Weder Walter, Inci Ilhan, Korom Stephan, Kestenholz Peter B, Hillinger Sven, Eich Christine, Irani Sarosh, Lardinois Didier
University Hospital, Division of Thoracic Surgery, University of Zurich, Switzerland.
Eur J Cardiothorac Surg. 2009 Feb;35(2):293-8; discussion 298. doi: 10.1016/j.ejcts.2008.09.035. Epub 2008 Nov 11.
Anastomotic complications following lung transplantation (LuTx) have been described in up to 15% of patients. Challenging to treat, they are associated with high morbidity and a mortality rate of 2-5%. The aim of this study was to analyze the incidence of complications in a consecutive series of bronchial anastomosis after LuTx at our center and to delineate the potential risk factors.
Between 1992 and 2007, 441 bronchial anastomoses were performed in 235 patients. Indications for transplantation were cystic fibrosis (35.7%) emphysema (28.1%) pulmonary fibrosis (12.8%) and pulmonary hypertension (7.7%). There were 206 sequential bilateral and 28 single transplants including lobar engraftments in 20 cases. The donor bronchus was shortened to the plane of the lobar carina including the medial wall of the intermediate bronchus. Peribronchial tissue was left untouched. Anastomosis was carried out using a continuous absorbable running suture (PDS 4/0) at the membranous and interrupted sutures at the cartilaginous part. Six elective surveillance bronchoscopies were done monthly during the first half-year post-LuTx, with detailed assessment of the pre- and post-anastomotic airways.
One-year survival since 2000 was 90.5%. In all 441 anastomoses performed, no significant dehiscence was observed. In one patient, a small fistula was detected and closed surgically on postoperative day five. Fungal membranes were found in 50% of the anastomoses at 1 month and in 14% at 6 months. Discrete narrowing of the anastomotic lumen without need for intervention was found in 4.9% of patients at 1 month and in 2.4% at 6 months. Age, cytomegalovirus status, induction therapy, immunosuppressive regimen, ischemic time, and ventilation time had no influence on bronchial healing.
Clinically relevant bronchial anastomotic complications after LuTx can be avoided by use of a simple standardized surgical technique. Aggressive antibiotic and antifungal therapy might play an important supportive role.
肺移植（LuTx）后吻合口并发症的发生率在高达15%的患者中有所报道。这些并发症治疗具有挑战性，与高发病率和2% - 5%的死亡率相关。本研究的目的是分析我们中心连续一系列肺移植术后支气管吻合口并发症的发生率，并确定潜在的危险因素。
1992年至2007年期间，对235例患者进行了441次支气管吻合术。移植指征包括囊性纤维化（35.7%）、肺气肿（28.1%）、肺纤维化（12.8%）和肺动脉高压（7.7%）。有206例序贯双侧移植和28例单肺移植，其中20例包括肺叶植入。供体支气管缩短至叶支气管隆突平面，包括中间支气管的内侧壁。支气管周围组织未受触动。在膜部使用连续可吸收缝线（PDS 4/0）进行吻合，在软骨部使用间断缝线。在肺移植后的前半年每月进行6次选择性监测支气管镜检查，详细评估吻合前后的气道情况。
自2000年以来的1年生存率为90.5%。在所有441次吻合术中，未观察到明显的裂开。1例患者在术后第5天发现小瘘口并通过手术闭合。1个月时，50%的吻合口发现真菌膜，6个月时为14%。1个月时，4.9%的患者发现吻合口管腔有离散性狭窄但无需干预，6个月时为2.4%。年龄、巨细胞病毒状态、诱导治疗、免疫抑制方案、缺血时间和通气时间对支气管愈合无影响。
通过使用简单的标准化手术技术可避免肺移植术后临床上相关的支气管吻合口并发症。积极的抗生素和抗真菌治疗可能起到重要的支持作用。
