Anastomotic Airway Complications after Lung Transplantation

Abstract

Purpose: Anastomotic airway complications are a major cause of morbidity and mortality after lung transplantation (LTx). In this study, the authors identified types and clinical outcomes of airway complications after LTx.

Materials and methods: All bronchial anastomotic complications were analyzed in a total of 94 LTx cases involving 90 recipients who underwent surgery between July 2006 and May 2014. Fifteen LTx cases (14 recipients) with incomplete medical records for fiberoptic bronchoscopy (FBS) and three cases underwent heart-lung transplantation (HLT) were excluded. Postoperative FBS at 24-48 hours, 1, 3, 6, and 12 months, and then yearly after the transplantation were performed.

Results: A total of 76 LTx cases (75 recipients) were analyzed. The mean age of the recipients was 49.55 years (range, 18-71 years), and 38 (49.4%) were male. Twenty-one out of 76 cases (27.6%) experienced early anastomotic complications, and 12 (15.8%) presented late anastomotic complications. The early anastomotic airway complications presented in various forms: stenosis, 1 case; narrowing, 1; necrosis & dehiscence, 3; fistula, 4; granulation, 10; and infection, 2. Late complications almost entirely presented in the form of bronchial stenosis; five recipients showed stenosis at the anastomosis site, and one of them showed improvement after ballooning. Five others were found to have stenosis at the bronchus intermedius, distal to the anastomosis site. Three of these patients showed improvement after ballooning or bronchoplasty.

Conclusion: By serial surveillance via FBS after LTx, we detected anastomotic airway complications in 42.9% of cases, which were successfully managed with improved clinical outcomes.

Keywords: Lung transplantation; postoperative complications; surgical anastomosis.

Fig. 1. Diagram of the study cases. Since July 1996, a total 90 patients (94 LTx cases) underwent LTx. Among 90 recipients, 18 LTx cases were excluded from this analysis. Among 76 LTx cases (75 recipients), 21 recipients showed early anastomotic complications and 12 late complications. LTx, lung transplantation; FOB, fiberoptic bronchoscopy; PFT, pulmonary function test.

Fig. 2. Representative photographs of early anastomotic airway complications. (A) A case of early airway complication presenting fistula at anastomosis site. No specific findings at the anastomosis site were detected by immediate post-op bronchoscope. At POD#12, fistula at the proximal portion of the right upper lobe bronchus was detected and re-suture was performed. Follow-up bronchoscope performed at POD#90 revealed stenosis of right upper lobe bronchus. (B) Another case of early airway complication showing fungal infection at anastomotic sites. Exophytic granulation tissues with 30% luminal narrowing at both anastomosis sites were identified at POD#18. Bronchoscopic biopsy and culture study revealed the granulation from A. fumigatus infection. After treatment with antifungal agents, the granulations were disappeared but there were minimal stenosis on a follow-up study at POD#60. POD, postoperative day.