral pneumonectomies were performed through a median sternotomy or after transverse thoracotomy En bloc transplantation of both lungs was performed in 14 patients using a modification of the Toronto procedure':" consisting of bilateral, end-to-end, main-stem bronchial anastomoses without
Bnmchoscopic Suroeillance Flexible 6beroptic bronchoscopy (FOB) was performed in the 6rst ten days after surgery and when indicated by clinical deterioration or suspicion of lung rejection. If patients were transportable or if they were discharged from the intensive care unit, bronchoscopy was performed at the Thoracic Endoscopy and Laser Center of Saint Marguerite Hospital. Because our protocol for surveillance
Table 1-BronchoBcopic InteroentionB in Ten lbtienta with BronchitJl Steraolia No. of Interventions
nosis*
Locationt
First Day Stenosis Diagnosed
No. of FOBs
No. of RBs
Dilatation Only
Laser Only
Bronchial Stent
1, F, 18
CF
L
13
7
31
4
6
16
2, F,9
CF
L
5
3
0
0
0
3,M,22
CF
L
44
5
10
0
4, F, 13
CF
L
294
5
4
0
5, F, 10
OB
R+L
13
3
7
6,F,9
CF
L
21
7
7, F,7
CF
R+L
73
8, F, 18
CF
L
9, M, 15
CF
10, M, 22
CF
Patient, Sex, Age (yr)
Diag-
Immediate Results*
Final Outcome§
0
Unsatisfactory NA
3
Excellent
Alive, day 625 Died, day 35 Died, day 360
0
0
NA
0
0
2
Excellent
14
1
0
2
Good
4
23
11
2
4
Unsatisfactory
7
14
0
0
0
0
NA
L
22
6
7
0
0
0
NA
R+L
136
6
6
1
0
0
Good
60
102
17
9
27
Total
Alive, day 369 Alive, day 254 Alive, day 387 Died, day 446 Died, day 45 Alive, day 236 Alive, day271
Ultimate Cause of Death** NA Lung rejection OB; failure of retransplantation NA NA NA Failure of surgical reanastomosis Suture dehiscence NA NA
*OB = obliterative bronchiolitis. tMain bronchial suture left (L) or right (R). *NA = not applicable. 'Outcome as of March 1, 1991. CHEST I 102 I 1 I JUL'(, 1992
11
also includes monthly bronchoscopy, most inte-rventions consist of riJ,(id hrondlOsmpy (RB) und er J,(e'll'ral anesthesia. Procedures were videotape-d , and color photographs of abnormal ith -s were ohtained. Afh'r intnhation and inspection with the- riJ,(id bronchoscope . a Hexible filll'ropti
