Mulligan M S
Lung Transplant Program, Division of Cardiothoracic Surgery, University of Washington, Seattle, Washington, USA.
Chest Surg Clin N Am. 2001 Nov;11(4):907-15.
Airway complications remain a source of significant morbidity after lung transplantation. The current incidence of such complications is 12% to 15%. The associated mortality is 2% to 3%. Extensive necrosis and anastomotic dehiscence have become rare, but granulation tissue accumulation, stenosis, and bronchomalacia persist. The major factors that increase the risk for such complications are those that aggravate anastomotic ischemia. Because blood flow to the donor main-stem bronchus is derived from collateral circulation from the pulmonary arteries, minimizing pulmonary inflammation, optimizing pulmonary blood flow, and limiting exposure to positive pressure ventilation are important considerations. Attention to organ preservation techniques and perioperative management is critically important. Controversy remains regarding the optimal anastomotic technique, but properly done, end-to-end anastomosis is readily reproducible and is associated with a low incidence of complications. Attempts to restore the bronchial circulation surgically are not associated with significant reductions in airway complications. Similarly, the routine use of vascularized soft tissue reinforcement no longer seems justified. Most complications can be managed readily with a combination of endoscopic techniques, including débridement (with or without laser or cryotherapy), dilation, and stent placement. Resective procedures rarely are indicated, and retransplantation should be reserved for exceptional cases.
气道并发症仍然是肺移植后显著发病的一个来源。此类并发症的当前发生率为12%至15%。相关死亡率为2%至3%。广泛坏死和吻合口裂开已变得罕见，但肉芽组织积聚、狭窄和支气管软化仍然存在。增加此类并发症风险的主要因素是那些加重吻合口缺血的因素。由于供体主支气管的血流来自肺动脉的侧支循环，因此尽量减少肺部炎症、优化肺血流以及限制正压通气的暴露是重要的考虑因素。关注器官保存技术和围手术期管理至关重要。关于最佳吻合技术仍存在争议，但操作得当的端端吻合很容易重复，且并发症发生率低。通过手术恢复支气管循环的尝试与气道并发症的显著减少无关。同样，常规使用带血管的软组织加固似乎不再合理。大多数并发症可以通过包括清创（有或无激光或冷冻疗法）、扩张和支架置入在内的内镜技术组合轻松处理。很少需要进行切除手术，再次移植应仅用于特殊情况。
