after double lung transplantation. Endoscopic ...

Endoscopic management of bronchial stenosis after double lung transplantation. H G Colt, J P Janssen, J F Dumon and M J Noirclerc Chest 1992;102;10-16 DOI 10.1378/chest.102.1.10 The online version of this article, along with updated information and services can be found online on the World Wide Web at: http://chestjournal.chestpubs.org/content/102/1/10

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clinical investigations Endoscopic Management of Bronchial Stenosis after Double Lung Transplantation* Henri

Colt,

G.

M.D.

Jean-Francois

F.C. C.P;t

,

Dunwn,

M. D.

,

Julius F. C. C.P;

P Janssen, and

M.D.;t

Michelj

Noirclerc,

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 liberoptic and rigid bronchoscopy under general anesthesia in all patients. Since 1988, there were 24 double lung transplantations (mean age, 19 yr) performed at the

endobronchial

University

management

of

Marseille

Hospitals

without

omental

fibrosis; fibrosis

of the ten individuals

wrapping.

using

Nineteen

Jyuble

lung accepted

had

cystic

with

cystic

pulmonary

bronchial stenosis, six intervention including Five patients required

(DLT)

selected

disease

and

is increasingly

patients

satisfactory

with

end-stage

cardiac

function.

stents.

prolonged

nosis).

most

yr

of

level

young

in

patients

stenosis)

bronchoscopy

were

good,

of physical

A

activity was maintained familiar with all aspects of

team

is essential

DLT = double lung transplantation; RB= rigid bronchoscopy; RMB transbronchial biopsy

to ensure

in patients (Chest 1992;

complications

airway

cularized omentum and then others3’ sutures. Regardless

without

prior to transplant surgery developed ste-

before

bronchoscopy

of

risk

included

interventional

patients.

therapeutic

significant

narrowing

ventilation

ventilated

Results

and an excellent in

24.0

mechanical

(all five patients

Statistically

airway

transplantation.

patients

transplantation for

sutures

(53 percent)

who ultimately developed therapeutic endoscopic or Nd:YAG laser resection.

required dilatation

bilateral

silicone

factors for postsurgical age (mean, 14.3 yr vs and

DII

M.

proper

after lung 102:10-16)

LMB left main bronchus; right main bronchus; TBB

to protect the suture site.’ We2 have advocated bilateral bronchial of the surgical technique em-

Despite improvements in surgical technique, postoperative care, and immunosuppression, complications still occur. These usually include infection, obliterative

ployed, close is essential.

bronchiolitis, and newly transplanted

intervention. Clinical deterioration, pulmonary function abnormalities, or abnormal chest roentgenographic findings often require transbronchial biopsy

or bronchial lung

of

graft lungs

suture

dehiscence.

transplantation

vascularization lost continuity bronchial tracheal

rejection. may be been

techniques

Ischemia prompted

at the operators

(TBB)

by poor

hampered

of the airway anastomoses because between pulmonary, coronary,

circulations. anastomosis

transplantation

In addition, the subject to tracheal Surgical

have

of and

level of the to use vas-

Thoracic

Sainte tAssistant, Currently

the

Departments Surger);

Marguerite,

of Laser Marseille

CIIU

and Thoracic Lung

Transplant

Stid, Marseille,

Endoscpy Group,

and

of

H#{244}pital

France.

Centre Laser et Service d’Endoscpie Thoracique. Assistant Professor of Medicine, Pulmonary Division, University of California San Diego Medical Center. lVisiting Scholar, CHU Sud de Marseille (funded by Astra and Dc Dde Lichten, the Netherlands). §Chief, Centre Laser et Service d’Endosupie Thoracique. Professor ofThoracic Surger) Supprted in part by a grant from the Association Francaise de Lutte c()ntre Ia Mucwiscidose. Manuscript received June 12; revision accepted October 8. Reprint requests: Dr. Dumon, Association REEL, Hopital Ste Marguerite, 270 Bid de Ste Marguerite, !slarseiiie, France 13009

10

permits

diagnostic

or bronchoalveolar

section may form around

airway

injury

traumatic

cularization.

When

stent

report patients

were

and

a

granulomas which be subsequent to infection,

or bronchial

stenosis may

occurs,

devasinsertion

be desirable.6

At the

of Marseille, France, bronchoare performed in all patients with transplants at regular intervals when clinically indicated. Since 24 DLTs

anastomoses our

to confirm

inflammation,

bronchial

University Hospitals scopic examinations lung and heart-lung after surgery and there

from suctioning,

of an endobronchial

1988,

(BAL)

therapeutic

obliterative bronchiolitis, Bronchoscopic laser re-

be required to remove suture sites and may

repeatedly

bronchial

and

lavage

diagnosis of graft rejection, or opportunistic infections.5

prolonged *Fn)m

endoscopic surveillance ofairway sutures In addition, bronchoscopy after lung

experience describe Endoscopic

performed

without with

using

omental bronchial

our current Management


stenosis management

of Bronchial

bilateral

wrapping.

Stenosis

We in ten strat(Colt et a!)

for mechanical

egy

problems

airway

after

omental

transplan-

the

tation.

were

AND

MATERIALS

wrapping.7

second

METHODS

The

trachea

Twenty-four

patients

bronchial Nineteen had

silicosis,

one

had

immotile

one

and

recipients

and

elsewhere. basis.

are

thoracic

of the

had

into

have

and

and

or prolonged

donor’s

The

proximal

and

illness,

prophylaxis

donor’s

the

kg/day)

and

Acute

chronic

with

block

was

harvested,

separation

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 E1. In the recipient, bilateral pneumonectomies were performed through a median sternotomy or after transverse thoracotomy. En transplantation

using

a

of both

modification

bilateral,

of

end-to-end,

lungs

the

main-stem

was

performed

in

procedure”

Toronto

bronchial

14

First

Sex,

Day

Ding-

Loca-

Stenosis

(yr)

nosis

tiont

Diagnosed

1, F, 18

CF

L

Age

13

anastomoses

first

of

of

of

was treated (15

managed

were

CF

L

5

lobe

or were 1 cm

or

bronchus.

period.

Oral

mg/m’)

were

with

in

the

as much

intravenous

therapy

three

Patients

care

days.

unit.

healing,

as possible

Because

high-dose

in the

first

of

cortico-

14 days

days

after

or suspicion

and

of lung

were

copy

performed

was

bronchoscopy surgery

from

at the

after

with

Bronchial

were

intensive

care

and

Endoscopy

our protocol

Because

in the

by clinical

If patients the

Thoracic

Hospital.

was performed

indicated

rejection.

discharged

Marguerite

(FOB)

when

deterio-

transportable unit,

bronchos-

Laser

Center

for surveillance

Stenosis

o f Interventions Ultimate

‘

Dilatation

RBs

Only

7

31

4

0

(2 mg/

administered.

Surveillance fiberoptic

in Ten Thtients

FOBs

3

fluconazole

for

intensive

narrow-

determined

also

pulsed

bronchial

and

patterns

mg/kg/day)

with

avoided

or if they ofSaint

interventions

No.

rejection

interference

ten

ration

without

No.

to 3,000

Laser Only 6

Bronchial Stent 16

Immediate

Final

Result$

0

0

0

Cause

Outcome*

Unsatis-

of Death*

Alive,

NA

day 625

factory 2, F, 9

thoracotomies

was performed

upper

sensitivity

preoperative (800

initially

Flexible

No.

Patient,

the

was

anastomoses

of broad-spectrum

on

acyclovir

Bronchoscopic

patients

consisting

Table 1-Bro,schoscopic

over

operation.

of

the

bloc

based

immediate

lung

were

with

separate

left

to

reimplantation

bronchial

anastomosis ofthe

methyiprednisolone

steroids

heart-lung

in order Peribronchial

stitched

sequential case,

recipient’s

dissected,

subsequently

consisted

antibiotics

during

ventila-

Technique

The

bronchial

to the orifice

running

The

Management

suspected Surgical

left

first.

hardly

through

In this

beyond

anastomoses

vascularization.

lungs patients

extrahilar.

Antibiotic

even

mechanical

with severe underlying respiratory distress.

ten

thoracotomy.

spectrum

thoracic

is considered

patients

in

were

was Bilateral

donor’s

Postoperative

a case-by-

cytomegalothe

bronchi

divided

monofilament

transplanted

peribronchiolar

transverse less

was

anastomoses.

were bronchial

described

on

recipient’s

to match

Transplantation

thoracotomy,

or terminal

been

recipients

the

performed

of donors

Age and donor-recipient

consideration

volumes.

bronchiectasis,

of

bronchi

Extramucosal nonabsorbable,

lung

preserve

bronchial

1991. obliterans,

for selection

for

tissue

in

bilateral

February

one

donor’s

is accepted.

and in high-risk

infection,

examined

and

bronchiolitis

procedure

surgical

are

DLTWith

had

for the

taken

tracheotomy,

tion,

one

Criteria

serology

recipient’s

(CF),

ranging

patients)

1988

September

emphysema,

Mismatching

perimeters after

had

14 female

10 yr) underwent

cilia syndrome.

Indications

virus (CMV)

and

19±

sutures between had cystic fibrosis

one

case

(10 male

7 to 55 yr (mean,

right

and the donor’s

maximally

age from

recipient’s ring.

with single,

performed

sutures.

Patients

The

cartilaginous

NA

Died,

Lung

rejection

day 35 3, M, 22

CF

44

L

5

10

0

1

3

Excellent

Died,

OB;

day 360 4, F, 13

CF

L

294

4

5

0

0

0

NA

Alive,

failure

of

retransplantation NA

day 369 5, F, 10

OB

13

R+L

7

3

0

0

2

Excellent

Alive,

NA

day 254 CF

6,F,9

L

21

7

14

1

0

2

Good

Alive,

NA

day 387 7,

CF

F, 7

73

R+L

4

23

11

2

4

Unsatis-

Died,

Failure

day 446

factory

of

surgical

re-

anastomosis 8,F,18

CF

L

7

14

0

0

0

0

NA

Died,

Suturedehis-

day45 9, M,

15

CF

M, 22

CF

22

L

6

7

0

0

0

NA

Alive,

6

6

1

0

0

Good

Alive,

cence NA

day 236 10,

R+

L

136

NA

day

Total SOB tMain NA=

.

=oblit

.

erative

.

.

.

.

.

60

.

102

17

9

27

.

.

.

.

.

.

...

bronchiolitis.

bronchial suture not applicable.

§OutcomeasofMarch

.

271

left (L) or right

(R).

1, 1991.

CHEST


I

102

I I I JULY,

1992

11

also

iticl,ides

Aftrr to

(.)lor

inttihation

fl(’Xil)lt’

hroichoscop (RB) tinder geiwral

fIU)flthlV

ngi(l hn)gldu)sc01)v i(ltOtaped, all1 fiheroptic

t)l)taifl

photographs

tfl(l specimens

or

below

(OI)siste(l

of

dilatation,

( Nd:YAG)

laser

(lehIIt’(l

The

.

bronchoscope.

Ofll\

if

tubes

had

of incre’asing

diameter

I15(’(l to pn)gressively granuloinas,

br.iies,

using

standard

lase

or

25(X)).

\Vlieim

or suture

through

rigi(l

nunber

of bronchoscopics,

vention

in

Statistic

Auaiisis

Life

itlm

tal)les

BMDP and

I)atits

afl(l

statistics Fishers

significance

was

were

used

the 24 patients ten sequential)

Among

and

tures

at

patients

the

in eight. days

As of March

(range,

bronchial

1

stenosis

for ten patients with of bronchial stenosis. formed in five patients

240

of patients stenosis and

with (p