bronchomalacia. (Fig. 1) in three pa- tients, and was bilateral inthree. Five patients did not require therapeutic intervention with laser resection or stenting. Five.
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
Chest is the official journal of the American College of Chest Physicians. It has been published monthly since 1935. Copyright1992by the American College of Chest Physicians, 3300 Dundee Road, Northbrook, IL 60062. All rights reserved. No part of this article or PDF may be reproduced or distributed without the prior written permission of the copyright holder. (http://chestjournal.chestpubs.org/site/misc/reprints.xhtml) ISSN:0012-3692
Downloaded from chestjournal.chestpubs.org by guest on July 10, 2011 © 1992 American College of Chest Physicians
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
Downloaded from chestjournal.chestpubs.org by guest on July 10, 2011 © 1992 American College of Chest Physicians
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
Downloaded from chestjournal.chestpubs.org by guest on July 10, 2011 © 1992 American College of Chest Physicians
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