A 19-year-old female, with an end-stage obstructive pulmonary disease, subsequent to childhood pulmonary viral infection, underwent bilateral lung transplantation. Owing to a congenital deformity of the left chest wall, complete right lung transplantation and only a left lower lobar transplantation were carried out. All anastomoses were performed by using running or uninterrupted Prolene 4/0 sutures. Both the recipient and donor bronchi were trimmed following standard procedures. The postoperative course was satisfactory and the patient was discharged from hospital 3 weeks later with 58% forced expiratory volume in first second (FEV1).
Two months after operation, 2 nonanastomotic stenoses were detected, 1 in the bronchus intermedius (BI) and another in the left main bronchus with 42% FEV1. The left stenosis was successfully treated by dilatation and Dumon stent (Bryan Corporation, Boston, USA) placement. The BI stenosis being incomplete, repeated dilatations were carried out with good results.
At 15 months after transplantation, the BI stenosis worsened and led to complete obstruction. The lower and middle lobes had collapsed. FEV1 decreased to 34%. A laser photoresection was attempted as the only possible option to perform additional dilatations and stent placement at a later stage. Despite these attempts, the obstruction remained unchanged, thus making it impossible and dangerous to pass a guide wire through the strictured area for a stent placement (Fig. 1). At that stage, it was deemed appropriate to carry out a sleeve resection of the BI.
A posterolateral thoracotomy was performed using intubation with double lumen tube. Dense pleural and mediastinal adhesions made the dissection difficult. The lung was mobilized in its entirety. Both the upper lobe bronchus and the BI were identified. The right pulmonary artery was secured at its base. A significant fibrosis between the middle lobar artery and the BI was found; therefore, a sleeve resection was technically impossible.
At this stage, BI was opened longitudinally using bronchoscopic guidance to localize proximal end of the stenosis. A partial debulking of the endobronchial fibrotic segment inside stenosis was carried out, while conserving airway wall. A 9 mm in diameter Dumon stent was inserted to obtain a better caliber airway. A bronchoplastic closure was carried out using interrupted Prolene 4/0. Before extubation, a flexible bronchoscopy was performed to confirm appropriate position of the stent.
The postoperative course, as gauged by flexible bronchoscopy and computerized tomography scanning, was satisfactory. One month after the procedure, the stent migrated distally, yet lumen of the BI was not compromised (Fig. 2). There were no symptoms associated with this complication and the FEV1 was maintained at 45%. We removed the stent 3 months after its placement, and at 8 months after the lung transplantation. The patient continues to lead a normal life.
Nonanastomotic stenoses after lung transplantations are rare and should be assessed separately from anastomotic stenoses.1 Hasegawa et al2 reported that among 246 lung transplantations, distal nonanastomotic stenoses developed in 6 patients (2.5%). Date et al3 found among 229 reported, 1 recalcitrant bronchus intermedius stenosis.
So far, pathogenesis of nonanastomotic stenoses has not been clearly defined. However, some hypotheses seem to highlight their individual or coercive causes: alloreactive injury, ischemic damage, and infection.4
While harvesting the donor lung, bronchial arterial circulation is lost. Rearterialization of the donor graft through the recipient bronchial arteries requires 3 to 4 weeks.5 Immediately after transplantation, the viability of the donor bronchus depends on the low-pressure, poorly oxygenated blood supply from the pulmonary circulation.6
The traditional treatment of bronchial nonanastomotic stenoses has already been well described. Balloon dilatation and a stent placement are often effective singly or in combination.7 In general, these conservative treatments are used for airway stenoses with reasonably good results.1,2,7 Bronchial sleeve resection is also a viable option8 in a selected group of patients. In our case, balloon dilatation was carried out with immediate satisfactory results and stent placement was deemed unnecessary. Eventually, however, complete obstruction of BI was discovered. At this stage, laser photoresection was the only viable option.
When the standard treatments failed and as the significant fibrotic reaction prevented the sleeve resection, we considered debulking of the endobrachial scar tissue using bronchoscopic guidance along with placement of a stent.
We believe that nonanastomotic stenosis of BI after lung transplantation is under reported. Our approach may provide an appropriate option if other less invasive treatments fail.
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