Original article
General thoracic
Impact of Anastomotic Techniques on Airway Complications After Lung Transplant

Presented at the Fifty-seventh Annual Meeting of the Southern Thoracic Surgical Association, Orlando, FL, Nov 3–6, 2010.
https://doi.org/10.1016/j.athoracsur.2011.03.031Get rights and content

Background

Airway complications are a source of morbidity and expense after lung transplant. Posttransplant stenosis can occur when the donor bronchus is rendered ischemic and is dependent upon collateral flow from the pulmonary capillary system. By shortening the donor bronchus, the tissue at risk for ischemia is reduced. In an effort to reduce airway complications, one surgeon at our institution began dividing the donor bronchus at the lobar carina.

Methods

This is a retrospective analysis of all transplanted patients over the 2-year period before and after the institution of the technique change. To adjust for covariates, we performed a propensity score analysis. Outcome endpoints were postoperative airway complications, specifically, the need for therapeutic bronchoscopy, dilation, stenting, or retransplant.

Results

After instituting the practice of dividing the bronchus at the lobar carina, the incidence of airway complication for the principle surgeon decreased from 13.2% (7 of 53) to 2.1% (1 of 48), resulting in an improved freedom from airway complication for that surgeon. Compared with all transplants performed during this period, the modified anastomosis resulted in fewer airway complications: 2.1% (1 of 48) versus 8.2% (19 of 231). The propensity analysis matched the 48 patients who received the modified anastomosis with 48 patients who received the standard two ring length anastomosis by surgical colleagues. The modified anastomosis group had fewer required interventions for airway complications and had significantly better freedom from airway complication when followed over time.

Conclusions

Decreasing the amount of potentially ischemic tissue implanted from the donor bronchus can reduce posttransplant airway complications.

Section snippets

Patient Information and Surgical Technique

This is a retrospective analysis of lung transplants performed at a single institution over the 4-year period from January 1, 2004, to December 31, 2008. Bilateral lobar and heart-lung transplants were excluded from this analysis. The general technique used has been described previously [11]. In the middle of this period (specifically, starting with a transplant performed on November 13, 2006), one surgeon at our institution (B.F.M.) altered his anastomotic technique with regard to the

Patient and Complication Details

The overall patient demographics for our patient population are outlined in Table 1. The majority of transplants performed at our institution are double lung transplants, and over this period, most were performed for emphysema. Of the 279 patients undergoing transplantation during this period, 20 (7.2%) had an airway complication, all of which were secondary to ischemic airway injury. The details of these complications are outlined in Table 2. The median number of interventions needed for

Comment

Although airway complications are not the frequent, catastrophic problem that they were in the early days of lung transplantation, they remain a significant source of morbidity and mortality. With the donor airway dependent on collateral blood flow in the postoperative period, it makes intuitive sense that shortening the donor airway before transplant would decrease the likelihood of ischemic injury to the bronchial anastomosis. There have been previous reports demonstrating the possibility of

References (12)

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