Bronchial Anastomotic Complications Research Articles

Two single lung transplantations from one donor: lung twinning in the LAS era.

The implementation of the Lung Allocation Score (LAS) in the Eurotransplant international collaborative framework decreased waiting list mortality, but organ shortage remains a significant problem. Transplantation of two single lungs from one donor into two recipients (lung twinning) may decrease waiting list mortality. We sought to analyze if this strategy can lead to an acceptable intermediate-term outcome. Since the LAS-implementation we performed 32 paired single-lung transplantations from 16 postmortal donors. Data and outcome were analyzed retrospectively comparing recipients receiving the first lung (first twins) with recipients receiving the second lung (second twins), left versus right transplantation and restrictive versus obstructive disease. Survival at one year was 81% and 54% at five years. Veno-venous ECMO had been successfully used as bridge-to-transplant in three patients with ECMO-explantation immediately after surgery. Bronchial anastomotic complications were not observed in any patient. First twins and second twins exhibited similar survival (p = 0.82) despite higher LAS in first twins (median 45 versus 34, p < 0.001) and longer cold ischemic time in second twins (280 ± 83 vs. 478 ± 125min, p < 0.001). Survival of left and right transplantation was similar (p = 0.45) with similar best post-transplant FEV1 (68 ± 15% versus 62 ± 14%, p = 0.26). Survival was similar in restrictive and obstructive disease (p = 0.28) with better post-transplant FEV1 (70 ± 15% versus 57 ± 11%, p = 0.02) in restrictive disease. Performing two single-lung transplantations from one donor can be performed safely with encouraging intermediate-term outcome and good functional capacity. Lung twinning maximizes the donor pool and may help to overcome severe organ shortage. This research is not a clinical trial. Thus no registration details will be provided.

Lung Transplant Outcome From Selected Older Donors (≥70 Years) Equals Younger Donors (

To describe our experience with lung transplantation (LTx) from donors ≥70 years and compare short and long-term outcomes to a propensity-matched cohort of donors <70 years. Although extended-criteria donors have been widely used to enlarge the donor pool, the experience with LTx from older donors (≥70 years) remains limited. All single-center bilateral LTx between 2010 and 2020 were retrospectively analyzed. Matching (1:1) was performed for the donor (type, sex, smoking history, x-ray abnormalities, partial pressure of oxygen/fraction of inspired oxygen ratio, and time on ventilator) and recipient characteristics (age, sex, LTx indication, perioperative extracorporeal life support, and cytomegalovirus mismatch). Primary graft dysfunction grade-3, 5-year patient, and chronic lung allograft dysfunction-free survival were analyzed. Out of 647 bilateral LTx, 69 were performed from donors ≥70 years. The mean age in the older donor cohort was 74 years (range: 70-84 years) versus 49 years (range: 12-69 years) in the matched younger group. No significant differences were observed in the length of ventilatory support, intensive care unit, or hospital stay. Primary graft dysfunction-3 was 26% in the older group versus 29% in younger donor recipients ( P = 0.85). Reintervention rate was comparable (29% vs 16%; P = 0.10). Follow-up bronchoscopy revealed no difference in bronchial anastomotic complications ( P = 1.00). Five-year patient and chronic lung allograft dysfunction-free survivals were 73.6% versus 73.1% ( P = 0.72) and 51.5% versus 59.2% ( P = 0.41), respectively. LTx from selected donors ≥70 years is feasible and safe, yielding comparable short and long-term outcomes in a propensity-matched analysis with younger donors (<70 years).

Use of Octopus™ Tissue Stabilizer for Minimal Manipulation Approach of Bronchial Anastomosis in Lung Transplant.

Bronchial anastomotic complications are a cause of grave concern for surgeons that perform lung transplantations. There are several risk factors that may lead to this complication, being inadequate surgical technique one of them, specifically regarding adequate exposure and manipulation of the bronchial stump and anastomosis. Here we report the use of Octopus™ Tissue Stabilizer as a mean to allow for a better exposure of the stump and facilitate a "no-touch" approach towards anastomosis. Systematic application of devices that facilitate the employment of the correct surgical techniques can have an effect in reducing the incidence of bronchial anastomotic complications.

Sleeve lobectomy in patients with non-small-cell lung cancer: a report from the European Society of Thoracic Surgery database 2021.

For centrally located lung tumours, sleeve lobectomy is preferred over pneumectomy. We report on the surgical practices and perioperative outcomes of sleeve resections based on data from the European Society of Thoracic Surgeons database. We retrieved data of patients undergoing sleeve lobectomy or bilobectomy from 2007 to 2021. We evaluated baseline characteristics, surgical approach, neoadjuvant treatments, morbidity and postoperative outcomes of open and video-assisted thoracoscopic surgery (VATS) procedures. In total, 1652 patients (median age: 63 years; females/males: 446/1206) underwent sleeve lobectomy (n = 1536) or bilobectomy (n = 116) by open thoracotomy (n = 1491; 90.2%) or VATS (n = 161; 9.8%) with a thoracotomy conversion rate of 21.1% (n = 34); 398 (24.1%) patients received neoadjuvant treatment. Overall morbidity and 30-day mortality were 40.6% and 2.2%, respectively. Bronchial anastomotic complications occurred in 29 patients (1.8%) with conservative treatment in 6 cases (20.7%) and operative management in 23 (79.3%). On multivariable analysis, factors related to the elevated risk of cardiopulmonary complications were body mass index &lt; 20 [odds ratio (OR): 2.26; P &lt; 0.001] and bilobectomy (OR : 2.28, P &lt; 0.001). Age &lt;60 years (OR: 0.71, P = 0.013), female sex (OR: 0.54, P &lt; 0.001) and VATS (0.64, P &lt; 0.001) were associated with decreased risk. Neoadjuvant treatment was not associated with increased risks of cardiopulmonary complications (OR: 1.05; P = 0.664). Compared to open thoracotomy, VATS was associated with significantly decreased overall morbidity (30.4% vs 41.7%, P = 0.006) and length of stay (median: 5 days vs 8 days; P &lt; 0.001). Sleeve lobectomies can be safely performed after neoadjuvant treatment. The VATS approach fosters shorter length of stay and decreased morbidity.

217.8: How to Do It: Use of Octopus Tissue Stabilizer for Minimal Manipulation Approach of the Bronchial Anastomosis in Lung Transplant

Introduction: Bronchial anastomotic complications (BAC) are a cause of grave concern for surgeons that perform lung transplantation. There are several risk factors that may lead to this complication, being inadequate surgical technique one of them, specifically regarding the adequate exposure and manipulation of the bronchial stump and anastomosis. Method: We report the use of the Octopus Tissue Stabilizer (Medtronic, Inc, Minneapolis, MN) as a mean of allowing for a better exposure of the stump and facilitate a “no touch” approach towards the anastomosis. Results: The Octopus Tissue Stabilizer (Medtronic, Inc, Minneapolis, MN) is a validated device for cardiac surgery as a tissue stabilizer for off-pump coronary artery bypass. It utilizes vacuum at the extremity of its “U” shaped claw to soothe the beating of the heart on a designated spot and assist the cardiac surgeon. Our idea was to employ the distal claw of such device to stabilize the bronchial stump and perform the bronchial anastomosis with a “no touch” technique. As we did not have a need to smooth the beating of the heart, the suction mechanism was kept turned off (FIGURE 1). It is important to report that in this case, as in others, several other techniques were applied to reduce BAC (the use of end-to-end anastomosis and pericardial flap), therefore it is impossible to affirm that the application of the Octopus Tissue Stabilizer (Medtronic, Inc, Minneapolis, MN) is responsible for the favorable outcome of this patient. Conclusion: We believe that the systematic application of devices that facilitate the employment of the correct surgical techniques can have an effect in reducing the incidence of BAC, while providing no additional risk to the patient.

Is sleeve lobectomy safe after induction therapy?-a systematic review and meta-analysis.

BackgroundSleeve lobectomy (SL) is a lung-sparing procedure, which is accepted as a valid operation for centrally-located advanced tumors. These tumors often require induction treatment by chemotherapy and/or radiotherapy to downstage the disease and thus facilitate subsequent surgery. However, induction therapy may potentially increase the risk of bronchial anastomotic complications and related morbidity. This meta-analysis aims to determine the impact of induction therapy on the outcomes of pulmonary SL.MethodsWe compared studies of patients undergoing SL or bilobectomy for non-small cell lung cancer (NSCLC) with and without induction therapy. Outcomes of interest were in-hospital mortality, morbidity, anastomosis complication and 5-year survival. Odds ratio (OR) were computed following the Mantel-Haenszel method.ResultsTen studies were included for a total of 1,204 patients. There was no statistical difference for between patients who underwent induction therapy followed by surgery and patients who underwent surgery alone in term of post-operative mortality (OR: 1.80, 95% confidence interval (CI): 0.76–4.25, P value =0.19) and morbidity (OR: 1.17, 95% CI: 0.90–1.52, P value =0.237). Anastomosis related complications rate were 5.2% and appears increased after induction therapy with a statistical difference close to the significance (OR: 1.65, 95% CI: 0.97–2.83, P value =0.06). Patients undergoing surgery alone showed better survival at 5 years (OR: 1.52, 95% CI: 1.15–2.00, P value =0.003).ConclusionsSL following induction therapy can be safely performed with no increase of mortality and morbidity. However, the need for induction therapy before surgery is associated with increased anastomotic complications and poorer survival prognosis at 5 years.

Does continuation of antifibrotics before lung transplantation influence post-transplant outcomes in patients with idiopathic pulmonary fibrosis?

SummaryA best evidence topic was written according to a structured protocol. The question addressed was: ‘Does continuation of antifibrotics before lung transplantation (LTx) influence post-transplant outcomes in patients with idiopathic pulmonary fibrosis (IPF) with regard to mortality, bronchial anastomotic dehiscence, reoperation for bleeding and wound complications, primary graft dysfunction or longer-term survival and allograft rejection?’ A total of 261 articles were found using the reported search strategy, of which 7 represented the best evidence to answer the clinical question. Six out of 7 studies demonstrated equivalent post-transplant survival among IPF patients on antifibrotics before LTx compared with controls. Five out of 6 studies showed no increase in the risk of major bleeding, wound or bronchial anastomotic complications. One bi-institutional study found a higher incidence of early bronchial anastomotic dehiscence, but this difference was not statistically significant after longer term follow-up. In a study that only included IPF patients who underwent single LTx, a lower incidence of grade 3 primary graft dysfunction was reported in the antifibrotic group compared with controls. Overall, to date, only small (N < 40 in the antifibrotic group), non-risk-adjusted, retrospective observational studies have been published. Notwithstanding, the summation of available evidence suggests that, in IPF patients, continuation of antifibrotic therapy before LTx is likely safe, and the rates of perioperative bleeding, wound or bronchial anastomotic complications, as well as 30-day and 1-year survival, are similar to patients not on antifibrotics before LTx.

Postoperative Bronchial Complications After Lung Transplantation Related to Anastomosis Suture

BackgroundPostoperative bronchial anastomotic complications are not uncommon in lung transplant recipients. We investigated 2 surgical techniques (continuous and interrupted sutures) during bronchial anastomosis, comparing survival and postoperative bronchial complications. MethodsWe retrospectively analyzed 421 patients who were transplanted in our center (February 2012 to March 2018). Patients were divided according to bronchial anastomotic technique (continuous or interrupted). Demographics and clinical parameters were compared for significance (P < .05). Comparison of postoperative morbidity included bronchial complications, venovenous extracorporeal membrane oxygenation support, and intervention requirements. Survival was assessed using Kaplan-Meier curve and log-rank tests (P < .05). ResultsOf the 421 patients, 290 underwent bronchial anastomoses with continuous suture; 44 of these patients had postoperative bronchial complications (15.2%). Contrarily, 131 patients underwent the interrupted suture technique; 9 patients in this group had postoperative bronchial complications (6.9%). Demographics and clinical parameters included age, sex, ethnicity, etiology, lung allocation score, body mass index, donor age, lung transplant type, cardiopulmonary bypass usage, surgical approaches, and median length of stay. Postoperative complications (continuous vs interrupted) were bronchial complications (P = .017), venovenous extracorporeal membrane oxygenation support (P = .41), venoarterial extracorporeal membrane oxygenation support (P = .38), and complications requiring dilatation with stent placement (P = .09). Kaplan-Meier curve showed better survival in the interrupted group (P = .0002). ConclusionsOur study demonstrated the comparable postoperative results between the continuous and interrupted technique.

Antifibrotic drugs in lung transplantation and chronic lung allograft dysfunction: a review.

This review aims to provide an overview of pre-transplant antifibrotic therapy on peri-transplant outcomes and to address the possible role of antifibrotics in lung transplant recipients with chronic lung allograft dysfunction.Lung transplantation is an established treatment modality for patients with various end-stage lung diseases, of which idiopathic pulmonary fibrosis and other progressive fibrosing interstitial lung diseases are growing indications. Theoretically, widespread use of antifibrotics prior to lung transplantation may increase the risk of bronchial anastomotic complications and impaired wound healing.Long-term graft and patient survival are still hampered by development of chronic lung allograft dysfunction, on which antifibrotics may have a beneficial impact.Antifibrotics until the moment of lung transplantation proved to be safe, without increasing peri-transplant complications. Currently, best practice is to continue antifibrotics until time of transplantation. In a large multicentre randomised trial, pirfenidone did not appear to have a beneficial effect on lung function decline in established bronchiolitis obliterans syndrome. The results of antifibrotic therapy in restrictive allograft syndrome are eagerly awaited, but nonrandomised data from small case reports/series are promising.

Repair of Bronchial Anastomosis Following Lung Transplantation.

Bronchial anastomotic complications are reported in 2 to 18% of patients after lung transplantation. The majority of complications can be managed with bronchoscopic intervention. When extensive dehiscence is present, surgical intervention can be entertained. Between March 1, 2006, and December 31, 2019, our program performed 244 lung transplantations. We conducted a retrospective review of our patient cohort and identified patients who suffered from significant anastomotic complications that required surgical interventions. Twenty-eight and 216 patients underwent single and bilateral lung transplantations, respectively. Eighteen patients developed airway complications (7.4%). The incidence of anastomotic complications was 5.2% (24 complications for a total of 460 bronchial anastomoses). Four patients were managed conservatively. The majority of the bronchial anastomotic complications were managed endoscopically (eight patients). Four patients with associated massive air leak underwent repair of the bronchial anastomosis and two patients were retransplanted because they developed severe distal airway stenosis. Bronchial anastomotic complications are a major cause of morbidity in lung transplantation. The majority of cases can be managed bronchoscopically. In more severe cases associated with massive air leak or imminent massive hemoptysis from bronchopulmonary arterial fistula, surgical intervention is necessary. Aortic homograft interposition along with vascularized pedicle wrapping may be a viable option to re-establish airway continuity when tension-free bronchial anastomotic revision is not possible. In cases with smaller bronchial defects, primary repair with utilization of a vascularized flap can be effective as treatment option.

Preoperative Corticosteroid Use and Early Postoperative Bronchial Anastomotic Complications after Lung Transplantation.

BackgroundAirway anastomotic complications are a leading cause of mortality after lung transplantation. Among the factors that cause airway complications, preoperative steroid use has been considered to be related with postoperative airway healing. We analyzed the influence of preoperative steroid use on postoperative airway complications.MethodsThe medical records of 66 double-lung transplant recipients from January 2014 to December 2015 were reviewed. Forty patients were prescribed steroids preoperatively. The daily steroid dose was standardized using the patient’s body mass index (BMI). Patients who received preoperative steroids were sub-divided into high-dose (HD) and low-dose (LD) groups (cut-off value, 1.6 mg/BMI/day).ResultsThirteen patients suffered from airway complications postoperatively (bronchopulmonary fistula, 9; bronchial stenosis, 4). There was a tendency for early development of airway complications in the steroid use group compared to the non-steroid use group, but it was not significant (percentage free from airway complications in year 1: non-steroid group, 90.9% vs. steroid group, 79.2%; p=0.43). The percentage of patients in the LD and HD groups who were free from airway complications in year 1 was not significantly different (84.0% vs. 77.8%, p=0.39).ConclusionThe airway complication rate did not vary significantly according to steroid use. Additionally, in patients who received preoperative steroids, the dose did not affect the rate of development of airway complications.

Initial experience of single-port video-assisted thoracoscopic surgery sleeve lobectomy and systematic mediastinal lymphadenectomy for non-small-cell lung cancer.

In this study, we evaluate the feasibility and safety of single-port video-assisted thoracoscopic surgery (VATS) sleeve lobectomy (SL) and systematic mediastinal lymphadenectomy and summarize our surgical experience. From October 2014 to December 2015, eight cases of single-port VATS SL [seven male patients and one female patient, median age 56.0 (range, 38-63) years] were performed by a single group of surgeons in Fujian Medical University Fujian Union Hospital. The median tumor size was 2.7 cm. Types of resection included four right upper, one right lower, and three left upper sleeve lobectomies. Systematic mediastinal lymphadenectomy was performed in all patients. A modified anastomosis technique developed by the author (Chen's technique) was applied for bronchial anastomosis. Postoperative outcome and short-term follow-up data were recorded and analyzed. All eight operations were completed uneventfully with no conversion to thoracotomy or reoperation required. No perioperative death was observed. Major results (medians or percentages) were as follows: operative duration, 234.5 [185-345] min; bronchial anastomosis duration, 38.0 [30-43] min; blood loss, 65.0 [50-200] mL; number of lymph node dissected, 22.5 [18-37]. The postoperative complication rate was 37.5% (three of eight cases, including two pulmonary infections and one atrial fibrillation). All patients recovered and were discharged uneventfully with symptomatic therapy. Pathology showed squamous cell carcinoma in seven patients and adenocarcinoma in one patient; two patients were in TNM stage IB, three in stage IIA, one in stage IIB, and two in stage IIIA. The mean follow-up was 7.5 [2-15] months. There were no tumor recurrences or bronchial anastomotic complications. Single-port VATS SL and mediastinal lymphadenectomy are safe and feasible. Improvements in operating procedures can help facilitate single-port VATS. The application of Chen's technique in bronchial anastomosis is easy and reliable and shows a satisfactory short-term clinical outcome.

Surgical Strategy for Lung Transplantation in Adults With Small Chests: Lobar Transplant Versus a Pediatric Donor.

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. 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. 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. 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.

(673) - Surgical Strategy for Small Adult Chests in Lung Transplantation: Lobar vs. Standard Using a Pediatric Donor

(673) - Surgical Strategy for Small Adult Chests in Lung Transplantation: Lobar vs. Standard Using a Pediatric Donor

Anastomotic Airway Complications after Lung Transplantation.

PurposeAnastomotic airway complications are a major cause of morbidity and mortality after lung transplantation (LTx). In this study, the authors identified types and clinical outcomes of airway complications after LTx.Materials and MethodsAll bronchial anastomotic complications were analyzed in a total of 94 LTx cases involving 90 recipients who underwent surgery between July 2006 and May 2014. Fifteen LTx cases (14 recipients) with incomplete medical records for fiberoptic bronchoscopy (FBS) and three cases underwent heart-lung transplantation (HLT) were excluded. Postoperative FBS at 24-48 hours, 1, 3, 6, and 12 months, and then yearly after the transplantation were performed.ResultsA total of 76 LTx cases (75 recipients) were analyzed. The mean age of the recipients was 49.55 years (range, 18-71 years), and 38 (49.4%) were male. Twenty-one out of 76 cases (27.6%) experienced early anastomotic complications, and 12 (15.8%) presented late anastomotic complications. The early anastomotic airway complications presented in various forms: stenosis, 1 case; narrowing, 1; necrosis & dehiscence, 3; fistula, 4; granulation, 10; and infection, 2. Late complications almost entirely presented in the form of bronchial stenosis; five recipients showed stenosis at the anastomosis site, and one of them showed improvement after ballooning. Five others were found to have stenosis at the bronchus intermedius, distal to the anastomosis site. Three of these patients showed improvement after ballooning or bronchoplasty.ConclusionBy serial surveillance via FBS after LTx, we detected anastomotic airway complications in 42.9% of cases, which were successfully managed with improved clinical outcomes.

Bronchial artery revascularization in lung transplantation: revival of an abandoned operation.

Current results of lung transplantation still lag behind those of other solid-organ transplants. Although bronchial dehiscence was the main cause of early mortality in the past, modern-day operative techniques and immunosuppression regiments have decreased, but not eliminated, this complication. Current barriers to long-term survival are chronic lung allograft dysfunction and infection. Bronchial artery revascularization was effective in decreasing bronchial anastomotic complications, but it was largely abandoned because of technical challenges. Long-term follow-up in patients with bronchial artery revascularization has shown a survival advantage compared with the standard lung transplant technique. Recent data also show decreased infection, decreased early rejection and decreased bronchiolitis obliterans syndrome, in addition to confirming the known advantages in bronchial healing. Modifications of the technique have also made bronchial artery revascularization feasible in the pediatric population. Bronchial artery revascularization, although initially designed for bronchial healing, has clinical advantages that extend long term, including survival, infection and decreased graft dysfunction. Its usage in lung transplantation needs to be revisited.

Managing Bronchial Anastomotic Complications – The Influence of Aspergillosis

Purpose Airway complications after lung transplantation remain a challenging problem. We reviewed our experience of managing airway complications and any causal or associated factors. Methods and Materials 170 lung transplants were performed between 2009 - 2012. Patient records were retrospectively reviewed to identify those with an airway complication. Our transplant database was utilised to determine contributing factors including age, ischaemic time, CMV status, pre –operative bacterial and fungal colonisation and early rejection. SPSS statistical analysis was performed. Results Of 170 patients, 156 (Group 1) had no anastomotic complications. 14 (8.2%) required airway intervention (Group 2). Group 1 mean age was 45.1yrs with 93 (54.7%) male recipients. 115 were bilateral lung transplants (BLT) and 41 single lung transplants Group 2 mean age was 46.7yrs with 9 (64.3%) male recipients with 7 BLT. Primary pathology in those with airway complications were IPF (35.7%), CF (28.6%), sarcoidosis (14.3%) and COPD (21.4%). 12 patients had a stenotic lesion at the anastomosis. The number of airway interventional procedures required ranged from 1-5 (mean 2.2). Time from transplant to first intervention ranged from 1- 8months with a mean of 3.8months. Interventions required were balloon dilatation (64.3%), bougie dilatation (28.6%), placement of stent (14.3%) and bronchial toilet alone (14.3%). Bronchial anastamotic stenosis was significantly higher in the presence of pre-transplant Aspergillosis positive sputum (21.7% vs5.4%, p=0.019). The presence of CMV, pseudomonas, and early rejection were comparable in both groups. Post lung transplant airway complication was associated with a mortality of 21.4% with 3 deaths at 7,8 and 13 months. Conclusions Airway complications in the modern era remain challenging to manage, often require multiple interventions and are associated with significant mortality. Our data establishes a relationship between Aspergillus and the development of airway complications. Aggressive peri-operative management with anti-fungals may lower the incidence of anastamotic stenosis.

530 Detection of Post Lung Transplant Airway Ischemia Using Autofluorescence Imaging (AFI) Bronchoscopy

Bronchial anastomotic complication related to ischemia is one of the major morbidity after lung transplantation. Early detection and optimum management for the anastomotic site could reduce the risk of late bronchial stenosis. AFI bronchoscopy has been increasingly recognized as an effective device to detect abnormal mucosal thickening. The aim of this study is to investigate whether AFI bronchoscopy can facilitate the detection of airway ischemic damage in lung transplant patients.

Reply to Dutau et al.

We thank Dr Dutau et al. [1] for their comments regarding our article ‘Novel biodegradable stents in the treatment of bronchial stenosis after lung transplantation’ [2]. In our previous experience, there was a place for both metal and silastic stents in tracheal and bronchial stenosis management, as the authors suggest. Silicone stents were used at our institution in the era before biodegradable stenting. Between January 1997 and January 2005, we performed 98 lung transplants in 67 patients (36 single-lung transplants and 31 bilateral-lung transplants). Four bronchial anastomotic complications requiring stenting (4.1%) occurred in four patients (6.0%). All were successfully treated with silicone–Dumon stents, which were removed at the end of the treatment. Due to our close cooperation with general surgeons, we were confronted with excellent results of biodegradable oesophageal stenting. After the appreciation of laboratory and ongoing animal studies [3], we decided to switch from silicone stents to biodegradable stents. We strongly believe that controlled biodegradation of stents is the future of any stenting, not only in airways. As our study was the very pilot study, we were limited in resources, patient population and of course experience. Currently, more biodegradable stents are available and the period of time for which the stents keeps its sufficient resistive radial forces could be chosen. We do not know if a multiple stent placement for a short period of time is superior to the single stent placement for a longer period of time with all concomitant risks (necrosis, granulation, displacement and complicated removal). This is an issue, which should be addressed in a multicentre trial, which is indeed inevitably needed. Currently, at our institution, we cannot justify the use of silicone stents in benign airway stenosis. Hence, we do not plan to conduct a prospective comparative study. Nevertheless, we feel that more evaluation is needed in designing, manufacturing and in vitro testing of polydioxanone biodegradable stents. Meanwhile, the use of these stents (currently not European Conformity marked) remains highly specifically indicated, although the recent results show high safety, efficacy and biocompatibility. First reports of biodegradable stenting in children (another challenging population with growing airways) were published by our colleagues from Great Ormond Street Hospital in London [4] and one prospective study is conducted in Hannover. To summarize, Dutau et al. are kind in their comments on the place of our work in the development of this field. We agree that future phase III trials of absorbable, and other new stents such as drug-eluting devices, should be compared with both metal and silastic stents, the gold standard comparator carefully chosen depending on the clinical setting. International collaboration in the design and conduct of these trials is essential, and for this reason, we fully welcome this debate and interest.

Outcomes of Sleeve Lobectomy versus Pneumonectomy for Lung Cancer

BackgroundSleeve lobectomy for lung cancer in close proximity to or involving the carina is widely accepted. Operative morbidity and mortality rates, recurrence, and survival rates have varied considerably across studies.Materials and MethodsFrom March of 2005 to July of 2010, sleeve lobectomy was performed in 19 patients and pneumonectomy was performed in 20 patients. In this paper, the results of sleeve lobectomy and pneumonectomy for patients with lung cancer will be compared and evaluated.ResultsThere were no postoperative complications in either group, but there was one mortality in the pneumonectomy group. There was better preservation of pulmonary function in the sleeve lobectomy group than the pneumonectomy group (p=0.066 in FVC, p=0.019 in FEV1). The 3-year survival rates were 46.7% in the sleeve lobectomy group and 54.5% in the pneumonectomy group (p=0.505). The 3-year disease-free survival rates were 38% in the sleeve lobectomy group and 45.8% in the pneumonectomy group (p=0.200).ConclusionSleeve lobectomy for lung cancer showed low mortality, low bronchial anastomotic complication rates, and good preservation of pulmonary function.