Improved airway healing after lung transplantation

Abstract

We evaluated various clinical factors to identify predictors of airway complication after lung transplantation. Two hundred twenty-nine consecutive single (n = 110) and bilateral (n = 119) lung transplants were done between September 1988 and August 1994. These 348 bronchial anastomoses were retrospectively analyzed. Airway complication that necessitated clinical intervention affected 33 anastomoses (9.5%) in 29 patients (12.8%). Satisfactory healing was achieved in 22 of these patients by conservative therapy such as one or a combination of dilation, stent, and laser. There were five deaths (2.2%) attributable to airway complications. One patient had an early postoperative death unrelated to airway complication and one patient has a recalcitrant bronchus intermedius stricture. Complication occurred more often in single-lung than in bilateral lung transplants (16/110, 14.4%, versus 17/238, 7.1%; p < 0.05). The use of a mattress suture (21/153, 13.7%) was associated with more frequent complications than was simple interrupted suture (8/122, 6.6%) or figure-of-eight suture (4/73, 5.5%) (p < 0.05). For patients in whom airway complications subsequently developed, the duration of postoperative mechanical ventilation was greater than that for those in whom an airway complication did not develop. The prevalence of airway complications as our program evolved was evaluated by separating the 229 transplants into three groups: phase I, the first 77 transplants; phase II, the next 76 transplants; and phase III, the most recent 76 transplants. The airway complication rate per anastomosis was significantly lower in phase III (5/126, 4.0%) than in phase I (12/110, 10.9%; p < 0.05) and phase II (16/112, 14.3%; p < 0.01). The majority of airway complications are successfully treated and rarely fatal. The recent reduction in prevalence of airway complications is likely a result of better maintenance immunosuppression and rejection surveillance.

Bronchial anastomotic complications following lung transplantation: still a major cause of morbidity?

“…The airway complication rate in this series dropped from 11% in the first 77 patients to 4% in the last 76 transplants [4]. WILSON et al [10] recently reported an incidence of severe airway complications as low as 1.6% in 100 consecutive anastomoses.…”

“…Sequential single-lung transplantation with bilateral bronchial anastomosis and further technical improvements, as well as better preservation and postoperative management, reduced the incidence of ischaemic airway complications [2]. Bronchial complications with a mortality of 2-4% are still reported in 4-12% of lung transplant recipients [3,4]. Various technical measures, such as reconstruction of the bronchial circulation [5], omental wrap [6] and other methods, have been proposed to improve healing of the donor bronchus.…”

Risk factors for airway complications within the first year after lung transplantation

“…Garfein and co-workers also reported a higher incidence of AC associated with the telescoping technique in patients who underwent single lung transplantation for emphysema [8]. In contrast with this, other investigators observed good results [13] with telescoped anastomoses and no correlation was found between telescoped anastomoses and the development of an AC [14,15]. The small number of telescoped anastomoses in comparison with the end-toend technique in this series could be a potential limitation in the comparison of both techniques.…”

“…Therefore, critical analysis of potential risk factors that may play a role in the development of AC is important. Date and co-workers from St. Louis [14] demonstrated that single lung transplantation and the use of mattress suture were associated with a higher prevalence of AC. This group also suggested that better maintenance immunosuppression and rejection surveillance reduced the prevalence of AC.…”

Current status of lung transplantation

“…Improvements in lung preservation, surgical technique and perioperative management of the recipient have reduced the frequency of this complication. In recent experience, the incidence of airway complications was only 4% [60]. These problems can usually be managed by conservative airway debridement.…”