Combined Surgical and Endoscopic Approach for Ring-Sling Complex.

BACKGROUND: Left pulmonary artery (LPA) sling (PAS) is a vascular ring, which is frequently associated with long-segment tracheal stenosis (TS). Mortality rate in operated children is still high, especially in cases of severe tracheal hypoplasia and/or associated congenital heart defects (CHDs). We report our experience of treatment and follow-up in a pediatric cohort of patients affected by PAS with severe tracheobronchial involvement. METHODS: From 2005 to 2017, we enrolled 11 children diagnosed with PAS and congenital TS requiring surgical intervention. Echocardiography, computed tomography, and bronchoscopy were performed in all patients. Associated CHD were present in 5 (45%) patients. Tracheal reconstruction techniques included slide tracheoplasty (7/11; 63%), slide tracheoplasty and costal cartilage graft (2/11; 18%), and Hazekamp technique (2/11; 18%).Nine patients underwent LPA direct reimplantation and concomitant tracheoplasty; concomitant surgical repair for CHD was performed in three children. RESULTS: Over a mean follow-up of 30 months (range: 3-75 months), a late mortality of 18% was registered; no early death occurred. Good flow through LPA could be documented in all patients. Ten children required operative bronchoscopies (mean: 16/patients) aimed at stent positioning/removal, treatment of granulomas, and tracheobronchial dilatation. CONCLUSIONS: Severe tracheobronchial stenosis and associated CHD were the main determinants for hospitalization time, intensive assistance, and repeated endoscopic procedures.Patients affected by PAS/TS complex require a careful management at high-specialized centers providing multidisciplinary team.Respiratory endoscopy may play a central role both in preoperatory assessment and in postoperative management of patients showing severe tracheobronchial involvement.

Tracheobronchial involvement of relapsing polychondritis.

Recent studies show that relapsing polychondritis patients with tracheobronchial involvement are distinct from others in terms of clinical characteristics, therapeutic management, and disease evolution. Tracheobronchial involvement affects 20 to 50% of patients and may reveal the disease. It should be sought at the time of diagnosis and at each follow-up visit. Respiratory impairment is confirmed by computed tomography (CT) of the chest, including the cervical portion of the trachea, with end-inspiratory and dynamic expiratory scans, and pulmonary function tests. These investigations should be performed, even in asymptomatic patients, at the time of diagnosis, and repeated as necessary during follow-up. Bronchoscopy and a fortiori endoscopic intervention should be considered with caution and performed only by expert endoscopists after careful evaluation of the risks and benefits of such procedures, which can lead to damage or perforation of the airways and bronchospasm. Early detection and management of tracheobronchial involvement in relapsing polychondritis has significantly improved the prognosis of patients, especially with the development of interventional fiberoptic bronchoscopy. However, relapsing polychondritis-related morbidity and mortality are still elevated, particularly in tracheobronchial disease.

Metallic small y stent placement at primary right carina for bronchial disease.

BACKGROUND: Metallic large Y stent placement has been used mainly for airway disease around the main carina. However, few studies have reported this treatment for bronchial disease around the primary right carina. METHODS: Twenty-eight patients were treated by small y stent. All stents were custom-designed and placed under fluoroscopic guidance. Clinical and imaging data were analyzed retrospectively. RESULTS: Thirty-one stents were successfully inserted in 28 patients. Twenty-five patients succeed at the first attempt (89.3%), and 3 patients needed a second attempt. Twelve complications occurred in 10 patients (35.7%). Stent restenosis and sputum retention were the most common complications. Five patients underwent successful stent removal due to complications or cure efficacy. During follow up, 17 patients died of tumors and one died of myocardial infarction. The 1-, 3-, and 5-year survival rates were 49.3, 19.6 and 19.6%, respectively. CONCLUSIONS: Metallic small y stent placement is technically feasible, effective and safe for bronchial disease around the primary right carina.

[Causes of death among prostate cancer patients of different ages].

To date, there is no unified approach to evaluating and treating patients with suspected prostate cancer taking into account their age and comorbidities. That was the rationale for conducting this study. AIM: To assess the clinical course of prostate cancer in men of all ages with comorbidities. MATERIALS AND METHODS: The study included 408 patients aged 50 to 92 years (mean age 74.3 years) with histologically verified prostate cancer. 30 (7.4%) patients had stage T1 disease, 273 (66.9%) - T2, 91 (22.3%) - T3 and 14 (3.4%) - T4. The maximum follow-up was 22 years, the minimum one - 6 months (on average 15.4 years). RESULTS: During the follow-up 159 patients died (39%), 51 of them (32%) of prostate cancer, 108 (68%) - from other diseases. Among the latter the causes of death were cancer (20.4%), cardiovascular and bronchopulmonary diseases (79.6%). Cancer-specific survival rate was 41.4 +/-12,4%, the survival rate for other diseases 23.4 +/-10,6% (p<0.05). CONCLUSION: We need a differentiated approach to selecting treatment for patients with prostate cancer, especially of old age, including the option for active surveillance of patients with clinically insignificant prostate cancer.

Anastomotic airway complications after lung transplantation: risk factors, treatment modalities and outcome-a single-centre experience.

OBJECTIVES: Anastomotic airway complications give rise to morbidity and mortality after lung transplantation. Knowledge about contributing factors helps in adopting diagnostic and therapeutic strategies. Systematic endoscopic description and classification play a key role. METHODS: A retrospective analysis of all bronchial anastomoses between 2005 and 2013 was performed to assess anastomotic complications and associated variables. Treatment modalities and outcome of endobronchial and surgical interventions are reported. RESULTS: The prevalence of anastomotic airway complications in our cohort was 11%. Contributive factors were all recipient-dependent: microbial infection during the first postoperative trimester [odds ratio (OR) 3.4 (2.1-5.5); P < 0.0001], recipient age [OR 3.0 (1.3-7.1); P = 0.01], right-sided anastomosis [OR 2.5 (1.4-3.3); P = 0.001], the presence of microbiological colonization prior to transplantation [OR 1.8 (1.1-3.1); P = 0.02] and [Formula: see text] during the first 72 h after transplantation [OR 1.6 (1.1-2.7); P = 0.04]. Seventy-five percent of cases were managed conservatively, of which 93% evolved clinically favourable during follow-up. Our data support the use of the proposed MDS classification and show that MDS class M3b, D2x, Sxe or higher are associated with an increased intervention rate. CONCLUSION: Anastomotic airway complications remain an important issue after lung transplantation. The identified risk factors may play a role in the pathophysiology of anastomotic complications. The indication for endobronchial intervention should be carefully considered based on endoscopic classification since most cases resolve or stabilize over time.

Bronchoscopic management of patients with symptomatic airway stenosis and prognostic factors for survival.

BACKGROUND: Interventional bronchoscopy is effective in the management of patients with symptomatic airway obstruction for both malignant and benign conditions. The main aim of this study is to report our experience with emergency interventional bronchoscopy in patients with symptomatic airway obstruction and identify prognostic factors for survival. METHODS: This is a retrospective observational study of patients undergoing emergency interventional bronchoscopy over a 4-year period. Survival times were analyzed separately for patients with benign and malignant airway obstruction by the Kaplan-Meier method. RESULTS: Between June 2009 and July 2013, 168 emergency interventional bronchoscopies were performed in 112 patients for airway obstruction. The median age was 63 years (range, 20 to 86), and 91 patients (54%) patients were female. Seventy-two cases (43%) had airway obstruction due to malignant disease. There were 3 in-hospital deaths (2.7%). Median survival of the study population was 5.6 months (range, 0 to 51) with a median follow-up of 7.3 months (range, 0 to 51). Median survival for patients with malignant airway obstruction was 3.5 months (range, 0 to 21), and 9.8 months (range, 0.1 to 51) for those with benign disease. Airway intervention facilitated palliative chemotherapy in 32 patients (44%) of those with malignant airway obstruction. At multivariate analysis in patients with malignant airway obstruction, presence of stridor (hazard ratio 1.919, 95% confidence interval: 1.082 to 3.404, p = 0.026) and not receiving postprocedure chemotherapy (hazard ratio 2.05, 95% confidence interval: 1.156 to 3.636, p = 0.014) were independent prognostic factors for death. CONCLUSIONS: Emergency interventional bronchoscopy for airway obstruction is safe, relieved symptoms, and facilitated palliative chemotherapy, which improved survival.

A comparative analysis of bronchial stricture after lung transplantation in recipients with and without early acute rejection.

BACKGROUND: Risk factors and outcomes of bronchial stricture after lung transplantation are not well defined. An association between acute rejection and development of stricture has been suggested in small case series. We evaluated this relationship using a large national registry. METHODS: All lung transplantations between April 1994 and December 2008 per the United Network for Organ Sharing (UNOS) database were analyzed. Generalized linear models were used to determine the association between early rejection and development of stricture after adjusting for potential confounders. The association of stricture with postoperative lung function and overall survival was also evaluated. RESULTS: Nine thousand three hundred thirty-five patients were included for analysis. The incidence of stricture was 11.5% (1,077/9,335), with no significant change in incidence during the study period (P=0.13). Early rejection was associated with a significantly greater incidence of stricture (adjusted odds ratio [AOR], 1.40; 95% confidence interval [CI], 1.22-1.61; p<0.0001). Male sex, restrictive lung disease, and pretransplantation requirement for hospitalization were also associated with stricture. Those who experienced stricture had a lower postoperative peak percent predicted forced expiratory volume at 1 second (FEV1) (median 74% versus 86% for bilateral transplants only; p<0.0001), shorter unadjusted survival (median 6.09 versus 6.82 years; p<0.001) and increased risk of death after adjusting for potential confounders (adjusted hazard ratio 1.13; 95% CI, 1.03-1.23; p=0.007). CONCLUSIONS: Early rejection is associated with an increased incidence of stricture. Recipients with stricture demonstrate worse postoperative lung function and survival. Prospective studies may be warranted to further assess causality and the potential for coordinated rejection and stricture surveillance strategies to improve postoperative outcomes.

[Pace of pulmonary function deterioration in patients with occupational bronchial diseases: influence of various factors].

Prospective cohort study covered 348 workers of dust-related occupations with verified occupational bronchial diseases. The authors studied dependence between industrial aerosol levels at workplace, smoking status and pace of pulmonary function decrease in individuals with chronic bronchitis and COLD. Conclusion is that totality of occupational bronchial diseases patients is uneven and differs in course and clinical and functional parameters.

Novel silicone stent to treat tracheobronchial lesions: results of 35 patients.

We describe a case series of 35 patients with either benign (14) or malignant (21) tracheal stenosis who were treated using a novel silicone stent, the HCPA-1, designed to prevent migration. Between March 2001 and September 2008, 13 women and 22 men received 41 HCPA-1 stents. The median duration of stenting in benign cases was 457 days (range, 4-2,961 days). Successful stent removal with curative results was accomplished in 2 patients with tracheomalacia and 1 with post-intubation stenosis. In malignant cases, the median duration of stenting was 162 days (range, 1-1,279 days). Five patients had tumor progression with obstruction requiring repeated laser resection, dilatation, or additional stents. Two patients died due to airway obstruction despite bronchoscopic intervention. Twelve patients with malignant lesions died with the stent in place. At the end of the study, 3 patients with malignant disease remained alive; 2 were lost to follow-up. The HCPA-1 stent proved to be safe, with no severe complications during the study period, and effective in improving quality of life with relief of dyspnea.

Changing patterns in interventional bronchoscopy.

BACKGROUND AND OBJECTIVE: Many interventional tools for airway disorders can now be delivered via flexible bronchoscopy (FB), including neodymium-yttrium aluminium garnet laser, electrocautery, argon plasma coagulation, cryotherapy, balloon dilatation and metal or hybrid stents. Comparison of outcomes for patients undergoing rigid bronchoscopy (RB) with those treated using FB highlights the usefulness of the FB approach. METHODS: A retrospective medical record review of all interventional bronchoscopy procedures performed at Lahey Clinic over the past 8 years was conducted. Patients were categorized into two groups according to the procedure used, that is, RB (251 patients), and FB (161 patients) groups. Patients with malignancies were included as a separate subgroup, comprising 178 RB and 117 FB patients. For every procedure, the location of the lesion, patient survival from the first interventional procedure performed, and in patients with malignancy, additional treatments received such as chemotherapy and radiation were recorded. RESULTS: Ninety per cent of RB procedures were performed in patients with tracheal or main stem lesions, while over half the patients undergoing FB had more distal lesions. A trend towards increasing use of FB for interventional procedures in recent years was noted. CONCLUSIONS: FB is a valuable alternative to RB for treating less advanced malignant disease or distal airway lesions.

Incidence, management and clinical outcomes of patients with airway complications following lung transplantation.

OBJECTIVE: Airway complications (AC) remain a significant contributing factor of morbidity after lung transplantation (LT). The aim of this study was to identify risk factors for AC, and to review the outcomes after endoscopic and surgical treatment. METHODS: From 1993 to 2006, 255 patients underwent LT. Seven retransplants and 34 patients not surviving beyond 7 days were excluded. The remaining patients were: 124 double LT (DLT), 85 single LT (SLT), 3 lobar LT and 2 liver-DLT, comprising 343 bronchial anastomoses at risk. Donor lungs were flushed with either modified Eurocollins or Perfadex. Bronchial anastomoses were telescoped when needed. Donor and recipient variables were recorded and analyzed by univariate and multivariate tests to identify risk factors for AC, and to assess differences between both complicated and non-complicated groups. RESULTS: Among 343 bronchial anastomoses, 31 presented AC (9%) in 27 patients (12.6%): 22 stenoses, 5 dehiscences, and 4 malacias, at 2.6+/-1.7 months post-transplant. Indications were 7 emphysema, 3 Alpha-1-antitrypsin deficiency, 12 cystic fibrosis (p=0.007), 4 pulmonary fibrosis, and 1 bronchiectasis. AC were observed in 4 SLT and 23 DLT (p=0.005). Incidence of AC did not differ between telescoped and non-telescoped anastomoses. By univariate analysis, AC were more frequent in grafts preserved with modified Eurocollins (p=0.033), CMV infection/disease (p=0.027) and airway colonizations post-transplant (p=0.021). Other donor and recipient variables did not differ between groups. By multivariate analysis, intubation longer than 72 h, DLT, and airway colonizations post-transplant remained independently associated with AC. Survival did not differ between groups. Most patients were successfully treated with endoscopic procedures; three required reoperation (lobectomy, pneumonectomy, retransplantation). AC related mortality was 1%. CONCLUSIONS: The incidence of AC after LT is 12.6% with a related mortality of 1%, irrespective of the technique of bronchial anastomosis performed. DLT, airway colonizations, and prolonged intubation post-transplant are associated with AC. Either endoscopic procedures or surgical therapy resolve these complications in most cases.

Risk factors for airway complications within the first year after lung transplantation.

OBJECTIVE: Lung transplantation (LTx) has enjoyed increasing success with better survival in recent years. Nevertheless, airway anastomotic complications (AC) are still a potential cause of early morbidity and mortality. In this retrospective cohort study we looked at possible predictors of AC within the first year after LTx. METHODS: Between July 1991 and December 2004, 232 consecutive single (n=102) and bilateral (n=130) LTx were performed (142 males and 90 females; mean age: 48 years [range 15-66 years]). Indications for LTx were emphysema (n=113), pulmonary fibrosis (n=45), cystic fibrosis (n=35), pulmonary hypertension (n=10), sarcoidosis (n=7) and miscellaneous (n=22). Donor variables (age, gender, PaO(2)/FiO(2), mechanical ventilation, ischemic time and preservation solution) and recipient variables (age, diagnosis, length, gender, pre-operative steroids, smoking, cytomegalovirus matching, LTx type, anastomotic type, wrapping and bypass) were evaluated in an univariate and multivariate model. RESULTS: Fifty-seven complications occurred in 362 airway anastomoses (15.7%) of which 55 (15.2%) within the first year after transplantation. Six patients died as a result of AC (mortality 2.6%) during the first year after LTx. In a univariate analysis (321 airway anastomoses at risk), anastomotic type (7/17 [Telescoping] vs 48/304 [End-to-end]; p=0.011), recipient length (p=0.0012), donor ventilation (>50-70h<; p=0.0015) and recipient male gender (43/191 [M] vs 12/130 [F]; p=0.0092) were significant predictors of AC. Three factors remained significant predictors in the multivariate analysis: telescoping technique (p=0.0495), recipient length (p=0.0029) and donor ventilation (p=0.003). CONCLUSIONS: Tall recipients and those receiving lungs from donors with prolonged ventilation have an increased risk to develop bronchial anastomotic problems. An end-to-end anastomosis should be preferred. Airway complications remain a matter of concern after lung transplantation.

Main bronchial reconstruction with sparing of pulmonary parenchyma for benign diseases.

Main bronchial reconstruction is anatomically suitable for benign main bronchial stenosis. But, it has been hardly recommended for operative mortality and morbidity. This study was aimed at providing validity and the proper clinical information of bronchoplasty for benign main bronchial stenosis by reviewing the results we obtained over the last ten years for main bronchial reconstruction operations. We retrospectively reviewed admission and office records. Twenty eight consecutive patients who underwent main bronchoplasty were included. Enrolled patients underwent main bronchial reconstruction for benign disease (tuberculosis in 21, trauma in 4, endobronchial mass in 3). Concomitant procedures with main stem bronchoplasty were performed in 19 patients. There were no incidences of postoperative mortality and significant morbidity. There were 2 cases of retained secretions, and these problems were resolved by bronchoscopy or intubation. All of the patients are still alive without obstructive airway problem. Bronchoplasty should be considered as one of the primary treatment modalities, if it is anatomically feasible.

Malignant esophageal-tracheobronchial strictures: parallel placement of covered retrievable expandable nitinol stents.

PURPOSE: To assess the safety and clinical effectiveness of the parallel placement of covered retrievable expandable metallic stents in the palliative treatment of malignant esophageal and tracheobronchial strictures. MATERIAL AND METHODS: Under fluoroscopic guidance, parallel stents were placed in 12 symptomatic patients with both malignant esophageal and tracheobronchial strictures. Seven of these 12 patients also had an esophagorespiratory fistula (ERF) and one patient had an esophagocutaneous fistula. Technical success, clinical improvement, complications, and survival rates were evaluated. RESULTS: A total of 28 esophageal and airway stents were successfully placed. The grade of dysphagia and dyspnea score significantly decreased after stent placement (P=0.002 and 0.003, respectively). ERF and esophagocutaneous fistula were sealed off in all eight patients after esophageal stent placement; however, the esophagocutaneous fistula reopened 1 month later. Complications included stent migration or expectoration (n=3), tracheal compression by the esophageal stent (n=3), new fistula development due to covering membrane degradation of the esophageal stent (n=1), and symptomatic sputum retention (n=1). Stent removal was easily performed for two stents; one migrated stent and the other with covering membrane degradation. All 12 patients died within the mean survival period of 72.50 days (range 7-375 days). CONCLUSION: Parallel placement of covered retrievable expandable metallic stents is safe and effective for the palliative treatment of malignant esophageal and tracheobronchial strictures.

Management of malignant tracheobronchial stenoses with the use of airway stents.

BACKGROUND: Tracheobronchial stenoses caused by malignant etiologies are life-threatening with respiratory distress symptoms. Airway stent insertion is an effective method of relieving the airway obstruction. We report our experience with the use of Dumon silicone stents and self-expandable metallic Ultraflex stents. METHODS: From July 1999 to December 2003, ten patients (7 men, 3 women) with a mean age of 56.3 years (range, 37 to 77 years) had stent insertion to manage their malignant airway stenoses. Underlying malignancies included 6 esophageal cancers, one NPC with mediastinal recurrence, 1 recurrent adenoid cystic carcinoma, 1 metastatic mediastinal lymphadenopathy and 1 mediastinal multiple myeloma. All patients had severe respiratory distress. All stents were placed through a rigid Efer-Dumon bronchoscope under general anesthesia. RESULTS: Eight Dumon silicone stents (4 tracheal, 1 bronchial and 3 Y-shaped) were placed in 7 patients. Four metallic Ultraflex stents (2 tracheal and 2 bronchial) were placed in 3 patients. There was no death related to stent placement, and there were no immediate complications after stenting. Significant improvement of respiratory distress was seen in 9 patients (90%) after stenting. Three stent migrations occurred in 12 stent placements. During follow-up to the present time, 7 patients died of disease progression, with a median survival of 5.2 months (range, 1 to 17.8 months) after stenting. Two patients remain alive, with survivals of 49 and 12 months respectively. CONCLUSIONS: The insertion of the airway stents, either Dumon silicone stents or metallic Ultraflex stents, can provide an effective method to immediately relieve respiratory distress, to improve the quality of life and to prolong survival in patients with malignant central airway stenoses.

Stenting at the flow-limiting segment in tracheobronchial stenosis due to lung cancer.

Airway stenting at the wave-speed flow-limiting segment (the choke point) is assessed. We determined prospectively the precise location of the choke point using the flow-volume curve, endobronchial ultrasonography, ultrathin bronchoscopy, and three-dimensional computed tomography scan before and after stenting in 64 patients with extrincic compression due to lung cancer. We noted distinct flow-volume curve patterns specific to the type of stenosis. The tracheal stenosis group indicated fixed narrowing patterns with an expiratory plateau, bronchial stenosis group dynamic collapse patterns with an expiratory flow deterioration (choking), carinal stenosis group combined fixed and dynamic patterns, and extensive stenosis group complex patterns containing elements of all the former. After stenting, almost full-function patterns with significant improvement in PEF were observed in all groups (p < 0.01, p < 0.05, p < 0.001, p < 0.01, respectively). In patients with extensive stenosis, implantation of additional stents was required when the choke points were observed to have migrated to the areas of malacia with cartilage destruction by the tumor. Secondary stenting at migrated choke points resulted in a significant improvement in PEF over the initial stenting (p < 0.01). Stenting at the choke point improved expiratory flow limitation by increasing the cross-sectional area, supporting the weakened airway wall and relieving dyspnea.

Incidence and underlying etiologies of bronchial secretion in terminally ill cancer patients: a multicenter, prospective, observational study.

Although bronchial secretion is frequently observed in terminally ill cancer patients and can cause significant distress for both patients and family members, the pathophysiology is unclear. The primary aim of this study was to investigate the incidence and underlying etiologies of bronchial secretion. A multicenter, prospective, observational study was conducted on consecutive terminally ill patients with lung or abdominal malignancies. Primary physicians and nurses prospectively evaluated patients' symptoms. Of 310 patients enrolled, bronchial secretions were observed in 41% in the final 3 weeks, and oral/bronchial suctioning, with considerable distress, was required in 9%; bronchial secretions were severe in 4.5% of all patients. Multiple logistic regression analyses revealed that the determinants of the development of bronchial secretion were primary lung cancer, pneumonia, and dysphagia. There were no statistically significant effects of severity of peripheral edema and pleural effusion on development of bronchial secretions and requirement for oral/bronchial suctioning. Etiology-based classification of bronchial secretion is useful to identify the most suitable palliative treatments and to clarify treatment efficacy in each specific pathophysiology.

Malignant tracheobronchial strictures: palliation with covered retrievable expandable nitinol stent.

PURPOSE: To evaluate the safety and clinical effectiveness of a covered retrievable expandable nitinol stent for the treatment of malignant tracheobronchial stricture and/or esophagorespiratory fistula (ERF). MATERIALS AND METHODS: With fluoroscopic guidance, stents were placed in 35 symptomatic patients with malignant tracheobronchial stricture and/or ERF in most cases caused by lung or esophageal cancer. The site of stricture was most commonly at the trachea or left main bronchus. If there were complications, the stent was removed with a retrieval set. Nine patients had combined symptomatic ERF. RESULTS: A total of 47 tracheobronchial stents were placed and were technically successful and well-tolerated in all patients. Improvement of dyspnea was achieved in 92% of the patients (24 of 26 patients). Associated ERF in nine patients was effectively treated with tracheobronchial stent placement with or without esophageal stent placement. Stent migration, tumor overgrowth, symptomatic sputum retention, and hemoptysis occurred in 17% (6/35), 6% (2/35), 20% (7/35), and 17% (6/35) of patients, respectively. There were no documented cases of tumor ingrowth. Stent removal was performed easily in five patients when stent migration (n = 2), severe pain (n = 1), tumor overgrowth (n = 1), or persistent gastrobronchial fistula (n = 1) developed. All patients died 2 days to 26 weeks (mean, 9.62 weeks) after stent placement because of disease progression (n = 18), pneumonia (n = 9), hemoptysis (n = 5), or unknown cause (n = 3). CONCLUSION: Use of a covered retrievable expandable nitinol stent is a safe and effective method for relieving dyspnea. This procedure contributed to improved quality of life for patients with malignant tracheobronchial stricture and/or ERF. Stent retrievability was useful in resolving stent-related complications.

A modified bronchial anastomosis technique for lung transplantation.

BACKGROUND: Low rates of major complications have been reported for the intussuscepting bronchial anastomotic technique but stenosis, malacia, and granulation tissue at the anastomosis may cause clinically important morbidity. We hypothesized that a modification of the telescoping technique that improves bronchial wall apposition might be associated with improved bronchial healing and clinical outcomes. METHODS: The telescoping horizontal mattress "U-stitch" suture technique was modified to incorporate figure-of-eight sutures placed in the cartilaginous wall between each of three intussuscepting U stitches. Serial videotape records of 152 individual anastomoses (99 modified, 53 telescoped) in 118 consecutive operative survivors were retrospectively reviewed by examiners blinded with respect to technique used. Stenosis, airway instability, mucosa quality, and devascularized luminal tissue were graded at 4 to 14 days (initial), 4 to 12 weeks (early), and 6 to 12 months (late) after transplantation. RESULTS: The incidence of anastomotic stenosis was significantly lower using the modified technique at the initial (p = 0.025) and late (p = 0.015) observations. In the initial phase airway instability (p = 0.015) and devascularization grades (p = 0.001) were also significant lower in the modified group. There were no significant differences in mucosal condition between techniques. The modified telescoping technique was associated with significant survival advantage (mean 17.7%; p = 0.029) by multivariate analysis. The incidence of major airway complications (dehiscences and stenoses required stents) tended to be lower (3% versus 6%) in the modified group. CONCLUSIONS: The modified telescoping bronchial anastomosis technique is associated with improved early and late bronchial healing and higher 5-year survival without increased major airway complications.