Bronchial dehiscence after lung transplantation is difficult to treat and associated with high mortality. We describe our experience using self-expanding metallic stents to treat post-lung transplant bronchial dehiscence. From January 1995 to June 2004, 189 single and 118 double lung transplants were performed in our institution, totaling 425 at-risk bronchial anastomoses. Seven (1.6%) incidents of life-threatening bronchial dehiscence were treated with self-expanding metallic stents. The interval between transplant and diagnosis of dehiscence was 29.1 +/- 18.5 days. All patients presented with respiratory distress, and three required mechanical ventilation. Self-expanding metallic stent placement resulted in complete bronchial healing. All three patients with respiratory failure requiring mechanical ventilation were successfully weaned after stent placement. In two later cases, the stents were electively removed after adequate healing of the dehiscence. Complications included stent migration (one patient) and in-stent stenosis (three patients). Two of these patients required repeat stent insertion after removal, due to bronchomalacia. In patients with life-threatening bronchial dehiscence, self-expanding metallic stents offer prospects for a successful outcome. Self-expanding metallic stents are known to be associated with significant granulation tissue formation, and this property provides a platform for healing of dehiscence and, in time, peribronchial soft tissue grows in to cover the defect, allowing stent removal.

Anastomosis, Surgical↗

PubMed2005

Invited commentary.

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Biopsy, Fine-Needle↗

PubMed2005

Thoracoscopically guided transaxillary resection of adjoining intercostal plexiform neurofibromas: review of mosaicism in neurofibromatosis: technical note.

OBJECTIVE AND IMPORTANCE: The present article describes a rare presentation of Type I neurofibromatosis (NFI) involving adjoining intercostal plexiform neurofibromas, as well as the novel use of thoracoscopy to guide surgical resection. This presentation highlights the manner in which NFI may affect selective regions of the body disproportionately through genetic mosaicism. CLINICAL PRESENTATION: A 40-year-old man had intractable neuropathic anterior right chest wall pain in the distribution of T2 and T3. Magnetic resonance imaging and computed tomography of the chest revealed masses deep to the second and third ribs in the axilla. Biopsy of a subcutaneous nodule in the right chest wall revealed a small neurofibroma. An extensive workup revealed no masses outside the region of the right chest wall and no stigmata of NFI. INTERVENTION: The patient underwent right-sided thoracoscopy for identification of the intrathoracic neurofibromas and placement of spinal needles to localize the anterior and posterior extent of the masses. These landmarks were used to guide a transaxillary approach to third rib resection and nerve-sparing neurofibroma resection. CONCLUSION: Isolated adjoining intercostal plexiform neurofibroma is a unique presentation of mosaic NFI. Because of its limited penetrance, this variant may present as a regional pain syndrome. Thoracoscopy can be used effectively to guide intercostal nerve sheath tumor resection.

Abdominal Neoplasms↗

PubMed2004

Pulmonary nodules in lung transplant recipients: etiology and outcome.

BACKGROUND: The pulmonary nodule (PN) poses a diagnostic and therapeutic challenge in the immunocompromised host. Common causes of PNs in lung transplant (LT) recipients include bacterial or fungal infections and posttransplant lymphoproliferative disorder (PTLD). However, experience in diagnosis and management of PNs is limited. METHODS: Two hundred thirty-four LTs were performed between February 1990 and December 2000. Medical records of all patients with PNs were reviewed retrospectively. Data on presentation, radiographic features, diagnostic methods, therapy, and outcome were collected and analyzed. RESULTS: Twenty-three patients had PNs after a follow-up of 20.1 +/- 20.1 months (mean +/- SD). The mean age was 45.5 +/- 14.4 years, with a male:female ratio of 17:6. Thirteen patients received single LT, 9 patients received bilateral LT, and 1 patient received heart-LT. Cough and dyspnea were the most common symptoms at presentation, and PNs were better detected by CT than chest radiography. Solitary PNs were due to bronchogenic carcinoma and PTLD, while multiple PNs were due to invasive pulmonary aspergillosis (IPA), cytomegalovirus pneumonitis, bronchiolitis obliterans, and metastatic carcinoma. Bronchoscopy with BAL and transbronchial lung biopsy was the usual method of diagnosis (n = 17, 74%), and our mortality rate was 70%. CONCLUSION: PNs are not uncommon in patients following LT. The majority were due to IPA and PTLD. Prophylaxis with itraconazole against Aspergillus, and acyclovir for Epstein-Barr virus-negative LT recipients, serial CT and surveillance bronchoscopy for early detection of Aspergillus infections, and rituximab therapy for PTLD could improve the outcome of these patients.

Aspergillosis↗

PubMed2003

The role of self-expandable metallic stents for the treatment of airway complications after lung transplantation.

BACKGROUND: Airway complications continue to be an important source of morbidity and mortality after lung transplantation (LTx). Different approaches have been used for their nonsurgical management. We describe our experience using self-expandable metallic stents (SEMSs) in patients with airway complications post-LTx. METHODS: We present a retrospective analysis of stent related-data of all the LTx patients who received SEMSs to treat postoperative airway complications. RESULTS: Between January 1992 and December 2001, 36 of 253 patients (14.2%) developed post-LTx airway complications involving 40 of 348 anastomoses (11.5%). A total of 15 SEMSs were placed in 12 patients (mean age 47.3+/-9.6 years) for tracheobronchomalacia, stenosis, and anastomotic dehiscence, including one patient referred from an outside hospital. Mean follow-up was 20.1+/-19.5 months (range 1.2-58 months). Patency and symptom improvement were achieved in 11 of 12 patients. Stenting of the airway led to successful weaning of two patients who were on prolonged mechanical ventilation. Suture dehiscence was effectively managed in two patients who were not candidates for surgical repair. Overall, the complication rate was 0.040 complications per patient per month (total number of complications and total number of months using the stent). Bacterial bronchitis (four patients) and obstructive granulomas (three patients) were the most frequent complications. The survival of LTx patients with airway SEMSs was similar when compared with the survival of all other LTx patients (P=0.74). CONCLUSIONS: SEMSs are safe and effective in the management of airway complications in selected patients post-LTx. Weaning from mechanical ventilation and management of anastomotic dehiscence are the unique attributes of this device.

Adult↗

PubMed2003

Self-expandable metallic airway stents and flexible bronchoscopy: long-term outcomes analysis.

STUDY OBJECTIVE: s: To report and analyze our 6-year experience with implanting 112 self-expandable metallic stents (SEMSs) using flexible bronchoscopy (FB). DESIGN AND SETTING: Retrospective study, tertiary-care hospital. PATIENTS AND METHODS: The studied population consisted of 82 patients (mean age, 59.1 years; range, 37 to 83 years), who received SEMSs from 1995 to 2001 using Wallstent (Boston Scientific; Galway, Ireland) or Ultraflex (Boston Scientific) stents. RESULTS: The indications for stent placement were airway obstruction caused by neoplasia (lung carcinoma [CA], n = 50), airway complications of lung transplantation (LTx) [n = 11], and miscellaneous benign conditions (BCs) [n = 21]. The most frequent clinical presentations for the airway obstruction were moderate-to-severe dyspnea (80%) and coughing (45%). The median follow-up duration for the CA group was 42.0 days (range, 1 to 672 days), 329.0 days (range, 35 to 1,540 days) for patients receiving LTx, and 336.0 days (range, 7 to 2,184 days) for the patients with miscellaneous BCs. The observed complications included infection (15.9%), obstructive granulomas (14.6%), and migration (4.7%). The incidence of granulomas was significantly lower in the patients with CA (4.0%) vs LTx and BC groups (17.3% and 33.3% respectively; p = 0.002). All other assessed variables showed no difference between the three analyzed groups. No cases of mucus plugging or fatal hemoptysis were observed. Forty-four patients (53.7%) had no complications related to the SEMS. The incidence of complications was not related to the type of stent (Wallstent or Ultraflex) or SEMS version (covered or uncovered). Fourteen of the 16 patients (87.5%) who were receiving mechanical ventilation could be weaned after the procedure. There were no deaths related to SEMS placement. CONCLUSIONS: An SEMS is a safe and effective modality for malignant as well as selected benign airway obstruction. An SEMS is an acceptable therapeutic alternative in patients with central airway obstruction who are not considered good surgical candidates and are receiving mechanical ventilation. Careful patient selection is of outmost importance for a good outcome after airway stenting. Insertion using FB adds to the ease of the procedure.

Adult↗

PubMed2002

Gastropericardial fistula after laparoscopic surgery for reflux disease.

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Aged↗