1
|
Tian D, Zuo YJ, Yan HJ, Huang H, Liu MZ, Yang H, Zhao J, Shi LZ, Chen JY. Machine learning model predicts airway stenosis requiring clinical intervention in patients after lung transplantation: a retrospective case-controlled study. BMC Med Inform Decis Mak 2024; 24:229. [PMID: 39160522 PMCID: PMC11331769 DOI: 10.1186/s12911-024-02635-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Accepted: 08/14/2024] [Indexed: 08/21/2024] Open
Abstract
BACKGROUND Patients with airway stenosis (AS) are associated with considerable morbidity and mortality after lung transplantation (LTx). This study aims to develop and validate machine learning (ML) models to predict AS requiring clinical intervention in patients after LTx. METHODS Patients who underwent LTx between January 2017 and December 2019 were reviewed. The conventional logistic regression (LR) model was fitted by the independent risk factors which were determined by multivariate LR. The optimal ML model was determined based on 7 feature selection methods and 8 ML algorithms. Model performance was assessed by the area under the curve (AUC) and brier score, which were internally validated by the bootstrap method. RESULTS A total of 381 LTx patients were included, and 40 (10.5%) patients developed AS. Multivariate analysis indicated that male, pulmonary arterial hypertension, and postoperative 6-min walking test were significantly associated with AS (all P < 0.001). The conventional LR model showed performance with an AUC of 0.689 and brier score of 0.091. In total, 56 ML models were developed and the optimal ML model was the model fitted using a random forest algorithm with a determination coefficient feature selection method. The optimal model exhibited the highest AUC and brier score values of 0.760 (95% confidence interval [CI], 0.666-0.864) and 0.085 (95% CI, 0.058-0.117) among all ML models, which was superior to the conventional LR model. CONCLUSIONS The optimal ML model, which was developed by clinical characteristics, allows for the satisfactory prediction of AS in patients after LTx.
Collapse
Affiliation(s)
- Dong Tian
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China.
- Wuxi Lung Transplant Center, Wuxi People's Hospital affiliated to Nanjing Medical University, Wuxi, 214023, China.
| | - Yu-Jie Zuo
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
- Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, China
| | - Hao-Ji Yan
- Department of General Thoracic Surgery, Juntendo University School of Medicine, Tokyo, 113-8431, Japan
| | - Heng Huang
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Ming-Zhao Liu
- Wuxi Lung Transplant Center, Wuxi People's Hospital affiliated to Nanjing Medical University, Wuxi, 214023, China
| | - Hang Yang
- Wuxi Lung Transplant Center, Wuxi People's Hospital affiliated to Nanjing Medical University, Wuxi, 214023, China
| | - Jin Zhao
- Wuxi Lung Transplant Center, Wuxi People's Hospital affiliated to Nanjing Medical University, Wuxi, 214023, China
| | - Ling-Zhi Shi
- Wuxi Lung Transplant Center, Wuxi People's Hospital affiliated to Nanjing Medical University, Wuxi, 214023, China.
| | - Jing-Yu Chen
- Wuxi Lung Transplant Center, Wuxi People's Hospital affiliated to Nanjing Medical University, Wuxi, 214023, China.
| |
Collapse
|
2
|
Li G, Liu Z, Salan-Gomez M, Keeney E, D’Silva E, Mankidy B, Leon A, Mattar A, Elsennousi A, Coster J, Kumar A, Rodrigues B, Li M, Shafii A, Garcha P, Loor G. Risk Factors, Incidence, and Outcomes Associated With Clinically Significant Airway Ischemia. Transpl Int 2024; 37:12751. [PMID: 38800671 PMCID: PMC11119282 DOI: 10.3389/ti.2024.12751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 04/10/2024] [Indexed: 05/29/2024]
Abstract
Airway complications following lung transplantation remain an important cause of morbidity and mortality. We aimed to identify the incidence, risk factors and outcomes associated with clinically significant airway ischemia (CSAI) in our center. We reviewed 217 lung transplants (386 airway anastomoses) performed at our institution between February 2016 and December 2020. Airway images were graded using the 2018 ISHLT grading guidelines modified slightly for retrospective analysis. Airways were considered to have CSAI if they developed ischemia severity >B2, stenosis >50%, and/or any degree of dehiscence within 6-months of transplant. Regression analyses were used to evaluate outcomes and risk factors for CSAI. Eighty-two patients (37.8%) met criteria for CSAI. Of these, twenty-six (32%) developed stenosis and/or dehiscence, and 17 (21%) required interventions. Patients with CSAI had lower one-year (80.5% vs. 91.9%, p = 0.05) and three-year (67.1% vs. 77.8%, p = 0.08) survival than patients without CSAI. Factors associated with CSAI included younger recipient age, recipient diabetes, single running suture technique, performance of the left anastomosis first, lower venous oxygen saturation within 48-h, and takeback for major bleeding. Our single-center analysis suggests that airway ischemia remains a major obstacle in contemporary lung transplantation. Improving the local healing milieu of the airway anastomosis could potentially mitigate this risk.
Collapse
Affiliation(s)
- Gloria Li
- Department of Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Zejian Liu
- Department of Statistics, Rice University, Houston, TX, United States
| | - Marcelo Salan-Gomez
- Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Emma Keeney
- Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Ethan D’Silva
- Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Babith Mankidy
- Department of Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Andres Leon
- Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Aladdein Mattar
- Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | | | - Jennalee Coster
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Anupam Kumar
- Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Bruno Rodrigues
- Department of Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Meng Li
- Department of Statistics, Rice University, Houston, TX, United States
| | - Alexis Shafii
- Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Puneet Garcha
- Department of Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Gabriel Loor
- Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| |
Collapse
|
3
|
Ruiz E, Fernández AM, Párraga JL, Cantador B, Salvatierra Á, Álvarez A. Surgical Complications After Lung Transplantation: The Reina Sofía Hospital Experience. Transplant Proc 2023; 55:2289-2291. [PMID: 37798165 DOI: 10.1016/j.transproceed.2023.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 08/29/2023] [Indexed: 10/07/2023]
Abstract
OBJECTIVE To assess the incidence of surgical complications after lung transplantation and its influence on early mortality and long-term survival. METHODS Retrospective review of 792 lung transplants (LTs) performed from 1994 to 2022. Among them, 769 with complete data were selected. Patients with and without surgical complications were compared by univariable and multivariable analyses. RESULTS There were 385 single LTs (50%), 371 double LTs (48%), 8 bilobar LTs (1%), and 5 combined liver LTs (1%). Two hundred forty-nine patients presented surgical complications (32%) as follows: bronchial (n = 61), vascular (n = 55), pneumothorax (n = 33), and phrenic nerve palsy (n = 22). Thirty-day mortality (noncomplicated vs complicated) was 57 (41%) vs 80 (59%), P < .001. Transplants for bronchiectasis (58%), pulmonary hypertension (50%), and re-transplants (78%) presented more surgical complications (P < .001). Double LT (40%), bilobar LT (88%), and combined liver LT (100%) presented more surgical complications (P < .001). Complicated recipients were younger (49 ± 15 vs 45 ± 17 years; P = .001), with longer ischemic times (429 ± 67 vs 450 ± 76 min [2nd graft]; P = .007), and required extracorporeal support (ECLS) more often (43% vs 57%; P < .001). Survival at 1, 5, 10, 15, and 20 years (noncomplicated vs complicated): 78%, 63%, 52%, 41%, 31% vs 52%, 42%, 35%, 26%, 22%; P < .001). Predictors of mortality were the need for ECLS (odds ratio [OR] 4.14; P < .001), postoperative ventilation (hours) (OR 1.01; P < .001), and vascular complications (OR 4.78; P < .001). CONCLUSION Surgical complications remain an important source of morbidity and mortality after lung transplantation. Complex surgical procedures requiring ECLS develop frequent surgical complications needing long postoperative ventilation that are associated with early mortality and poorer long-term survival.
Collapse
Affiliation(s)
- Eloísa Ruiz
- Department of Thoracic Surgery and Lung Transplantation, University Hospital Reina Sofía, Córdoba, Spain; Maimónides Biomedical Research Institute of Córdoba, University of Córdoba, Spain
| | - Alba María Fernández
- Department of Thoracic Surgery and Lung Transplantation, University Hospital Reina Sofía, Córdoba, Spain; Maimónides Biomedical Research Institute of Córdoba, University of Córdoba, Spain
| | - Juan Luis Párraga
- Department of Thoracic Surgery and Lung Transplantation, University Hospital Reina Sofía, Córdoba, Spain; Maimónides Biomedical Research Institute of Córdoba, University of Córdoba, Spain
| | - Benito Cantador
- Department of Thoracic Surgery and Lung Transplantation, University Hospital Reina Sofía, Córdoba, Spain; Maimónides Biomedical Research Institute of Córdoba, University of Córdoba, Spain
| | - Ángel Salvatierra
- Department of Thoracic Surgery and Lung Transplantation, University Hospital Reina Sofía, Córdoba, Spain; Maimónides Biomedical Research Institute of Córdoba, University of Córdoba, Spain
| | - Antonio Álvarez
- Department of Thoracic Surgery and Lung Transplantation, University Hospital Reina Sofía, Córdoba, Spain; Maimónides Biomedical Research Institute of Córdoba, University of Córdoba, Spain.
| |
Collapse
|
4
|
van Pel R, Gan CT, van der Bij W, Verschuuren EAM, van Gemert JPA, Van De Wauwer C, Erasmus ME, Slebos DJ. Three Decades Single Center Experience of Airway Complications After Lung Transplantation. Transpl Int 2023; 36:11519. [PMID: 37908674 PMCID: PMC10613691 DOI: 10.3389/ti.2023.11519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 10/02/2023] [Indexed: 11/02/2023]
Abstract
Post lung transplantation airway complications like necrosis, stenosis, malacia and dehiscence cause significant morbidity, and are most likely caused by post-operative hypo perfusion of the anastomosis. Treatment can be challenging, and airway stent placement can be necessary in severe cases. Risk factors for development of airway complications vary between studies. In this single center retrospective cohort study, all lung transplant recipients between November 1990 and September 2020 were analyzed and clinically relevant airway complications of the anastomosis or distal airways were identified and scored according to the ISHLT grading system. We studied potential risk factors for development of airway complications and evaluated the impact on survival. The treatment modalities were described. In 651 patients with 1,191 airway anastomoses, 63 patients developed 76 clinically relevant airway complications of the airway anastomoses or distal airways leading to an incidence of 6.4% of all anastomoses, mainly consisting of airway stenosis (67%). Development of airway complications significantly affects median survival in post lung transplant patients compared to patients without airway complication (101 months versus 136 months, p = 0.044). No significant risk factors for development of airway complication could be identified. Previously described risk factors could not be confirmed. Airway stents were required in 55% of the affected patients. Median survival is impaired by airway complications after lung transplantation. In our cohort, no significant risk factors for the development of airway complications could be identified.
Collapse
Affiliation(s)
- R. van Pel
- Department of Respiratory Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
- Department of Respiratory Medicine, Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands
- Erasmus MC Transplant Institute, Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands
| | - C. T. Gan
- Department of Respiratory Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - W. van der Bij
- Department of Respiratory Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - E. A. M. Verschuuren
- Department of Respiratory Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - J. P. A. van Gemert
- Department of Respiratory Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - C. Van De Wauwer
- Department of Cardio-Thoracic Surgery, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - M. E. Erasmus
- Department of Cardio-Thoracic Surgery, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - D. J. Slebos
- Department of Respiratory Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| |
Collapse
|
5
|
Huang J, Lin J, Zheng Z, Liu Y, Lian Q, Zang Q, Huang S, Guo J, Ju C, Zhong C, Li S. Risk factors and prognosis of airway complications in lung transplant recipients: A systematic review and meta-analysis. J Heart Lung Transplant 2023; 42:1251-1260. [PMID: 37088339 DOI: 10.1016/j.healun.2023.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 03/22/2023] [Accepted: 04/13/2023] [Indexed: 04/25/2023] Open
Abstract
BACKGROUND Airway complications (AC) are one of leading causes of morbidity and mortality after lung transplant (LTx), but their predictors and outcomes remain controversial. This study aimed to identify potential risk factors and prognosis of AC. METHODS A systematic review was performed by searching PubMed, Embase, and Cochrane Library. All observational studies reporting outcome and potential factors of AC after LTx were included. The incidence, mortality, and estimated effect of each factor for AC were pooled by using the fixed-effects model or random-effects model. RESULTS Thirty-eight eligible studies with 52,116 patients undergoing LTx were included for meta-analysis. The pooled incidence of AC was 12.4% (95% confidence interval [CI] 9.5-15.8) and the mean time of occurrence was 95.6 days. AC-related mortality rates at 30-days, 90-days, 6 months, 1 year, and 5 years were 6.7%, 17.9%, 18.2%, 23.6%, and 66.0%, respectively. Airway dehiscence was the most severe type with a high mortality at 30 days (60.9%, 95% CI 20.6-95.2). We found that AC was associated with a higher risk of mortality in LTx recipients (hazard ratio [HR] 1.71, 95% CI 1.04-2.81). Eleven significant predictors for AC were also identified, including male donor, male recipient, diagnosis of COPD, hospitalization, early rejection, postoperative infection, extracorporeal membrane oxygenation, mechanical ventilation, telescopic anastomosis, and bilateral and right-sided LTx. CONCLUSION AC was significantly associated with higher mortality after LTx, especially for dehiscence. Targeted prophylaxis for modifiable factors and enhanced early bronchoscopy surveillance after LTx may improve the disease burden of AC.
Collapse
Affiliation(s)
- Junfeng Huang
- Department of Respiratory and Critical Care Medicine, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Jinsheng Lin
- Department of Respiratory and Critical Care Medicine, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Ziwen Zheng
- Department of Respiratory and Critical Care Medicine, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China; Department of Respiratory and Critical Care Medicine, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Yuheng Liu
- Department of Respiratory and Critical Care Medicine, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China; Department of Respiratory and Critical Care Medicine, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Qiaoyan Lian
- Department of Respiratory and Critical Care Medicine, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Qing Zang
- Department of Respiratory and Critical Care Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Song Huang
- Department of Respiratory and Critical Care Medicine, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Jiaming Guo
- Department of Respiratory and Critical Care Medicine, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China; Department of Respiratory and Critical Care Medicine, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Chunrong Ju
- Department of Respiratory and Critical Care Medicine, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China.
| | - Changhao Zhong
- Department of Respiratory and Critical Care Medicine, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China.
| | - Shiyue Li
- Department of Respiratory and Critical Care Medicine, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China.
| |
Collapse
|
6
|
Muñoz-Fos A, Moreno P, González FJ, Ruiz E, Vaquero JM, Baamonde C, Cerezo F, Algar J, Ramos-Izquierdo R, Salvatierra Á, Alvarez A. Airway Complications after Lung Transplantation-A Contemporary Series of 400 Bronchial Anastomoses from a Single Center. J Clin Med 2023; 12:jcm12093061. [PMID: 37176502 PMCID: PMC10179286 DOI: 10.3390/jcm12093061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 04/12/2023] [Accepted: 04/20/2023] [Indexed: 05/15/2023] Open
Abstract
(1) Objective: To determine whether recent advances in lung transplantation (LT) have reduced the incidence and changed the risk factors for airway complications (AC). (2) Methods: Retrospective analysis of patients receiving a lung transplant between January 2007 and January 2019. An AC was defined as a bronchoscopic abnormality in the airway, either requiring or not requiring an endoscopic or surgical intervention. Both univariable and multivariable analyses were performed to identify risk factors for AC. (3) Results: 285 lung transplants (170 single and 115 bilateral lung transplants) were analysed, comprising 400 anastomoses at risk. A total of 50 anastomoses resulted in AC (12%). There were 14 anastomotic and 11 non-anastomotic stenoses, 4 dehiscences, and 3 malacias. Independent predictors for AC were: gender male (OR: 4.18; p = 0.002), cardiac comorbidities (OR: 2.74; p = 0.009), prolonged postoperative mechanical ventilation (OR: 2.5; p = 0.02), PaO2/FiO2 < 300 mmHg at 24 h post-LT (OR: 2.48; p = 0.01), graft infection (OR: 2.16; p = 0.05), and post-LT isolation of Aspergillus spp. (OR: 2.63; p = 0.03). (4) Conclusions: In spite of advances in lung transplantation practice, the risk factors, incidence, and lethality of AC after LT remains unchanged. Graft dysfunction, an infected environment, and the need of prolonged mechanical ventilation remain an Achilles heel for AC.
Collapse
Affiliation(s)
- Anna Muñoz-Fos
- Department of Thoracic Surgery, Bellvitge University Hospital, 08907 Barcelona, Spain
| | - Paula Moreno
- Department of Thoracic Surgery and Lung Transplantation, University Hospital Reina Sofía, 14004 Córdoba, Spain
| | - Francisco Javier González
- Department of Thoracic Surgery and Lung Transplantation, University Hospital Reina Sofía, 14004 Córdoba, Spain
| | - Eloisa Ruiz
- Department of Thoracic Surgery and Lung Transplantation, University Hospital Reina Sofía, 14004 Córdoba, Spain
| | - Jose Manuel Vaquero
- Department of Pulmonology and Lung Transplantation, University Hospital Reina Sofía, 14004 Córdoba, Spain
| | - Carlos Baamonde
- Department of Thoracic Surgery and Lung Transplantation, University Hospital Reina Sofía, 14004 Córdoba, Spain
| | - Francisco Cerezo
- Department of Thoracic Surgery and Lung Transplantation, University Hospital Reina Sofía, 14004 Córdoba, Spain
| | - Javier Algar
- Department of Thoracic Surgery and Lung Transplantation, University Hospital Reina Sofía, 14004 Córdoba, Spain
| | - Ricard Ramos-Izquierdo
- Department of Thoracic Surgery, Bellvitge University Hospital, 08907 Barcelona, Spain
- Department of Pathology and Experimental Therapeutics, University of Barcelona, 08036 Barcelona, Spain
| | - Ángel Salvatierra
- Department of Thoracic Surgery and Lung Transplantation, University Hospital Reina Sofía, 14004 Córdoba, Spain
| | - Antonio Alvarez
- Department of Thoracic Surgery and Lung Transplantation, University Hospital Reina Sofía, 14004 Córdoba, Spain
| |
Collapse
|
7
|
Avasarala SK, Dutau H, Mehta AC. Forbearance with endobronchial stenting: cognisance before conviction. Eur Respir Rev 2023; 32:32/167/220189. [PMID: 36889785 PMCID: PMC10032587 DOI: 10.1183/16000617.0189-2022] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 01/13/2023] [Indexed: 03/10/2023] Open
Abstract
Endobronchial stenting is an important aspect of the practice of interventional pulmonology. The most common indication for stenting is the management of clinically significant airway stenosis. The list of endobronchial stents available on the market continues to grow. More recently, patient-specific 3D-printed airway stents have been approved for use. Airway stenting should be considered only when all other options have been exhausted. Due to the environment of the airways and the stent-airway wall interactions, stent-related complications are common. Although stents can be placed in various clinical scenarios, they should only be placed in scenarios with proven clinical benefit. The unwarranted placement of a stent can expose the patient to complications with little or no clinical benefit. This article reviews and outlines the key principles of endobronchial stenting and important clinical scenarios in which stenting should be avoided.
Collapse
Affiliation(s)
- Sameer K Avasarala
- Division of Pulmonary, Critical Care, and Sleep Medicine, University Hospitals - Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Hervé Dutau
- Thoracic Oncology, Pleural Disease and Interventional Pulmonology Department, North University Hospital, Marseille, France
| | - Atul C Mehta
- Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
8
|
Wang Z, Zhao B, Deng M, Tong R, Bian Y, Zhang Q, Hou G. Utility and safety of airway stenting in airway stenosis after lung transplant: A systematic review. Front Med (Lausanne) 2023; 10:1061447. [PMID: 36968822 PMCID: PMC10034355 DOI: 10.3389/fmed.2023.1061447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 02/20/2023] [Indexed: 03/11/2023] Open
Abstract
BackgroundAirway complications seriously affect the clinical outcomes and long-term prognosis of lung-transplantation patients. Airway stenting provides effective palliation for patients with airway stenosis. However, a lack of consensus regarding the efficacy and safety of airway stents in airway stenosis after lung transplantation. This study critically evaluated all available evidence regarding this concern.MethodsWe retrieved studies from EMBASE, PubMed, and Cochrane Library databases. Studies were included if they reported baseline characteristics of airway complications after lung transplantation, stenting for airway stenosis, or prognosis.ResultsIn total, 279 papers were screened and 17 papers were included in final analysis. The short-term efficacy of airway stenting was assessed in almost all studies, with immediate palliation in symptom and improved pulmonary function reported. Eleven of the included studies evaluated the long-term efficacy of stent therapy, with no distinct lung function. The median overall survival time was 1,124 (95% confidence interval 415–1,833) days in stented patients only. Stent-related complications are common regardless of the material; However, serious complications are rare and can be improved with routine management.ConclusionWe demonstrated that airway stenting is a safe and effective method to treat airway stenosis after lung transplantation. The short-term effect was significant, while the long-term efficacy on survival rate needed further investigations.Systematic review registrationwww.crd.york.ac.uk/prospero/, identifier: CRD42022364427.
Collapse
Affiliation(s)
- Zilin Wang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Center for Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Bo Zhao
- Department of Pulmonary and Critical Care Medicine, Shengjing Hospital of China Medical University, Shenyang, China
| | - Mingming Deng
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Center for Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Run Tong
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Center for Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Yiding Bian
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Center for Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Qin Zhang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Center for Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Gang Hou
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Center for Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
- *Correspondence: Gang Hou
| |
Collapse
|
9
|
Mohanka M, Banga A. Alterations in Pulmonary Physiology with Lung Transplantation. Compr Physiol 2023; 13:4269-4293. [PMID: 36715279 DOI: 10.1002/cphy.c220008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Lung transplant is a treatment option for patients with end-stage lung diseases; however, survival outcomes continue to be inferior when compared to other solid organs. We review the several anatomic and physiologic changes that result from lung transplantation surgery, and their role in the pathophysiology of common complications encountered by lung recipients. The loss of bronchial circulation into the allograft after transplant surgery results in ischemia-related changes in the bronchial artery territory of the allograft. We discuss the role of bronchopulmonary anastomosis in blood circulation in the allograft posttransplant. We review commonly encountered complications related to loss of bronchial circulation such as allograft airway ischemia, necrosis, anastomotic dehiscence, mucociliary dysfunction, and bronchial stenosis. Loss of dual circulation to the lung also increases the risk of pulmonary infarction with acute pulmonary embolism. The loss of lymphatic drainage during transplant surgery also impairs the management of allograft interstitial fluid, resulting in pulmonary edema and early pleural effusion. We discuss the role of lymphatic drainage in primary graft dysfunction. Besides, we review the association of late posttransplant pleural effusion with complications such as acute rejection. We then review the impact of loss of afferent and efferent innervation from the allograft on control of breathing, as well as lung protective reflexes. We conclude with discussion about pulmonary function testing, allograft monitoring with spirometry, and classification of chronic lung allograft dysfunction phenotypes based on total lung capacity measurements. We also review factors limiting physical exercise capacity after lung transplantation, especially impairment of muscle metabolism. © 2023 American Physiological Society. Compr Physiol 13:4269-4293, 2023.
Collapse
Affiliation(s)
- Manish Mohanka
- Pulmonary and Critical Care Medicine, University of Texas Southwestern, Dallas, Texas, USA
| | - Amit Banga
- Pulmonary and Critical Care Medicine, Stanford University School of Medicine, Stanford, California, USA
| |
Collapse
|
10
|
Incidence, risk factors, and clinical characteristics of airway complications after lung transplantation. Sci Rep 2023; 13:667. [PMID: 36635329 PMCID: PMC9837050 DOI: 10.1038/s41598-023-27864-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 01/09/2023] [Indexed: 01/14/2023] Open
Abstract
Airway complications may occur after lung transplantation and are associated with considerable morbidity and mortality. We investigated the incidence, risk factors, and clinical characteristics of these complications. We retrospectively reviewed the medical records of 137 patients who underwent lung transplantation between 2008 and 2021. The median follow-up period was 20 months. Of the 137 patients, 30 (21.9%) had postoperative airway complications, of which 2 had two different types of airway complications. The most common airway complication was bronchial stenosis, affecting 23 patients (16.8%). Multivariable Cox analysis revealed that a recipient's body mass index ≥ 25 kg/m2 (hazard ratio [HR], 2.663; p = 0.013) was a significant independent risk factor for airway complications, as was postoperative treatment with extracorporeal membrane oxygenation (ECMO; HR, 3.340; p = 0.034). Of the 30 patients who had airway complications, 21 (70.0%) were treated with bronchoscopic intervention. Survival rates did not differ significantly between patients with and without airway complications. Thus, our study revealed that one fifth of patients who underwent lung transplantation experienced airway complications during the follow-up period. Obesity and receiving postoperative ECMO are risk factors for airway complications, and close monitoring is warranted in such cases.
Collapse
|
11
|
Gottlieb J, Fuehner T, Zardo P. Management and outcome of obstructive airway complications after lung transplantation - a 12-year retrospective cohort study. Ther Adv Respir Dis 2023; 17:17534666231181541. [PMID: 37526226 PMCID: PMC10395170 DOI: 10.1177/17534666231181541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 05/26/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND Obstructive airway complications (OACs) represent a significant problem after lung transplantation (LTx). Bilateral OACs after double lung transplantation are infrequently reported. OBJECTIVES The aim of this study was to investigate management and outcome of OAC. DESIGN Retrospective single-center cohort study. METHODS Adult patients with bilateral LTx performed between 2010 and 2021 were included. Patients with follow-ups of less than 3 months and after heart-lung transplantation were excluded. OAC was defined either as the need for stenting, surgical revision, or balloon dilatation. Outcome parameters included graft survival, graft function, quality of life, and management. RESULTS During the study period, 1,170 patients were included. Hundred thirty-five (11.5%) patients developed OAC. Forty-six (4.4%) patients had significant bilateral OAC. Thirty-seven (80%) bilateral OAC patients were treated by stent insertion; in 34 patients, biodegradable stents were used. The median number of bronchoscopies in bilateral OAC was 26 during the first postoperative year compared with nine in controls (p < 0.001). Fourteen OAC patients (n = 10 bilateral) underwent surgical revision including six re-do transplantations. Graft loss occurred significantly more frequently in patients with bilateral OAC with a graft survival of 63% and 50% in these after 3 and 5 years compared with 83% and 73% in controls without OAC (p < 0.001). Baseline forced expiratory volume in 1 s (FEV1) in patients with bilateral OAC was median 58% predicted in comparison with 90% in controls (p < 0.001). Quality of life was significantly reduced. CONCLUSION Bilateral OACs impose a high burden of disease on patients after lung transplantation and were associated with early and late graft loss. Affected patients' OAC demonstrated reduced graft function and impaired quality of life. Most OACs were managed by bronchoscopy preferably by non-permanent stenting. Surgery including re-do transplantation was used in selected cases.
Collapse
Affiliation(s)
- Jens Gottlieb
- Department of Respiratory Medicine and Infectious Diseases OE 6870, Hannover Medical School (Medizinische Hochschule Hannover, MHH), Carl Neuberg Strasse 1, 30625 Hannover, Germany. German Center for Lung Research (DZL), Gießen, Germany
| | - Thomas Fuehner
- Department of Respiratory Medicine, Siloah Hospital, Hannover, Germany
| | - Patrick Zardo
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| |
Collapse
|
12
|
Atchade E, Ren M, Jean-Baptiste S, Tran Dinh A, Tanaka S, Tashk P, Lortat-Jacob B, Assadi M, Weisenburger G, Mal H, Sénémaud JN, Castier Y, de Tymowski C, Montravers P. ECMO support as a bridge to lung transplantation is an independent risk factor for bronchial anastomotic dehiscence. BMC Pulm Med 2022; 22:482. [PMID: 36539752 PMCID: PMC9764472 DOI: 10.1186/s12890-022-02280-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Airway complications are frequent after lung transplantation (LT), as they affect up to 23% of recipients. The implication of perioperative extracorporeal membrane oxygenation (ECMO) support and haemodynamic instability has never been specifically assessed. The first aim of this study was to explore the impact of perioperative ECMO support on bronchial anastomotic dehiscence (BAD) at Day 90 after LT. METHODS This prospective observational monocentric study analysed BAD in all consecutive patients who underwent LT in the Bichat Claude Bernard Hospital, Paris, France, between January 2016 and May 2019. BAD visible on bronchial endoscopy and/or tomodensitometry was recorded. A univariate analysis was performed (Fisher's exacts and Mann-Whitney tests), followed by a multivariate analysis to assess independent risk factors for BAD during the first 90 days after LT (p < 0.05 as significant). The Paris North Hospitals Institutional Review Board approved the study. RESULTS A total of 156 patients were analysed. BAD was observed in the first 90 days in 42 (27%) patients and was the main cause of death in 22 (14%) patients. BAD occurred during the first month after surgery in 34/42 (81%) patients. ECMO support was used as a bridge to LT, during and after surgery in 9 (6%), 117 (75%) and 40 (27%) patients, respectively. On multivariate analysis, ECMO as a bridge to LT (p = 0.04) and septic shock (p = 0.01) were independent risk factors for BAD. CONCLUSION ECMO as a bridge to LT is an independent risk factor for BAD during the first 90 days after surgery. Close monitoring of bronchial conditions must be performed in these high-risk recipients.
Collapse
Affiliation(s)
- Enora Atchade
- grid.411119.d0000 0000 8588 831XAPHP, CHU Bichat-Claude Bernard, DMU PARABOL, 46 Rue Henri Huchard, 75018 Paris, France
| | - Mélissa Ren
- grid.411119.d0000 0000 8588 831XAPHP, CHU Bichat-Claude Bernard, DMU PARABOL, 46 Rue Henri Huchard, 75018 Paris, France
| | - Sylvain Jean-Baptiste
- grid.411119.d0000 0000 8588 831XAPHP, CHU Bichat-Claude Bernard, DMU PARABOL, 46 Rue Henri Huchard, 75018 Paris, France
| | - Alexy Tran Dinh
- grid.411119.d0000 0000 8588 831XAPHP, CHU Bichat-Claude Bernard, DMU PARABOL, 46 Rue Henri Huchard, 75018 Paris, France ,grid.411119.d0000 0000 8588 831XINSERM U1148, LVTS, CHU Bichat-Claude Bernard, 46 Rue Henri Huchard, 75018 Paris, France ,Université de Paris, UFR Diderot, Paris, France
| | - Sébastien Tanaka
- grid.411119.d0000 0000 8588 831XAPHP, CHU Bichat-Claude Bernard, DMU PARABOL, 46 Rue Henri Huchard, 75018 Paris, France ,grid.11642.300000 0001 2111 2608INSERM UMR 1188, Diabète Athérothrombose Réunion Océan Indien (DéTROI), Université de La Réunion, Saint-Denis de La Réunion, France
| | - Parvine Tashk
- grid.411119.d0000 0000 8588 831XAPHP, CHU Bichat-Claude Bernard, DMU PARABOL, 46 Rue Henri Huchard, 75018 Paris, France
| | - Brice Lortat-Jacob
- grid.411119.d0000 0000 8588 831XAPHP, CHU Bichat-Claude Bernard, DMU PARABOL, 46 Rue Henri Huchard, 75018 Paris, France
| | - Maksud Assadi
- grid.411119.d0000 0000 8588 831XAPHP, CHU Bichat-Claude Bernard, DMU PARABOL, 46 Rue Henri Huchard, 75018 Paris, France
| | - Gaelle Weisenburger
- grid.411119.d0000 0000 8588 831XService de Pneumologie B et Transplantation Pulmonaire, APHP, CHU Bichat-Claude Bernard, 46 Rue Henri Huchard, 75018 Paris, France
| | - Hervé Mal
- grid.411119.d0000 0000 8588 831XService de Pneumologie B et Transplantation Pulmonaire, APHP, CHU Bichat-Claude Bernard, 46 Rue Henri Huchard, 75018 Paris, France
| | - Jean Nicolas Sénémaud
- grid.411119.d0000 0000 8588 831XService de Chirurgie Thoracique et Vasculaire, APHP, CHU Bichat-Claude Bernard, 46 Rue Henri Huchard, 75018 Paris, France
| | - Yves Castier
- Université de Paris, UFR Diderot, Paris, France ,grid.411119.d0000 0000 8588 831XService de Chirurgie Thoracique et Vasculaire, APHP, CHU Bichat-Claude Bernard, 46 Rue Henri Huchard, 75018 Paris, France ,grid.462432.50000 0004 4684 943XPhysiopathologie et Epidémiologie des Maladies Respiratoires, INSERM UMR 1152, Paris, France
| | - Christian de Tymowski
- grid.411119.d0000 0000 8588 831XAPHP, CHU Bichat-Claude Bernard, DMU PARABOL, 46 Rue Henri Huchard, 75018 Paris, France ,grid.411119.d0000 0000 8588 831XINSERM UMR 1149, Immunorecepteur et Immunopathologie Rénale, CHU Bichat-Claude Bernard, 46 Rue Henri Huchard, 75018 Paris, France
| | - Philippe Montravers
- grid.411119.d0000 0000 8588 831XAPHP, CHU Bichat-Claude Bernard, DMU PARABOL, 46 Rue Henri Huchard, 75018 Paris, France ,Université de Paris, UFR Diderot, Paris, France ,grid.462432.50000 0004 4684 943XPhysiopathologie et Epidémiologie des Maladies Respiratoires, INSERM UMR 1152, Paris, France
| |
Collapse
|
13
|
Jindal A, Avasaral S, Grewal H, Mehta A. Airway complications following lung transplantation. Indian J Thorac Cardiovasc Surg 2022; 38:326-334. [DOI: 10.1007/s12055-022-01376-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 05/11/2022] [Indexed: 11/28/2022] Open
|
14
|
Loor G, Mattar A, Schaheen L, Bremner RM. Surgical Complications of Lung Transplantation. Thorac Surg Clin 2022; 32:197-209. [PMID: 35512938 DOI: 10.1016/j.thorsurg.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Lung transplantation is a life-saving intervention and the most effective therapy for select patients with irreversible lung disease. Despite the effectiveness of lung transplantation, it is a major operation with several opportunities for complications. For example, recipient and donor factors, technical issues, early postoperative events, and immunology can all contribute to potential complications. This article highlights some of the key surgery-related complications that can undermine a successful lung transplantation. The authors offer their expert opinion and experience to help practitioners avoid such complications and recognize and treat them early should they occur.
Collapse
Affiliation(s)
- Gabriel Loor
- Department of Surgery and Baylor Lung Institute, Baylor College of Medicine, One Baylor Plaza, MS: BCM390, Houston, TX 77030, USA; Division of Cardiothoracic Transplantation and Circulatory Support, Texas Heart Institute, 6720 Bertner Avenue Suite C355K, Houston, TX 77030, USA.
| | - Aladdein Mattar
- Department of Surgery and Baylor Lung Institute, Baylor College of Medicine, One Baylor Plaza, MS: BCM390, Houston, TX 77030, USA
| | - Lara Schaheen
- Norton Thoracic Institute, St. Joseph's Medical Center, 500 W Thomas Rd Ste 500, Phoenix, AZ 85013, USA; Creighton University School of Medicine-Phoenix Regional Campus, 350 W. Thomas Rd, Phoenix, AZ 85013, USA
| | - Ross M Bremner
- Norton Thoracic Institute, St. Joseph's Medical Center, 500 W Thomas Rd Ste 500, Phoenix, AZ 85013, USA; Creighton University School of Medicine-Phoenix Regional Campus, 350 W. Thomas Rd, Phoenix, AZ 85013, USA
| |
Collapse
|
15
|
Furukawa M, Chan EG, Morrell MR, Ryan JP, Rivosecchi RM, Iasella CJ, Lendermon EA, Pilewski JM, Sanchez PG. Risk factors of bronchial dehiscence after primary lung transplantation. J Card Surg 2022; 37:950-957. [PMID: 35133655 DOI: 10.1111/jocs.16291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 10/15/2021] [Accepted: 11/03/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Although the incidence of bronchial dehiscence following lung transplantation has decreased significantly due to improvements in perioperative managements and surgical techniques, it remains a devastating postoperative complication associated with high morbidity and mortality. METHODS We retrospectively reviewed 811 lung transplantation performed at our institution between January 2011 and December 2020. Bronchial dehiscence was confirmed with flexible bronchoscopy, computed tomography (CT) scan, or clinical findings grade using International Society for Heart and Lung Transplantation recommendations. RESULTS Bronchial dehiscence was diagnosed in 38 patients (4.7%). The overall survival rates of the patients with bronchial dehiscence were significantly worse than those of the patients without bronchial dehiscence (p = .003). Multivariate analysis identified use of our basiliximab induction protocol (odds ratio = 3.03, p = .008) as an independent predictive factor of postoperative airway dehiscence in our multivariable model, along with total ventilator duration (odds ratio = 1.02, p = .002). CONCLUSIONS Based on our analysis, patients that underwent our basiliximab induction protocol for lung transplantation experienced a higher rate of postoperative bronchial dehiscence when compared with patients who receive alemtuzumab induction. We believe this may be associated with a higher steroid exposure in this population. Additional studies are necessary to further characterize the relationship between different induction protocols and bronchial dehiscence following transplantation.
Collapse
Affiliation(s)
- Masashi Furukawa
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ernest G Chan
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Matthew R Morrell
- Division of Pulmonary, Critical Care and Occupational Medicine, University of Utah
| | - John P Ryan
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ryan M Rivosecchi
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Carlo J Iasella
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Elizabeth A Lendermon
- Department of Pulmonology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Joseph M Pilewski
- Department of Pulmonology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Pablo G Sanchez
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
16
|
Crespo MM. Airway complications in lung transplantation. J Thorac Dis 2021; 13:6717-6724. [PMID: 34992847 PMCID: PMC8662498 DOI: 10.21037/jtd-20-2696] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 07/13/2021] [Indexed: 12/03/2022]
Abstract
Airway complications (ACs) after lung transplantation remain an important source of morbidity and mortality despite significant advances in the surgical technics, leading to increased cost, and decrease quality of life. The incidences of ACs after lung transplantation range from 2% to 33%, even though most transplant centers have reported rates in the range of 7% to 8%. However, the reported rate of ACs has been inconsistent as a result of a lack of standardized airway definitions and grading protocols before the recent 2018 International Society for Heart and Lung Transplantation (ISHLT) proposed consensus guidelines on ACs after lung transplantation. The ACs include stenosis, perioperative and postoperative bronchial infections, bronchial necrosis and dehiscence, excess granulation tissue, and tracheobronchomalacia (TBM). Anastomosis infection, necrosis, or dehiscence typically develops within the first month after lung transplantation. The most frequent AC after lung transplantation is bronchial stenosis. Several risk factors have been proposed to the development of ACs after lung transplantation, including surgical anastomosis techniques, hypoperfusion, infections, donor and recipient factors, immunosuppression agents, and organ preservation. ACs might be prevented by early recognition of the airway pathology, using advance medical management, and interventional bronchoscopy procedures. Balloon bronchoplasty, cryotherapy, laser photo resection, electrocautery, high-dose endobronchial brachytherapy, and bronchial stents placement are the most frequent interventional bronchoscopic procedures utilized for the management of ACs.
Collapse
Affiliation(s)
- Maria M Crespo
- Pulmonary, Allergy and Critical Care Division, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
17
|
Agrawal A, Baird BJ, Madariaga MLL, Blair EA, Murgu S. Multi-disciplinary management of patients with benign airway strictures: A review. Respir Med 2021; 187:106582. [PMID: 34481304 DOI: 10.1016/j.rmed.2021.106582] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 08/18/2021] [Indexed: 11/29/2022]
Abstract
Histologically benign airway strictures are frequently misdiagnosed as asthma or COPD and may present with severe symptoms including respiratory failure. A clear understanding of pathophysiology and existing classification systems is needed to determine the appropriate treatment options and predict clinical course. Clinically significant airway strictures can involve the upper and central airways extending from the subglottis to the lobar airways. Optimal evaluation includes a proper history and physical examination, neck and chest computed tomography, pulmonary function testing, endoscopy and serology. Available treatments include medical therapy, endoscopic procedures and open surgery which are based on the stricture's extent, location, etiology, morphology, severity of airway narrowing and patient's functional status. The acuity of the process, patient's co-morbidities and operability at the time of evaluation determine the need for open surgical or endoscopic interventions. The optimal management of patients with benign airway strictures requires the availability, expertise and collaboration of otolaryngologists, thoracic surgeons and interventional pulmonologists. Multidisciplinary airway teams can facilitate accurate diagnosis, guide management and avoid unnecessary procedures that could potentially worsen the extent of the disease or clinical course. Implementation of a complex airway program including multidisciplinary clinics and conferences ensures that such collaboration leads to timely, patient-centered and evidence-based interventions. In this article we outline algorithms of care and illustrate therapeutic techniques based on published evidence.
Collapse
Affiliation(s)
- Abhinav Agrawal
- Interventional Pulmonology & Bronchoscopy, Division of Pulmonary, Critical Care & Sleep Medicine, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA.
| | - Brandon J Baird
- Section of Otolaryngology - Head and Neck Surgery, Department of Surgery, University of Chicago, Chicago, IL, USA.
| | - Maria Lucia L Madariaga
- Section of Thoracic Surgery, Department of Surgery, University of Chicago, Chicago, IL, USA.
| | - Elizabeth A Blair
- Section of Otolaryngology - Head and Neck Surgery, Department of Surgery, University of Chicago, Chicago, IL, USA.
| | - Septimiu Murgu
- Interventional Pulmonology, Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL, USA.
| |
Collapse
|
18
|
Mohseni MM, Li Z, Simon LV. Emergency Department Visits Among Lung Transplant Patients: A 4-Year Experience. J Emerg Med 2020; 60:150-157. [PMID: 33158689 DOI: 10.1016/j.jemermed.2020.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 09/02/2020] [Accepted: 10/04/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Emergency department (ED) visits by lung transplant (LT) patients have not been well documented in the literature. OBJECTIVES To analyze outcomes among LT recipients with ED visits, to better inform clinicians regarding evaluation and treatment. METHODS This was a retrospective cohort study of LT patients at our ED (2015-2018). Demographics, transplant indication, laboratory studies, ED interventions, disposition, death, and revisit data were collected. Logistic regression models were used to identify univariable and multivariable predictors of ED revisit, intensive care unit (ICU) admission, or death. RESULTS For 505 ED visits among 160 LT recipients, respiratory-related concerns were most frequent (n = 152, 30.1%). Infection was the most common ED diagnosis (n = 101, 20.0%). Many patients were sent home from the ED (n = 235, 46.5%), and 31.3% (n = 158) returned to the ED within 30 days. Fourteen patients (2.8%) needed advanced airway measures. One patient died in the ED, and 18 died in the hospital. On multivariable analysis, more previous ED visits significantly increased the probability of 30-day ED revisit. Heart rate faster than 100 beats/min and systolic blood pressure < 90 mm Hg were significantly associated with ICU admission or death. CONCLUSION Infection should be prominent on the differential diagnosis for LT patients in the ED. A large proportion of patients were discharged from the ED, but a higher number of previous ED visits was most predictive of ED revisit within 30 days. Mortality rate was low in our study, but higher heart rate and lower systolic blood pressure were associated with ICU admission or death.
Collapse
Affiliation(s)
- Michael M Mohseni
- Department of Emergency Medicine, Mayo Clinic, Jacksonville, Florida
| | - Zhuo Li
- Biostatistics Unit, Mayo Clinic, Jacksonville, Florida
| | - Leslie V Simon
- Department of Emergency Medicine, Mayo Clinic, Jacksonville, Florida
| |
Collapse
|
19
|
Dunlap DG, Ma KC, DiBardino D. Airway Complications and Endoscopic Management After Lung Transplantation. CURRENT PULMONOLOGY REPORTS 2020. [DOI: 10.1007/s13665-020-00260-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
20
|
Frye BC, Gasplmayr M, Hettich I, Zissel G, Müller-Quernheim J. Surveillance Bronchoscopy for the Care of Lung Transplant Recipients: A Retrospective Single Center Analysis. Transplant Proc 2020; 53:265-272. [PMID: 32981692 DOI: 10.1016/j.transproceed.2020.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 07/30/2020] [Accepted: 08/12/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Lung transplantation is often the only treatment for end-stage lung disease. Following lung transplantation, infections and transplant rejections are major obstacles to short- and long-term success. Therefore, close monitoring for these complications is required after lung transplantation. The role of prescheduled surveillance bronchoscopies after lung transplantation is controversial. Thus, we aimed to retrospectively analyze the therapeutic implications of surveillance bronchoscopies in 110 consecutive lung transplant recipients. MATERIALS AND METHODS Results of 400 prescheduled surveillance bronchoscopies of 110 consecutive lung transplant recipients were analyzed. Positive results (pathologic histology, microbiology, or virology) were further investigated for their effect on clinical decision making. Additionally, cellular composition of bronchoalveolar lavage (BAL) was analyzed. RESULTS Two hundred five surveillance bronchoscopies showed pathologic findings. In 81 cases clinical treatment was changed based on the results. That is, 20% of all prescheduled bronchoscopies directly influenced clinical decision making. Furthermore, analyses of BAL indicate that increased alveolar eosinophils are associated with an increased risk of transplant rejection. CONCLUSIONS Prescheduled surveillance bronchoscopies identify clinically unsuspected but therapeutically relevant pathologic findings in approximately 20% of cases. BAL cell composition may confer additional information, especially in cases when biopsy is not possible.
Collapse
Affiliation(s)
- Björn Christian Frye
- Department of Pneumology, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Markus Gasplmayr
- Department of Pneumology, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ina Hettich
- Department of Pneumology, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Gernot Zissel
- Department of Pneumology, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Joachim Müller-Quernheim
- Department of Pneumology, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| |
Collapse
|
21
|
Bronchoscopic Interventions as a Management of Airway Complications After Lung Transplant Including Assessment of Risk Factors With Special Consideration for Pretransplant Pulmonary Hypertension. Transplant Proc 2020; 52:2155-2159. [PMID: 32482446 DOI: 10.1016/j.transproceed.2020.03.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 03/04/2020] [Accepted: 03/30/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Lung transplant (LTx) is a procedure associated with risk of complications related to airway stenosis that can be treated with bronchoscopic interventions (BIs). The aim of the study was to assess the frequency and risk factors associated with increased need of bronchial interventions in the post-transplant period. METHODS The retrospective study reviewed cases of 165 patients (63 women) who underwent LTx from April 2013 to June 2019. For dichotomous discrete variables (occurrence or lack of intervention) multivariate logistic regression analysis was performed to assess the aforementioned risk factors. RESULTS BIs were required among 38.55% of lung recipients (n = 65). The number of interventions/patient/y decreases between years 1 and 2 (P < .001), 2 and 3 (P = .013), and 3 and 4 (P < .001); after the fourth year post LTx the differences are not statistically significant. Each 1 mm Hg above 25 mm Hg of mean pulmonary arterial pressure causes statistically significant elevation in the number of interventions by 0.7% in the first year after the procedure. The number of BIs per patient among lung recipients who received a transplant because of idiopathic pulmonary arterial hypertension was statistically significantly higher compared with patients with another underlying lung disease. CONCLUSIONS Airway complications developed in the post-transplant period caused a significant number of patients to be in need of BI, especially balloon bronchoplasty. The highest number of interventions occurred within the first year after LTx, and BI decreases over time. Mean pulmonary arterial pressure measured during qualification may have the ability to predict whether the patient would require BI after LTx.
Collapse
|
22
|
Nęcki M, Antończyk R, Pandel A, Gawęda M, Latos M, Urlik M, Stącel T, Wajda-Pokrontka M, Zawadzki F, Przybyłowski P, Zembala M, Ochman M. Impact of Cold Ischemia Time on Frequency of Airway Complications Among Lung Transplant Recipients. Transplant Proc 2020; 52:2160-2164. [PMID: 32430145 DOI: 10.1016/j.transproceed.2020.03.047] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 03/09/2020] [Accepted: 03/30/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND The cold ischemia time (CIT) is a period of time between harvesting an organ for transplant and its reperfusion just after implantation. CIT may have an impact on frequency of complications after lung transplant that can be treated by means of bronchoscopic intervention. The aim of the study was to investigate the correlation between CIT and frequency of bronchoscopic intervention. METHODS The retrospective study consists of 91 patients: 22 single lung recipients (24%) and 69 double lung recipients (76%) who underwent lung transplant from March 2012 to June 2019. All statistical analyses were performed in SPSS 25.0 and R 3.5.3. The P levels less than .05 were deemed statistically significant. RESULTS The average CIT in single lung transplant was 5.91 hours, and in double lung transplant it was 8.61 hours. For the 4- to 8-hour CIT the percentages were 80.95% for single lung recipients and 46.38% for double lung recipients. For CIT longer than 8 hours, the following percentages were observed: 9.53% in single lung transplant and 53.62% in double lung transplant. Each subsequent hour of CIT exponentially increases the risk of intervention 1505 times (50.05%). CONCLUSIONS Prolonged CIT seems to be a risk factor for airway complication, especially in the double lung recipient group.
Collapse
Affiliation(s)
| | - Remigiusz Antończyk
- Silesian Center for Heart Diseases, Zabrze, Poland; Department of Cardiac, Vascular, and Endovascular Surgery and Transplantology, Medical University of Silesia in Katowice, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Anastazja Pandel
- Silesian Center for Heart Diseases, Zabrze, Poland; Department of Cardiac, Vascular, and Endovascular Surgery and Transplantology, Medical University of Silesia in Katowice, Silesian Centre for Heart Diseases, Zabrze, Poland.
| | - Martyna Gawęda
- Silesian Center for Heart Diseases, Zabrze, Poland; Department of Cardiac, Vascular, and Endovascular Surgery and Transplantology, Medical University of Silesia in Katowice, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Magdalena Latos
- Silesian Center for Heart Diseases, Zabrze, Poland; Department of Cardiac, Vascular, and Endovascular Surgery and Transplantology, Medical University of Silesia in Katowice, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Maciej Urlik
- Silesian Center for Heart Diseases, Zabrze, Poland
| | | | - Marta Wajda-Pokrontka
- Silesian Center for Heart Diseases, Zabrze, Poland; Department of Cardiac, Vascular, and Endovascular Surgery and Transplantology, Medical University of Silesia in Katowice, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Fryderyk Zawadzki
- Silesian Center for Heart Diseases, Zabrze, Poland; Department of Cardiac, Vascular, and Endovascular Surgery and Transplantology, Medical University of Silesia in Katowice, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Piotr Przybyłowski
- Silesian Center for Heart Diseases, Zabrze, Poland; First Chair of General Surgery, Jagiellonian University, Medical College, Kraków, Poland
| | - Marian Zembala
- Silesian Center for Heart Diseases, Zabrze, Poland; Department of Cardiac, Vascular, and Endovascular Surgery and Transplantology, Medical University of Silesia in Katowice, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Marek Ochman
- Silesian Center for Heart Diseases, Zabrze, Poland; Department of Cardiac, Vascular, and Endovascular Surgery and Transplantology, Medical University of Silesia in Katowice, Silesian Centre for Heart Diseases, Zabrze, Poland
| |
Collapse
|
23
|
Patoir A, Luchez A, Tiffet O, Vercherin P, Grima R, Tronc F, Philit F, Mornex JF, Vergnon JM, Maury JM. Airway complications after lung transplantation: benefit of a conservative bronchoscopy strategy. J Thorac Dis 2020; 12:2625-2634. [PMID: 32642170 PMCID: PMC7330399 DOI: 10.21037/jtd.2020.03.21] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background After lung transplantation (LT), between 2% and 25% of bronchial anastomoses develop complications requiring therapeutic intervention. The status of healing of both bronchial anastomoses and downhill airways are well described by the French consensual MDS standardized grading system (Macroscopic, Diameter, Suture). We analyzed risks factors for airway complications (AC) after transplantation and the way we managed them. We report here our challenging method of early rigid bronchoscopic intervention with airway stenting on bronchial healing. Methods All single center consecutives LTs were retrospectively analyzed between 2010-2016. Patient-level data (demographic, peri-operative data) and anastomosis-level data (surgical parameters, bronchoscopy findings) were monitored. The incidence and contributive factors of ACs are reported. We also reported modalities of the conservative treatment and outcome. Results A total of 121 LTs were performed, 39 single-lung and 82 bilateral sequential LT. Main indication for LT were cystic fibrosis (45%) and emphysema (25%) and 58 were male patients (n=70). After a waiting period of healing, 28 patients presented AC on 41 anastomoses (prevalence: 23%). A multivariate analysis found as contributive factors of ACs, post-operative infection by Aspergillus [odds ratio (OR) 2.7, 95% confidence interval (CI): 1.08-6.75; P=0.033] at the patient level, and at the anastomosis level, emphysema (OR 2.4, 95% CI: 1.02-5.6; P=0.045), early dehiscence (OR 11.2, 95% CI: 1.7-76; P=0.01) and cold ischemia time >264 min (OR 2.45, 95% CI: 1.08-5.6; P=0.03). All the 41 ACs were managed conservatively with rigid bronchoscopy (range, 1-10), 41 stents (21 in silicone and 20 fully-covered Silicone Expandable Metallic Stents) without major complication. Two AC were still under regular bronchoscopic care and silicone stenting for long left bronchus reason. No surgical intervention was needed. The 2-years overall survival rate where not different between AC group and controls, respectively 85% and 81%. Conclusions Airway healing after transplantation remains a scalable process and the French consensual MDS classification helped us for therapeutic decisions. Rigid bronchoscopy and safety use of current stenting devices may have the pivotal role in the conservative management of ACs, avoiding perilous situation of surgery for AC. Despite a high rate of AC, their favorable evolution may be explained by the cautious care of airway healing and maybe by the use of the Celsior antioxidant solution.
Collapse
Affiliation(s)
- Arnaud Patoir
- Department of Thoracic Surgery, Saint-Etienne University Hospital, North Hospital, 42055 Saint Étienne CEDEX 2, France
| | - Antoine Luchez
- Pneumology Department, Saint-Etienne University Hospital, North Hospital, 42055 Saint Étienne CEDEX 2, France
| | - Olivier Tiffet
- Department of Thoracic Surgery, Saint-Etienne University Hospital, North Hospital, 42055 Saint Étienne CEDEX 2, France
| | - Paul Vercherin
- Department of Thoracic Surgery, Saint-Etienne University Hospital, North Hospital, 42055 Saint Étienne CEDEX 2, France.,Pneumology Department, Saint-Etienne University Hospital, North Hospital, 42055 Saint Étienne CEDEX 2, France.,Public Health and Medical Informatics Department, Saint-Etienne University Hospital, North Hospital, 42055 Saint Étienne CEDEX 2, France.,Department of Thoracic Surgery and Lung and Heart-Lung Transplantation, Hospices Civils de Lyon, Lyon, France.,Pneumology and Lung Transplantation Department, Hospices Civils de Lyon, Lyon, France.,Université Claude Bernard Lyon 1, UMR754, INRA, Lyon, France.,Université de Lyon, Université Jean Monnet de Saint-Etienne, INSERM, U 1059 Sainbiose, F-42023, Saint-Etienne, France
| | - Renaud Grima
- Department of Thoracic Surgery and Lung and Heart-Lung Transplantation, Hospices Civils de Lyon, Lyon, France
| | - François Tronc
- Department of Thoracic Surgery and Lung and Heart-Lung Transplantation, Hospices Civils de Lyon, Lyon, France
| | - François Philit
- Pneumology and Lung Transplantation Department, Hospices Civils de Lyon, Lyon, France
| | - Jean-François Mornex
- Pneumology and Lung Transplantation Department, Hospices Civils de Lyon, Lyon, France.,Université Claude Bernard Lyon 1, UMR754, INRA, Lyon, France
| | - Jean-Michel Vergnon
- Pneumology Department, Saint-Etienne University Hospital, North Hospital, 42055 Saint Étienne CEDEX 2, France.,Université de Lyon, Université Jean Monnet de Saint-Etienne, INSERM, U 1059 Sainbiose, F-42023, Saint-Etienne, France
| | - Jean-Michel Maury
- Department of Thoracic Surgery and Lung and Heart-Lung Transplantation, Hospices Civils de Lyon, Lyon, France.,Université Claude Bernard Lyon 1, UMR754, INRA, Lyon, France
| |
Collapse
|
24
|
Schweiger T, Nenekidis I, Stadler JE, Schwarz S, Benazzo A, Jaksch P, Hoetzenecker K, Klepetko W. Single running suture technique is associated with low rate of bronchial complications after lung transplantation. J Thorac Cardiovasc Surg 2020; 160:1099-1108.e3. [PMID: 32580901 DOI: 10.1016/j.jtcvs.2019.12.119] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 12/18/2019] [Accepted: 12/20/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Lung transplantation has evolved to a routinely performed surgical procedure in patients with end-stage pulmonary disease. Bronchial healing problems are rare but represent a potential life-threatening complication. Herein, we aimed to define the incidence, classification, and treatment of bronchial complications after lung transplantation. MATERIAL AND METHODS All patients receiving lung transplantation between January 1999 and December 2017 were included in this retrospective study. All bronchial anastomoses were performed in a standardized technique using a single, polydioxanone running suture. The rate of anastomotic complications requiring an intervention, type of complication according the 2018 International Society for Heart and Lung Transplantation classification, and the clinical management were retrospectively analyzed. RESULTS A total of 2941 anastomoses were performed in 1555 patients. The overall incidence of relevant anastomotic complications was 1.56%, 0.68% for left anastomoses, and 2.44% for right anastomoses. In 6 patients, a surgical revision or retransplantation was performed, whereas endoscopic treatment alone was sufficient in 39 patients. One patient underwent right-sided retransplantation 6 months after the first lung transplantation after failed endoscopic treatment attempts. International Society for Heart and Lung Transplantation grade "S Lc Ec" was the most common type of anastomotic complication. The overall incidence decreased within the study period from 2.4% in the era 1999 to 2003 to 0.8% in the era 2014 to 2017. We found no significant difference in overall survival of patients with and without anastomotic complications (P = .995; hazard ratio, 0.99; 95% confidence interval, 0.63-1.58). CONCLUSIONS The single running suture technique is associated with a very low rate of true anastomotic complications. Close follow-up and early endoscopic treatment of patients with anastomotic complications result in excellent long-term outcomes.
Collapse
Affiliation(s)
- Thomas Schweiger
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | | | | | - Stefan Schwarz
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Alberto Benazzo
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Peter Jaksch
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Walter Klepetko
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria.
| |
Collapse
|
25
|
Impact of Cold Ischemic Time on Airway Complications After Lung Transplantation: A Single-center Cohort Study. Transplant Proc 2019; 51:2981-2985. [DOI: 10.1016/j.transproceed.2019.04.092] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 04/13/2019] [Indexed: 11/21/2022]
|
26
|
Fallis RJ, Jablonski L, Moss S, Axelrod P, Clauss H. Infectious complications of bronchial stenosis in lung transplant recipients. Transpl Infect Dis 2019; 21:e13100. [PMID: 31056837 DOI: 10.1111/tid.13100] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 03/13/2019] [Accepted: 04/21/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Bronchial stenosis is a known complication of lung transplantation, but there are limited data regarding whether transplant recipients with bronchial stenosis develop more infectious complications than those without bronchial stenosis. METHODS We conducted a retrospective single-center observational cohort study between January 1, 2011 and September 29, 2016 of 35 lung transplant recipients diagnosed with bronchial stenosis and a random sample of 35 lung transplant recipients without bronchial stenosis. Data collected included donor/recipient demographic and anatomic information, respiratory cultures, episodes of respiratory infections diagnosed using CDC-NNIS criteria, hospitalizations, and 1-year all-cause mortality. Patients were followed up to 1 year after transplant. RESULTS Bronchial stenosis occurred at a median of 54 days post-transplant (range 5-365 days). Bronchial stenosis patients spent more time in the hospital (87.4 vs 46.8 days, P = 0.011) and had more total hospitalizations (4.54 vs 2.37, P < 0.01) than their counterparts. The relative risk of pneumonia among cases vs controls was 4.0 (95% CI 2.2-7.3, P < 0.01); for purulent tracheobronchitis the relative risk was 3.1 (95% CI 1.6-6.1, P < 0.01). Patients with bronchial stenosis were significantly more likely to have respiratory cultures growing Staphylococcus aureus (RR 5.0; P = 0.001) and Pseudomonas aeruginosa (RR 2.1, P = 0.026). Mortality within the first year following transplant was equal in both the groups (14.3% vs 14.3%). CONCLUSIONS There was no significant increase in 1-year mortality for lung transplant patients who developed bronchial stenosis. However, bronchial stenosis patients had significantly higher risks of pneumonia and tracheobronchitis, and spent more days in the hospital than those without bronchial stenosis.
Collapse
Affiliation(s)
- Rebecca J Fallis
- Section of Infectious Diseases, Department of Internal Medicine, Temple University Hospital, Philadelphia, Pennsylvania
| | | | - Sean Moss
- Section of Infectious Diseases Tufts Medical Center, Boston, Massachusetts
| | - Peter Axelrod
- Section of Infectious Diseases, Department of Internal Medicine, Temple University Hospital, Philadelphia, Pennsylvania
| | - Heather Clauss
- Section of Infectious Diseases, Department of Internal Medicine, Temple University Hospital, Philadelphia, Pennsylvania
| |
Collapse
|
27
|
Mazzetta A, Porzio M, Riou M, Coiffard B, Olland A, Dégot T, Seitlinger J, Massard G, Renaud-Picard B, Kessler R. Patients Treated for Central Airway Stenosis After Lung Transplantation Have Persistent Airflow Limitation. Ann Transplant 2019; 24:84-92. [PMID: 30760698 PMCID: PMC6383442 DOI: 10.12659/aot.911923] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background Although central airway stenosis (CAS) is a common complication after lung transplantation, its consequences have been poorly evaluated. The objective of our study was to evaluate the impact of CAS on lung function after lung transplantation. Material/Methods All lung transplant recipients from June 2009 to August 2014 in a single center (Strasbourg, France) were retrospectively reviewed. Results A total of 191 lung transplantations were performed: 175 bilateral, 15 single, and 1 heart-lung transplantation. Of the 161 bilateral lung-transplanted patients who survived >3 months, 22 (13.6%) developed CAS requiring endobronchial treatment. All these patients were treated by endoscopic balloon dilatation, and 9 additionally needed endobronchial stents. Respiratory function tests demonstrated persistent obstructive ventilatory pattern despite endoscopic treatment in recipients with CAS compared to those without CAS at 6, 12, and 18 months post-transplant. At 18 months, CAS patients had significantly lower post-transplant FEV1 (1.96±0.60 L versus 2.57±0.76 L, p=0.001) and FEV1/FVC (61±14% versus 81±13%, p<0.001). The percentage of patients hospitalized for respiratory infections and number of hospital days were significantly increased in recipients with CAS (20 [91%] versus 92 [66%] p=0.036, and 144±110 days versus 103±83 days p=0.042, respectively). Survival in transplant recipients did not significantly differ between those with CAS and those without. Conclusions CAS after lung transplantation was not associated with worse survival, but it did have a significant and persistent effect on lung function, and was associated with increased rate of respiratory infection.
Collapse
Affiliation(s)
- Andrea Mazzetta
- Department of Respiratory Medicine, Federation of Translational Medicine of Strasbourg (FMTS), University Hospitals, Strasbourg, France
| | - Michele Porzio
- Department of Respiratory Medicine, Federation of Translational Medicine of Strasbourg (FMTS), University Hospitals, Strasbourg, France
| | - Marianne Riou
- Department of Respiratory Medicine, Federation of Translational Medicine of Strasbourg (FMTS), University Hospitals, Strasbourg, France
| | - Benjamin Coiffard
- Department of Respiratory Medicine, Federation of Translational Medicine of Strasbourg (FMTS), University Hospitals, Strasbourg, France
| | - Anne Olland
- Department of Thoracic Surgery, University Hospitals, Strasbourg, France.,EA 7293 Vascular and Tissue Stress in Transplantation, UNISTRA, Strasbourg, France
| | - Tristan Dégot
- Department of Respiratory Medicine, Federation of Translational Medicine of Strasbourg (FMTS), University Hospitals, Strasbourg, France
| | - Joseph Seitlinger
- Department of Thoracic Surgery, University Hospitals, Strasbourg, France
| | - Gilbert Massard
- Department of Thoracic Surgery, University Hospitals, Strasbourg, France.,EA 7293 Vascular and Tissue Stress in Transplantation, UNISTRA, Strasbourg, France
| | - Benjamin Renaud-Picard
- Department of Respiratory Medicine, Federation of Translational Medicine of Strasbourg (FMTS), University Hospitals, Strasbourg, France.,EA 7293 Vascular and Tissue Stress in Transplantation, UNISTRA, Strasbourg, France
| | - Romain Kessler
- Department of Respiratory Medicine, Federation of Translational Medicine of Strasbourg (FMTS), University Hospitals, Strasbourg, France.,EA 7293 Vascular and Tissue Stress in Transplantation, UNISTRA, Strasbourg, France
| |
Collapse
|
28
|
Walters DM, Kuckelman JP, Mulligan MS. Electromagnetic navigational bronchoscopic airway recanalization in patients with vanishing bronchus. J Surg Res 2018; 231:154-160. [DOI: 10.1016/j.jss.2018.05.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 05/10/2018] [Accepted: 05/23/2018] [Indexed: 12/27/2022]
|
29
|
Dark JH. Pathophysiology and Predictors of Bronchial Complications After Lung Transplantation. Thorac Surg Clin 2018; 28:357-363. [PMID: 30054073 DOI: 10.1016/j.thorsurg.2018.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Bronchial anastomotic breakdown was a major complication in the early days of lung transplantation. Their solution, achieved through an understanding of airway ischemia from the laboratory, was key to the initial clinical success. Subsequently, risk factors, such as prolonged ventilation in both donor and recipient, primary graft dysfunction, and recipient age, have emerged. Innovations, such as local tissue wrapping, telescoping the anastomosis, and bronchial artery revascularization, have not stood the test of time. The short donor bronchus, with a suture line at the level of the lobar bronchus carina, is a proven technique that should be adopted by surgeons.
Collapse
Affiliation(s)
- John H Dark
- Faculty of Medical Sciences, Institute of Cellular Medicine, Newcastle University, 1st floor William Leech Building, Medical School, Framlington Place, Newcastle NE2 4HH, UK.
| |
Collapse
|
30
|
Varela A, Hoyos L, Romero A, Campo-Cañaveral JL, Crowley S. Management of Bronchial Complications After Lung Transplantation and Sequelae. Thorac Surg Clin 2018; 28:365-375. [DOI: 10.1016/j.thorsurg.2018.04.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
|
31
|
Closure of a Post-Transplant Bronchial Dehiscence With Endobronchial Fibrin Sealant. Ann Thorac Surg 2018; 106:e193-e195. [PMID: 29738754 DOI: 10.1016/j.athoracsur.2018.03.077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 03/21/2018] [Accepted: 03/26/2018] [Indexed: 11/22/2022]
Abstract
Airway complications after lung transplantation are well described and can lead to significant morbidity and mortality. Treatment options for anastomotic dehiscence include expectant management, placement of endobronchial stents, or surgical repair. The use of fibrin sealant instilled by bronchoscopy to seal a dehiscence has not been well described. Our patient is a 57-year-old man who underwent orthotropic bilateral lung transplantation for end-stage chronic obstructive pulmonary disease. He was found to have a partial bronchial anastomosis dehiscence and was subsequently treated with endobronchial fibrin sealant glue instillation. This case illustrates the successful use of endobronchial fibrin sealant for bronchial anastomosis dehiscence.
Collapse
|
32
|
Sugimoto S, Yamane M, Otani S, Kurosaki T, Okahara S, Hikasa Y, Toyooka S, Kobayashi M, Oto T. Airway complications have a greater impact on the outcomes of living-donor lobar lung transplantation recipients than cadaveric lung transplantation recipients. Surg Today 2018; 48:848-855. [PMID: 29680912 DOI: 10.1007/s00595-018-1663-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Accepted: 04/02/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE Airway complications (ACs) after living-donor lobar lung transplantation (LDLLT) could have different features from those after cadaveric lung transplantation (CLT). We conducted this study to compare the characteristics of ACs after LDLLT vs. those after CLT and investigate their impact on outcomes. METHODS We reviewed, retrospectively, data on 163 recipients of lung transplantation, including 83 recipients of LDLLT and 80 recipients of CLT. RESULTS The incidence of ACs did not differ between LDLLT and CLT. The initial type of AC after LDLLT was limited to stenosis in all eight patients, whereas that after CLT consisted of stenosis in three patients and necrosis in ten patients (p = 0.0034). ACs after LDLLT necessitated significantly earlier initiation of treatment than those after CLT (p = 0.032). The overall survival rate of LDLLT recipients with an AC was significantly lower than that of those without an AC (p = 0.030), whereas the overall survival rate was comparable between CLT recipients with and those without ACs (p = 0.25). CONCLUSION ACs after LDLLT, limited to bronchial stenosis, require significantly earlier treatment and have a greater adverse impact on survival than ACs after CLT.
Collapse
Affiliation(s)
- Seiichiro Sugimoto
- Department of General Thoracic Surgery, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan.
| | - Masaomi Yamane
- Department of General Thoracic Surgery, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Shinji Otani
- Department of Organ Transplant Center, Okayama University Hospital, Okayama, Japan
| | - Takeshi Kurosaki
- Department of Organ Transplant Center, Okayama University Hospital, Okayama, Japan
| | - Shuji Okahara
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, Okayama, Japan
| | - Yukiko Hikasa
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, Okayama, Japan
| | - Shinichi Toyooka
- Department of General Thoracic Surgery, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Motomu Kobayashi
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, Okayama, Japan
| | - Takahiro Oto
- Department of Organ Transplant Center, Okayama University Hospital, Okayama, Japan
| |
Collapse
|
33
|
Gust L, D'Journo XB, Brioude G, Trousse D, Dizier S, Doddoli C, Leone M, Thomas PA. Single-lung and double-lung transplantation: technique and tips. J Thorac Dis 2018; 10:2508-2518. [PMID: 29850159 DOI: 10.21037/jtd.2018.03.187] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The first successful single-lung and double-lung transplantations were performed in the eighties. Since then both surgical and anesthesiological management have improved. The aim of this paper is to describe the surgical technique of lung transplantation: from the anesthesiological preparation, to the explantation and implantation of the lung grafts, and the preparation of the donor lungs. We will also describe the main surgical complications after lung transplantation and their management. Each step of the surgical procedure will be illustrated with photos and videos.
Collapse
Affiliation(s)
- Lucile Gust
- Department of Thoracic Surgery, Disease of the Oesophagus and Lung Transplantations, Hôpital Nord, Aix-Marseille University, Marseille, France
| | - Xavier-Benoit D'Journo
- Department of Thoracic Surgery, Disease of the Oesophagus and Lung Transplantations, Hôpital Nord, Aix-Marseille University, Marseille, France
| | - Geoffrey Brioude
- Department of Thoracic Surgery, Disease of the Oesophagus and Lung Transplantations, Hôpital Nord, Aix-Marseille University, Marseille, France
| | - Delphine Trousse
- Department of Thoracic Surgery, Disease of the Oesophagus and Lung Transplantations, Hôpital Nord, Aix-Marseille University, Marseille, France
| | - Stephanie Dizier
- Department of Anesthesiology, Hôpital Nord, Aix-Marseille University, Marseille, France
| | - Christophe Doddoli
- Department of Thoracic Surgery, Disease of the Oesophagus and Lung Transplantations, Hôpital Nord, Aix-Marseille University, Marseille, France
| | - Marc Leone
- Department of Anesthesiology, Hôpital Nord, Aix-Marseille University, Marseille, France
| | - Pascal-Alexandre Thomas
- Department of Thoracic Surgery, Disease of the Oesophagus and Lung Transplantations, Hôpital Nord, Aix-Marseille University, Marseille, France
| |
Collapse
|
34
|
Crespo MM, McCarthy DP, Hopkins PM, Clark SC, Budev M, Bermudez CA, Benden C, Eghtesady P, Lease ED, Leard L, D'Cunha J, Wigfield CH, Cypel M, Diamond JM, Yun JJ, Yarmus L, Machuzak M, Klepetko W, Verleden G, Hoetzenecker K, Dellgren G, Mulligan M. ISHLT Consensus Statement on adult and pediatric airway complications after lung transplantation: Definitions, grading system, and therapeutics. J Heart Lung Transplant 2018; 37:548-563. [PMID: 29550149 DOI: 10.1016/j.healun.2018.01.1309] [Citation(s) in RCA: 93] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 01/31/2018] [Indexed: 11/18/2022] Open
Abstract
Airway complications remain a major cause of morbidity and mortality after cardiothoracic transplantation. The reported incidence of airway ischemic complications varies widely, contributed to by the lack of a universally accepted grading system and standardized definitions. Furthermore, the majority of the existing classification systems fail to integrate the wide range of possible bronchial complications that may develop after lung transplant. Hence, a Working Group was created by the International Society for Heart and Lung Transplantation with the aim of elaborating a universal definition of adult and pediatric airway complications and grading system. One such area of focus is to understand the problem in the context of a more standardized consensus of classifying airway ischemia. This consensus definition will have major clinical, therapeutics, and research implications.
Collapse
Affiliation(s)
- Maria M Crespo
- Division of Pulmonary, Allergy and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Daniel P McCarthy
- Division of Cardiothoracic Surgery, University of Wisconsin School of Medicine, Madison, Wisconsin
| | | | | | - Marie Budev
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Christian A Bermudez
- Division of Cardiothoracic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christian Benden
- Department of Pulmonary Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Pirooz Eghtesady
- Division of Pediatric Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Erika D Lease
- Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington
| | - Lorriana Leard
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco Medical Center, San Francisco, California
| | - Jonathan D'Cunha
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Marcelo Cypel
- Division of Thoracic Surgery, Toronto General Hospital UHN, Toronto, Ontario, Canada
| | - Joshua M Diamond
- Division of Pulmonary, Allergy and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - James J Yun
- Division of Cardiothoracic Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Lonny Yarmus
- Division of Pulmonary and Critical Care, The John Hopkins University Hospital, Baltimore, Maryland
| | | | - Walter Klepetko
- Department of Thoracic Surgery, Vienna Medical University, Vienna, Austria
| | - Geert Verleden
- Department of Respiratory Diseases, University Hospital of Gasthuisberg, Leuven, Belgium
| | | | - Göran Dellgren
- Cardiothoracic Department, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Michael Mulligan
- Division of Cardiothoracic Surgery, University of Washington, Seattle, Washington
| |
Collapse
|
35
|
Golovinskiy SV, Nechaev NB, Poptsov VN, Rusakov MA. Treatment of distal bronchial stenosis after bilateral lung transplantation. ACTA ACUST UNITED AC 2018. [DOI: 10.15825/1995-1191-2017-4-41-47] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The effi ciency of lung transplantation is considerably limited by the complications associated with the bronchial pathologies. Despite the progress of the treatment methods, bronchial complications are still remaining as an actual problem in the postoperative period with frequency of occurrence from 7 to 29%. However, the bronchial stenosis are the most common bronchial complications after lung transplantation with mortality from 2 to 4%.Aim. To study an experience of our center of bronchial stenosis treatment in lung recipients. Materials and methods. 34 patients underwent lung transplantation from September 2014 to January 2017. 6 (16%) of them had a stenosis of lobar or segmental bronchi from 84 to 494 postoperative day. 5 (83%) of them have demonstrated multifocal lesions. In all of the cases there was performed an endoscopic bougienage, which involved a balloon dilatation and electrocoagulated incision of granular tissue under X-ray control. After that the patients were administrated by everolimus.Results. Restenosis was formed in 132,0 ± 94,2 postoperative day after primary treatment in all patients. In four cases (67%) we used nitinol stent placement under X-ray control. There were no complications. In 3 cases stents were dislocated distally, so we needed to use repeated endoscopic bougienage to replace the stent. Using of everolimus has allowed to decrease the rate of restenosis, but it need future research.Conclusion. Distal bronchial stenosis after lung transplantation can be managed with endoscopic bougienage and stent placement. Adding everolimus has not signifi cantly affected the risk of frequency of restenosis.
Collapse
Affiliation(s)
- S. V. Golovinskiy
- V.I. Shumakov National Medical Research Center of Transplantology and Artifi cial Organs of the Ministry of Healthcare of the Russian Federation
| | - N. B. Nechaev
- V.I. Shumakov National Medical Research Center of Transplantology and Artifi cial Organs of the Ministry of Healthcare of the Russian Federation
| | - V. N. Poptsov
- V.I. Shumakov National Medical Research Center of Transplantology and Artifi cial Organs of the Ministry of Healthcare of the Russian Federation
| | - M. A. Rusakov
- I.M. Sechenov First Moscow State Medical University of the Ministry of Healthcare of the Russian Federation
| |
Collapse
|
36
|
Hoetzenecker K, Klepetko W. Is it really dumb to leave a stump? J Thorac Cardiovasc Surg 2018; 156:461-462. [PMID: 29305030 DOI: 10.1016/j.jtcvs.2017.11.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Accepted: 11/15/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Konrad Hoetzenecker
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria.
| | - Walter Klepetko
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
37
|
|
38
|
Transplanted fibroblasts proliferate in host bronchial tissue and enhance bronchial anastomotic healing in a rodent model. Int J Artif Organs 2017. [PMID: 28623643 DOI: 10.5301/ijao.5000601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Healing of airway anastomoses after preoperative irradiation can be a significant clinical problem. The augmentation of bronchial anastomoses with a fibroblast-seeded human acellular dermis (hAD) was shown to be beneficial, although the underlying mechanism remained unclear. Therefore, in this study we investigated the fate of the fibroblasts transplanted to the scaffold covering the anastomosis. MATERIAL AND METHODS 32 Fisher rats underwent surgical anastomosis of the left main bronchus. In a 2 × 2 factorial design, they were randomized to receive preoperative irradiation of 20 Gy and augmentation of the anastomosis with a fibroblast-seeded transplant. Fibroblasts from subcutaneous fat of Fischer-344 rat were transduced retrovirally with tdTomato for cell tracking. After 7 and 14 days, animals were sacrificed and cell concentration of transplanted and nontransplanted fibroblasts in the hAD as well as in the bronchial tissue was measured using RT-PCR. RESULTS Migration of transplanted fibroblasts from dermis to bronchus were demonstrated in both groups, irradiated and nonirradiated. In the irradiated groups, there was a cell count of 7 × 104 ± 1 × 104 tomato+-fibroblasts in the bronchial tissue at day 7, rising to 1 × 105 ± 1 × 104 on day 14 (p <0.0001). Tomato+-cell concentration in hAD increased from 6 × 103 ± 1 × 103 at day 7 to 6 × 104 ± 1 × 104 at day 14 (p <0.0001). In the nonirradiated groups, tomato+-cell concentration in bronchus was 4 × 103 ± 1 × 103 on day 7 and 4 × 103 ± 1 × 103 at day 14. In the hAD tomato+ cell concentration rising from 1 × 104 ± 1 × 103 at day 7 to 2 × 104 ± 3 × 103 cells at day 14 (p = 0.0028). CONCLUSIONS Transplanted fibroblasts in the irradiated groups proliferate and migrate into the irradiated host bronchial tissue, but not in the nonirradiated groups.
Collapse
|
39
|
Successful conservative management of an anastomotic airway dehiscence at the left main bronchus following bilateral cadaveric lung transplantation. Gen Thorac Cardiovasc Surg 2017; 66:368-371. [DOI: 10.1007/s11748-017-0826-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 08/25/2017] [Indexed: 10/18/2022]
|
40
|
Mahajan AK, Folch E, Khandhar SJ, Channick CL, Santacruz JF, Mehta AC, Nathan SD. The Diagnosis and Management of Airway Complications Following Lung Transplantation. Chest 2017; 152:627-638. [DOI: 10.1016/j.chest.2017.02.021] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 01/30/2017] [Accepted: 02/20/2017] [Indexed: 10/20/2022] Open
|
41
|
Surgical Strategy for Lung Transplantation in Adults With Small Chests: Lobar Transplant Versus a Pediatric Donor. Transplantation 2017; 100:2693-2698. [PMID: 26760568 DOI: 10.1097/tp.0000000000001048] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Adult lung transplant recipients with small chests have traditionally received lungs from pediatric donors, placing an additional strain on the already restricted pediatric donor pool. Performing lobar lung transplantation (LLT) can circumvent issues with donor-recipient size mismatch; however, LLT imparts additional risks. Here, we review our experience using LLT and standard lung transplantation using a pediatric donor (PDLT) for adults with small chests. METHODS We retrospectively reviewed consecutive patients with end-stage lung disease and a height of 65 inches or less who underwent LLT (n = 15) or PDLT (n = 15) between 2006 and 2012 at our institution, a high-volume lung transplant center. RESULTS Lobar lung transplantation recipients were older (54 ± 10 vs 48 ± 8 years) and had higher pulmonary pressure (57 ± 11 vs 52 ± 27 mmHg) and higher lung allocation scores (70 ± 9 vs 51 ± 8) than PDLT recipients (all P < 0.05). Mean waiting time was 62 days for PDLT and 9 days for LLT. Postoperatively, the incidence of severe primary graft dysfunction and the incidence of acute renal insufficiency were higher, and the mean intensive care unit stay was longer in the LLT group, but the incidence of bronchial anastomotic complications was higher in the PDLT group because of significant size discrepancy in the main bronchus (P < 0.05). Interestingly, long-term functional outcomes and survival rates were similar between the groups. CONCLUSIONS Both LLT and PDLT are viable surgical options for adult patients with small chests. Because of the potential impact on posttransplant outcomes, the technical complexity of transplantation, decisions regarding the best surgical approach should be made by experienced surgeons.
Collapse
|
42
|
Long B, Koyfman A. The emergency medicine approach to transplant complications. Am J Emerg Med 2016; 34:2200-2208. [DOI: 10.1016/j.ajem.2016.08.049] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 08/18/2016] [Accepted: 08/20/2016] [Indexed: 02/07/2023] Open
|
43
|
Goldberg HJ. Maintaining airway integrity after lung transplantation-Could an ounce of prevention be worth a pound of cure? J Heart Lung Transplant 2016; 36:136-137. [PMID: 27773455 DOI: 10.1016/j.healun.2016.08.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 08/27/2016] [Accepted: 08/31/2016] [Indexed: 10/21/2022] Open
Affiliation(s)
- Hilary J Goldberg
- Lung Transplant Program, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| |
Collapse
|
44
|
Airway complications in the lung transplant recipient. CURRENT PULMONOLOGY REPORTS 2016. [DOI: 10.1007/s13665-016-0150-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
45
|
|
46
|
Olland A, Reeb J, Puyraveau M, Hirschi S, Seitlinger J, Santelmo N, Collange O, Mertes PM, Kessler R, Falcoz PE, Massard G. Bronchial complications after lung transplantation are associated with primary lung graft dysfunction and surgical technique. J Heart Lung Transplant 2016; 36:157-165. [PMID: 27618455 DOI: 10.1016/j.healun.2016.08.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 08/03/2016] [Accepted: 08/10/2016] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND After lung transplantation, bronchial complications are one of the major concerns for surgeons and physicians. In the era of evolving immunosuppressive regimens and surgical approaches, we have reassessed risk factors for bronchial complications after lung transplantation. METHODS We undertook a retrospective study of all consecutive lung transplantations performed at a single center from 2004 to 2014. We monitored the incidence of symptomatic bronchial complications. Demographic data of donors and recipients were also studied. Our objective was to evaluate the impact of 3 subsequent immunosuppressive regimens (including the use of induction therapy), and of a technical modification of bronchial anastomosis on the incidence of airway complications. RESULTS We performed 270 consecutive lung transplantations during the study period. On multivariate analysis, bronchial complications were not directly associated with the different immunosuppressive regimens. In subgroup analysis, when comparing different immunosuppressive regimens, primary graft dysfunction within 72 hours (odds ratio [OR] = 2.55; p = 0.08), lung infection within the first month (OR = 2.96; p = 0.039), diabetes before transplantation (OR = 2.66; p = 0.11) and chronic obstructive pulmonary disease (OR = 2.20; p = 0.04) appeared as major risk factors (c-index = 0.77 on multivariate analysis). The use of a modified bronchial suture technique was associated with fewer bronchial complications (OR = 0.47; p = 0.059) (c-index = 0.71 on multivariate analysis). CONCLUSIONS The mode of immunosuppression had no influence on airway complications. We were able to reproduce the beneficial effect of a modified suture technique.
Collapse
Affiliation(s)
- Anne Olland
- Lung Transplantation Group, Thoracic Surgery Department, University Hospital Strasbourg, Strasbourg, France; EA 7293 "Stress Vasculaire et Tissulaire en Transplantation," Translational Medecine Federation Strasbourg, University of Strasbourg, Strasbourg, France.
| | - Jérémie Reeb
- Lung Transplantation Group, Thoracic Surgery Department, University Hospital Strasbourg, Strasbourg, France; EA 7293 "Stress Vasculaire et Tissulaire en Transplantation," Translational Medecine Federation Strasbourg, University of Strasbourg, Strasbourg, France
| | - Marc Puyraveau
- Clinical Methodology Center, University Hospital Besançon, Besançon, France
| | - Sandrine Hirschi
- Lung Transplantation Group, Thoracic Surgery Department, University Hospital Strasbourg, Strasbourg, France
| | - Joseph Seitlinger
- Lung Transplantation Group, Thoracic Surgery Department, University Hospital Strasbourg, Strasbourg, France
| | - Nicola Santelmo
- Lung Transplantation Group, Thoracic Surgery Department, University Hospital Strasbourg, Strasbourg, France
| | - Olivier Collange
- Intensive Care and Anesthesiology Department, University Hospital Strasbourg, Strasbourg, France
| | - Paul-Michel Mertes
- Intensive Care and Anesthesiology Department, University Hospital Strasbourg, Strasbourg, France
| | - Romain Kessler
- Lung Transplantation Group, Thoracic Surgery Department, University Hospital Strasbourg, Strasbourg, France; EA 7293 "Stress Vasculaire et Tissulaire en Transplantation," Translational Medecine Federation Strasbourg, University of Strasbourg, Strasbourg, France
| | - Pierre-Emmanuel Falcoz
- Lung Transplantation Group, Thoracic Surgery Department, University Hospital Strasbourg, Strasbourg, France
| | - Gilbert Massard
- Lung Transplantation Group, Thoracic Surgery Department, University Hospital Strasbourg, Strasbourg, France; EA 7293 "Stress Vasculaire et Tissulaire en Transplantation," Translational Medecine Federation Strasbourg, University of Strasbourg, Strasbourg, France
| |
Collapse
|
47
|
Mahmood K, Kraft BD, Glisinski K, Hartwig MG, Harlan NP, Piantadosi CA, Shofer SL. Safety of hyperbaric oxygen therapy for management of central airway stenosis after lung transplant. Clin Transplant 2016; 30:1134-9. [PMID: 27410718 DOI: 10.1111/ctr.12798] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Central airway stenosis (CAS) is common after lung transplantation and causes significant post-transplant morbidity. It is often preceded by extensive airway necrosis, related to airway ischemia. Hyperbaric oxygen therapy (HBOT) is useful for ischemic grafts and may reduce the development of CAS. METHODS The purpose of this study was to determine whether HBOT could be safely administered to lung transplant patients with extensive necrotic airway plaques. Secondarily, we assessed any effects of HBOT on the incidence and severity of CAS. Patients with extensive necrotic airway plaques within 1-2 months after lung transplantation were treated with HBOT along with standard care. These patients were compared with a contemporaneous reference group with similar plaques who did not receive HBOT. RESULTS Ten patients received HBOT for 18.5 (interquartile range, IQR 11-20) sessions, starting at 40.5 (IQR 34-54) days after transplantation. HBOT was well tolerated. Incidence of CAS was similar between HBOT-treated patients and reference patients (70% vs 87%, respectively; P=.34), but fewer stents were required in HBOT patients (10% vs 56%, respectively; P=.03). CONCLUSIONS This pilot study is the first to demonstrate HBOT safety in patients who develop necrotic airway plaques after lung transplantation. HBOT may reduce the need for airway stent placement in patients with CAS.
Collapse
Affiliation(s)
- Kamran Mahmood
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, USA.
| | - Bryan D Kraft
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Kristen Glisinski
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Matthew G Hartwig
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Nicole P Harlan
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, USA.,Center for Hyperbaric Medicine and Environmental Physiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Claude A Piantadosi
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, USA.,Center for Hyperbaric Medicine and Environmental Physiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Scott L Shofer
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| |
Collapse
|
48
|
Iga N, Miyoshi K, Takata K, Hirano Y, Konishi Y, Otani S, Sugimoto S, Yamane M, Miyoshi S, Oto T. Visualization of bronchial circulation at bronchial anastomotic site using bronchial fluorescein angiography technique. Interact Cardiovasc Thorac Surg 2016; 23:716-721. [PMID: 27382046 DOI: 10.1093/icvts/ivw210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 05/18/2016] [Accepted: 05/26/2016] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Successful bronchial healing after a bronchoplastic procedure mainly depends on bronchial circulation at the anastomostic site. We developed a bronchial fluorescein angiography (B-FAG) technique for visualizing circulation on the bronchial surface. The technique was evaluated in animals. METHODS Fluorescein was used as a contrast agent and an autofluorescence imaging (AFI) bronchoscope as a detector. The left main pulmonary artery (PA) and main bronchus of 10 pigs were isolated. After transection of the left main bronchus and bronchial arteries and re-anastomosis of the bronchus, the pigs were randomly divided into two groups: the PA- group (n = 5), in which the pulmonary artery was transected; and the PA+ group (n = 5), in which the pulmonary artery was preserved. Following intravenous injection of fluorescein, the distal anastomotic site was observed for 30 min with autofluorescence imaging bronchoscopy. Bronchial specimens sampled 2 days after the surgical intervention were histologically evaluated. RESULTS In the PA- group, there was no fluorescein enhancement in the distal bronchus throughout the observation time. However, enhancement, which turned the bronchial surface from magenta to bright green, was clearly observed in less than 207 ± 102.5 s in the PA+ group. The enhancement status detected by bronchial fluorescein angiography was related to the extent of tissue damage, as was proven histologically in the acute healing stage. CONCLUSIONS Bronchial fluorescein angiography clearly visualized the circulatory status promptly after the anastomosis procedure at the central bronchus. This technique is a potentially practical approach to predict ischaemic airway complications following bronchial anastomosis.
Collapse
Affiliation(s)
- Norichika Iga
- Department of Thoracic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Kentaroh Miyoshi
- Department of Thoracic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Katsuyoshi Takata
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yutaka Hirano
- Department of Thoracic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yusuke Konishi
- Department of Thoracic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Shinji Otani
- Organ Transplant Center, Okayama University Hospital, Okayama, Japan
| | - Seiichiro Sugimoto
- Department of Thoracic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Masaomi Yamane
- Department of Thoracic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Shinichiro Miyoshi
- Department of Thoracic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Takahiro Oto
- Organ Transplant Center, Okayama University Hospital, Okayama, Japan
| |
Collapse
|
49
|
Daimiel Naranjo I, Alonso Charterina S. What can happen after lung transplantation and the importance of the time since transplantation: Radiological review of post-transplantation complications. RADIOLOGIA 2016. [DOI: 10.1016/j.rxeng.2016.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
50
|
Tejwani V, Panchabhai TS, Kotloff RM, Mehta AC. Complications of Lung Transplantation. Chest 2016; 149:1535-45. [DOI: 10.1016/j.chest.2015.12.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Revised: 11/16/2015] [Accepted: 12/11/2015] [Indexed: 01/30/2023] Open
|