Successful Surgical Management of Bronchial Dehiscence After Single-Lung Transplantation A. J. B. Kirk, FRCS, I. D. Conacher, FFARCS, P. A. Corris, MRCP, T. Ashcroft, FRCPath, and J. H. Dark, FRCS Cardiopulmonary Transplant Unit, Freeman Hospital, Newcastle upon Tyne, England
A case of bronchial dehiscence despite bronchial omentopexy is described in a patient nine days after singlelung transplantation. Rethoracotomy was undertaken as soon as the diagnosis was established before superinfection occurred. Necrotic bronchus was excised, with the
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ingle-lung transplantation is now a realistic therapeutic option for carefully selected patients with endstage pulmonary fibrosis [l, 21. Early attempts at singlelung transplantation resulted in no long-term survivors; most patients who survived more than 2 weeks died of bronchial anastomotic dehiscence [3]. This occurred because isolated lung transplants (both single and double) are unique among solid organ transplants in not receiving a systemic blood supply. The recipient bronchus receives an adequate blood supply directly from bronchial arteries, and the intrapulmonary bronchus is reasonably well served by pulmonary collaterals. The intervening portion of bronchus, including the anastomosis, is rendered critically ischemic for at least 12 days until revascularization occurs from the recipient bronchial arteries [4]. Introduction of the omentum as a vascularized pedicle to wrap around the bronchial anastomosis promotes early revascularization and anastomotic healing [5] and is now a routine practice in single-lung transplantation [6]. We describe a case of bronchial dehiscence that occurred despite bronchial omentopexy and that was successfully managed by prompt surgical intervention. A 54-year-old man with progressive cryptogenic fibrosing alveolitis, unresponsive to immunosuppressive therapy, was accepted for single-lung transplantation. Before transplantation, he was successfully weaned from steroid therapy. When a suitable donor became available, he underwent an uneventful single left lung transplantation without the need for cardiopulmonary bypass. Although he had previously undergone appendectomy for perforated appendicitis associated with generalized peritonitis, the dissected omental pedicle was believed to be satisfactory. The donor bronchus was trimmed two cartilage rings proximal to the upper lobe bronchus. Early lung function, assessed radiologically and by alveolar-arterial oxygen gradient, was excellent. The paAccepted for publication July 27, 1989 Address reprint requests to Dr Dark, Cardiopulmonary Transplant Unit, Freeman Hospital, Freeman Road, High Heaton, Newcastle upon Tyne NE7 7DN, England.
0 1990 by The Society of Thoracic Surgeons
anastomosis sited distally on the donor bronchus. The omentum was necrotic, and the new anastomosis was wrapped with a vascularized pedicle of pericardium. Six months after this procedure, the patient remains well. (Ann Thoruc Surg 1990;49:247-9)
tient was extubated 12 hours postoperatively and breathing room air by 72 hours with arterial oxygen tension of 12.4 kPa. On day 4, he suffered an acute dyspneic episode, associated with a decrease in oxygenation and with hemodynamic instability. Immediate transbronchial lung biopsy demonstrated histological evidence of both perivascular and bronchial rejection (Fig 1).The bronchial mucosa was edematous and inflamed, with fragments of necrotic slough in the mucosal biopsy specimen. He responded rapidly and completely to a three-day course of pulsed intravenous methylprednisolone (10 mg/ kg/day). Bronchoalveolar lavage excluded pulmonary infection. However, on day 9, he again became unwell, and chest radiography revealed an obvious pneumopericardium (Fig 2). Fiberoptic bronchoscopy showed circumferential necrosis 1cm long immediately distal to the anastomosis, although no perforation was observed. The patient underwent thoracotomy. The omental pedicle was dusky and loosely adherent. After removal of the omentum, the necrotic bronchus was excised and healthy bronchus was reanastomosed directly with interrupted polypropylene sutures. This suture line lay at the level of the bifurcation of the donor left main bronchus. Adequate oxygenation during this period of bronchial reconstruction was ensured by the use of high-frequency jet ventilation of the left lung in addition to intermittent positive-pressure ventilation of the right lung accomplished through a catheter passed down the left bronchial limb of the double-lumen endotracheal tube and across the anastomosis into the distal bronchial tree. Jet ventilation of one lung and conventional ventilation of the other has been described previously [7], and use of this technique avoided the need for cardiopulmonary bypass, which otherwise would have been essential. A vascularized flap of pericardium was wrapped around the new anastomosis. Fluid from pleural and pericardial cavities and from the mediastinum grew scanty amounts of Candida albicans but was otherwise sterile. 0003-4975/90/$3.50
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Ann Thorac Surg 1990;49147-9
The patient's clinical state allowed extubation 14 hours postoperatively. After operation, the patient made a slow but steady recovery and was discharged from the hospital 22 days later. Postoperative bronchoscopy demonstrated a patent airway with healthy bronchial mucosa in the region of the anastomosis. At follow-up 6 months later, the patient is fully rehabilitated and has excellent pulmonary function. Fiberoptic bronchoscopy was performed 5 months postoperatively after a temporary decrease in spirometry suggested lung rejection. The anastomosis was pink and well vascularized with no evidence of stenosis.
Comment The greater omentum is probably the ideal vascularized pedicle and has a role in a number of complex problems in the chest [8]. Its use has been crucial to the success of single-lung transplantation in the modern era [l].It is not an infallible guarantor of bronchial integrity, however, as demonstrated by this case. In particular, previous abdominal operation may make development of a suitable pedi-
A
B Fig 1. (A)A focus of periuascular Zymphocytic infiltration in lung parenchyma. (Hematoxylin and eosin, X400 before 41% reduction.) (B)Lymphocytic infiltration in bronchial muscle and subrnucosa. (Hematoxylin and eosin, X400 before 41% reduction.)
Fig 2. Chest roentgenogram shows pneumopericardium.
cle difficult or impossible. In addition, there is the risk of torsion and compression as the pedicle passes through the diaphragm. The already impaired bronchial healing after singlelung transplantation may be worsened by a mucosal inflammation that may accompany pulmonary rejection. Such a mechanism may have been important in our patient and has been suggested in another [2]. In the experimental situation, an intercostal muscle graft will ensure bronchial anastomotic integrity [9], and we have successfully used such a technique at retransplantation. The pericardial pedicle has also been described in this situation [lo] and was chosen for our patient because of easy availability. Both of these approaches may be applicable when the omentum is not available. We constructed the second anastomosis as close as possible to the lung parenchyma to ensure complete debridement of the necrotic segment. The donor bronchus at this site may receive perfusion from pulmonarybronchial collaterals [111, and there is direct experimental evidence that siting the anastomosis distally results in better healing [12]. Introduction of steroids at day 4 for the treatment of pulmonary rejection may have been an additional insult in our patient. Use of steroids at an early stage has been associated with impaired bronchial healing ~31. Although bronchial omentopexy is an important adjunct to single-lung transplantation, it is not infallible. Should it fail, rapid intervention, reanastomosis distally in the donor bronchus, and use of an intercostal or pericardial pedicle may permit salvage of the situation. These alternative techniques should be considered when omentum is not available.
Addendum The patient remains fit and well 15 months after operation.
Ann Thorac Surg 1990;49147-9
References 1. The Toronto Transplant Group. Experience with single-lung transplantation for pulmonary fibrosis. JAMA 1988;259: 2258-62. 2. The Toronto Lung Transplant Group. Unilateral lung transplantation for pulmonary fibrosis. N Engl J Med 1986;314: 1140-5. 3. Veith FJ. Symposium on organ transplantation-lung transplantation. Surg Clin North Am 1978;58:357-64. 4. Siegelman SS, Hagstrom JWC, Koerner SK, Veith FJ. Restoration of bronchial artery circulation after canine lung allotransplantation. J Thorac Cardiovasc Surg 1977;73:792-5. 5. Dubois P, Choiniere L, Cooper JD. Bronchial omentopexy in canine lung allotransplantation. Ann Thorac Surg 1984;38: 211-4. 6. Cooper JD, Pearson FG, Patterson GA, et al. Technique of successful lung transplantation in humans. J Thorac Cardiovasc Surg 1987;93:173-81. 7. Morgan BA, Perks D, Conacher ID, Paes ML. Combined uni-
CASE REPORT KIRK ET AL BRONCHIAL DEHISCENCE IN SLT
149
lateral high frequency jet ventilation and contralateral intermittent positive pressure ventilation. Anaesthesia 1987;42:975-9. 8. Mathisen DJ, Grillo HC, Vlahakes GJ, Daggett WM. The omentum in the management of complicated cardiothoracic problems. J Thorac Cardiovasc Surg 1988;95:677-84. 9. Fell SC, Mollenkopf PA-C, Montefusco CM, et al. Revascularisation of ischemic bronchial anastomoses by an intercostal pedicle flap. J Thorac Cardiovasc Surg 1985;90:172-8. 10. The Toronto Lung Transplant Group. Sequential bilateral lung transplantation for paraquat poisoning. J Thorac Cardiovasc Surg 1985;89:734-42. 11. Ladowski JS, Hardesty RL, Griffith BP. Pulmonary artery blood supply to the supracarinal trachea. Heart Transplant 1984;440-2. 12. Pinsker KL, Koerner SK, Kamholz SL, Hagstrom JWC, Veith FJ. Effect of donor bronchial length on healing. J Thorac Cardiovasc Surg 1979;77:669-73. 13. Lima 0, Cooper JD, Peters WJ, et al. Effects of methylprednisolone and azathioprine on bronchial healing following lung autotransplantation. J Thorac Cardiovasc Surg 1981; 82:211-5.
A case of bronchial dehiscence despite bronchial omentopexy is described in a patient nine days after singlelung transplantation. Rethoracotomy was undertaken as soon as the diagnosis was established before superinfection occurred. Necrotic bronchus was excised, with the
S
ingle-lung transplantation is now a realistic therapeutic option for carefully selected patients with endstage pulmonary fibrosis [l, 21. Early attempts at singlelung transplantation resulted in no long-term survivors; most patients who survived more than 2 weeks died of bronchial anastomotic dehiscence [3]. This occurred because isolated lung transplants (both single and double) are unique among solid organ transplants in not receiving a systemic blood supply. The recipient bronchus receives an adequate blood supply directly from bronchial arteries, and the intrapulmonary bronchus is reasonably well served by pulmonary collaterals. The intervening portion of bronchus, including the anastomosis, is rendered critically ischemic for at least 12 days until revascularization occurs from the recipient bronchial arteries [4]. Introduction of the omentum as a vascularized pedicle to wrap around the bronchial anastomosis promotes early revascularization and anastomotic healing [5] and is now a routine practice in single-lung transplantation [6]. We describe a case of bronchial dehiscence that occurred despite bronchial omentopexy and that was successfully managed by prompt surgical intervention. A 54-year-old man with progressive cryptogenic fibrosing alveolitis, unresponsive to immunosuppressive therapy, was accepted for single-lung transplantation. Before transplantation, he was successfully weaned from steroid therapy. When a suitable donor became available, he underwent an uneventful single left lung transplantation without the need for cardiopulmonary bypass. Although he had previously undergone appendectomy for perforated appendicitis associated with generalized peritonitis, the dissected omental pedicle was believed to be satisfactory. The donor bronchus was trimmed two cartilage rings proximal to the upper lobe bronchus. Early lung function, assessed radiologically and by alveolar-arterial oxygen gradient, was excellent. The paAccepted for publication July 27, 1989 Address reprint requests to Dr Dark, Cardiopulmonary Transplant Unit, Freeman Hospital, Freeman Road, High Heaton, Newcastle upon Tyne NE7 7DN, England.
0 1990 by The Society of Thoracic Surgeons
anastomosis sited distally on the donor bronchus. The omentum was necrotic, and the new anastomosis was wrapped with a vascularized pedicle of pericardium. Six months after this procedure, the patient remains well. (Ann Thoruc Surg 1990;49:247-9)
tient was extubated 12 hours postoperatively and breathing room air by 72 hours with arterial oxygen tension of 12.4 kPa. On day 4, he suffered an acute dyspneic episode, associated with a decrease in oxygenation and with hemodynamic instability. Immediate transbronchial lung biopsy demonstrated histological evidence of both perivascular and bronchial rejection (Fig 1).The bronchial mucosa was edematous and inflamed, with fragments of necrotic slough in the mucosal biopsy specimen. He responded rapidly and completely to a three-day course of pulsed intravenous methylprednisolone (10 mg/ kg/day). Bronchoalveolar lavage excluded pulmonary infection. However, on day 9, he again became unwell, and chest radiography revealed an obvious pneumopericardium (Fig 2). Fiberoptic bronchoscopy showed circumferential necrosis 1cm long immediately distal to the anastomosis, although no perforation was observed. The patient underwent thoracotomy. The omental pedicle was dusky and loosely adherent. After removal of the omentum, the necrotic bronchus was excised and healthy bronchus was reanastomosed directly with interrupted polypropylene sutures. This suture line lay at the level of the bifurcation of the donor left main bronchus. Adequate oxygenation during this period of bronchial reconstruction was ensured by the use of high-frequency jet ventilation of the left lung in addition to intermittent positive-pressure ventilation of the right lung accomplished through a catheter passed down the left bronchial limb of the double-lumen endotracheal tube and across the anastomosis into the distal bronchial tree. Jet ventilation of one lung and conventional ventilation of the other has been described previously [7], and use of this technique avoided the need for cardiopulmonary bypass, which otherwise would have been essential. A vascularized flap of pericardium was wrapped around the new anastomosis. Fluid from pleural and pericardial cavities and from the mediastinum grew scanty amounts of Candida albicans but was otherwise sterile. 0003-4975/90/$3.50
148
CASE REPORT KIRK ET AL BRONCHIAL DEHISCENCE IN SLT
Ann Thorac Surg 1990;49147-9
The patient's clinical state allowed extubation 14 hours postoperatively. After operation, the patient made a slow but steady recovery and was discharged from the hospital 22 days later. Postoperative bronchoscopy demonstrated a patent airway with healthy bronchial mucosa in the region of the anastomosis. At follow-up 6 months later, the patient is fully rehabilitated and has excellent pulmonary function. Fiberoptic bronchoscopy was performed 5 months postoperatively after a temporary decrease in spirometry suggested lung rejection. The anastomosis was pink and well vascularized with no evidence of stenosis.
Comment The greater omentum is probably the ideal vascularized pedicle and has a role in a number of complex problems in the chest [8]. Its use has been crucial to the success of single-lung transplantation in the modern era [l].It is not an infallible guarantor of bronchial integrity, however, as demonstrated by this case. In particular, previous abdominal operation may make development of a suitable pedi-
A
B Fig 1. (A)A focus of periuascular Zymphocytic infiltration in lung parenchyma. (Hematoxylin and eosin, X400 before 41% reduction.) (B)Lymphocytic infiltration in bronchial muscle and subrnucosa. (Hematoxylin and eosin, X400 before 41% reduction.)
Fig 2. Chest roentgenogram shows pneumopericardium.
cle difficult or impossible. In addition, there is the risk of torsion and compression as the pedicle passes through the diaphragm. The already impaired bronchial healing after singlelung transplantation may be worsened by a mucosal inflammation that may accompany pulmonary rejection. Such a mechanism may have been important in our patient and has been suggested in another [2]. In the experimental situation, an intercostal muscle graft will ensure bronchial anastomotic integrity [9], and we have successfully used such a technique at retransplantation. The pericardial pedicle has also been described in this situation [lo] and was chosen for our patient because of easy availability. Both of these approaches may be applicable when the omentum is not available. We constructed the second anastomosis as close as possible to the lung parenchyma to ensure complete debridement of the necrotic segment. The donor bronchus at this site may receive perfusion from pulmonarybronchial collaterals [111, and there is direct experimental evidence that siting the anastomosis distally results in better healing [12]. Introduction of steroids at day 4 for the treatment of pulmonary rejection may have been an additional insult in our patient. Use of steroids at an early stage has been associated with impaired bronchial healing ~31. Although bronchial omentopexy is an important adjunct to single-lung transplantation, it is not infallible. Should it fail, rapid intervention, reanastomosis distally in the donor bronchus, and use of an intercostal or pericardial pedicle may permit salvage of the situation. These alternative techniques should be considered when omentum is not available.
Addendum The patient remains fit and well 15 months after operation.
Ann Thorac Surg 1990;49147-9
References 1. The Toronto Transplant Group. Experience with single-lung transplantation for pulmonary fibrosis. JAMA 1988;259: 2258-62. 2. The Toronto Lung Transplant Group. Unilateral lung transplantation for pulmonary fibrosis. N Engl J Med 1986;314: 1140-5. 3. Veith FJ. Symposium on organ transplantation-lung transplantation. Surg Clin North Am 1978;58:357-64. 4. Siegelman SS, Hagstrom JWC, Koerner SK, Veith FJ. Restoration of bronchial artery circulation after canine lung allotransplantation. J Thorac Cardiovasc Surg 1977;73:792-5. 5. Dubois P, Choiniere L, Cooper JD. Bronchial omentopexy in canine lung allotransplantation. Ann Thorac Surg 1984;38: 211-4. 6. Cooper JD, Pearson FG, Patterson GA, et al. Technique of successful lung transplantation in humans. J Thorac Cardiovasc Surg 1987;93:173-81. 7. Morgan BA, Perks D, Conacher ID, Paes ML. Combined uni-
CASE REPORT KIRK ET AL BRONCHIAL DEHISCENCE IN SLT
149
lateral high frequency jet ventilation and contralateral intermittent positive pressure ventilation. Anaesthesia 1987;42:975-9. 8. Mathisen DJ, Grillo HC, Vlahakes GJ, Daggett WM. The omentum in the management of complicated cardiothoracic problems. J Thorac Cardiovasc Surg 1988;95:677-84. 9. Fell SC, Mollenkopf PA-C, Montefusco CM, et al. Revascularisation of ischemic bronchial anastomoses by an intercostal pedicle flap. J Thorac Cardiovasc Surg 1985;90:172-8. 10. The Toronto Lung Transplant Group. Sequential bilateral lung transplantation for paraquat poisoning. J Thorac Cardiovasc Surg 1985;89:734-42. 11. Ladowski JS, Hardesty RL, Griffith BP. Pulmonary artery blood supply to the supracarinal trachea. Heart Transplant 1984;440-2. 12. Pinsker KL, Koerner SK, Kamholz SL, Hagstrom JWC, Veith FJ. Effect of donor bronchial length on healing. J Thorac Cardiovasc Surg 1979;77:669-73. 13. Lima 0, Cooper JD, Peters WJ, et al. Effects of methylprednisolone and azathioprine on bronchial healing following lung autotransplantation. J Thorac Cardiovasc Surg 1981; 82:211-5.
