Anastomotic Suturing Techniques and Their Association With Post-Lung Transplantation Complications.

INTRODUCTION: Currently, standard practice is to use the continuous suturing technique on the bronchial anastomosis during lung transplantation. This study used a large cohort to investigate and contrast continuous and interrupted suturing techniques, comparing survival outcomes and occurrence of postoperative bronchial complications to examine if utilization of interrupted suturing has merit. METHODS: Survival outcomes of 740 single-center lung transplant recipients over 8 y (February 2012-March 2020) were compared by suturing techniques: either continuous or interrupted at the bronchial anastomosis. Clinical parameters and demographics were compared between two suturing groups, with P values < 0.05 considered significant. The groups were compared for postoperative morbidity, including need for bronchial interventions. Survival was compared using Kaplan-Meier curves and log-rank tests. Cox regression analysis was run with statistically significant variables to study association with survival. RESULTS: Of the 740 patients, 462 received the continuous suturing technique and 278 received the interrupted suturing technique. Most demographic and clinical data were not statistically significant between the two groups, and those that were significant were not associated with worse survival outcomes, with the exception of the variable diagnosis. Bronchial complications were comparable between the continuous and interrupted groups (12.6% versus 10.4%, P = 0.382). Extracorporeal membrane oxygenation (ECMO) use did not differ significantly between the two groups (P = 0.12). The Kaplan-Meier curve showed comparable survival between groups (P = 0.98), and Cox regression analysis showed that only diagnosis, bronchial complications, and ECMO utilization were associated with different survival outcomes. Chronic obstructive pulmonary disorder was shown to be associated with more favorable survival outcomes as opposed to idiopathic pulmonary fibrosis and the category "other". The need for ECMO and the occurrence of a bronchial complication were also associated with worse survival outcomes. CONCLUSIONS: Both techniques showed reasonable post-transplant outcomes, as our study demonstrated similar survival outcomes and bronchial complication rates.

Airway Complications after Lung Transplantation-A Contemporary Series of 400 Bronchial Anastomoses from a Single Center.

(1) Objective: To determine whether recent advances in lung transplantation (LT) have reduced the incidence and changed the risk factors for airway complications (AC). (2) Methods: Retrospective analysis of patients receiving a lung transplant between January 2007 and January 2019. An AC was defined as a bronchoscopic abnormality in the airway, either requiring or not requiring an endoscopic or surgical intervention. Both univariable and multivariable analyses were performed to identify risk factors for AC. (3) Results: 285 lung transplants (170 single and 115 bilateral lung transplants) were analysed, comprising 400 anastomoses at risk. A total of 50 anastomoses resulted in AC (12%). There were 14 anastomotic and 11 non-anastomotic stenoses, 4 dehiscences, and 3 malacias. Independent predictors for AC were: gender male (OR: 4.18; p = 0.002), cardiac comorbidities (OR: 2.74; p = 0.009), prolonged postoperative mechanical ventilation (OR: 2.5; p = 0.02), PaO2/FiO2 < 300 mmHg at 24 h post-LT (OR: 2.48; p = 0.01), graft infection (OR: 2.16; p = 0.05), and post-LT isolation of Aspergillus spp. (OR: 2.63; p = 0.03). (4) Conclusions: In spite of advances in lung transplantation practice, the risk factors, incidence, and lethality of AC after LT remains unchanged. Graft dysfunction, an infected environment, and the need of prolonged mechanical ventilation remain an Achilles heel for AC.

Surgical Outcome after Sleeve Pneumonectomy for Thoracic Malignancy: A Comparison Between Salvage and Non-salvage.

Objectives: Tumors invading the tracheobronchial angle or carina have long presented a challenge due to the complexity of airway reconstruction and management; thus, few medical centers have developed experience with this type of surgery. In this report, we review our experience with Sleeve Pneumonectomy (SP) and analyze both operative risks and outcomes. Materials and Methods: A retrospective review identified 34 patients who underwent SP: 19 underwent salvage SP and 15 underwent non-salvage SP. Salvage surgery was performed for recurrent lung cancer after chemoradiotherapy and could be considered if there were no other therapeutic options or in the presence of urgent symptoms, such as hemoptysis, obstructive pneumonia, superior vena cava syndrome, or tracheoesophageal fistula.The perioperative morbidity and oncological outcomes of salvage and non-salvage SP were analyzed. Results: Most cases were of lung cancer, whereas salvage SP included one case of SVC syndrome due to metastasis of colon cancer and one case of hemoptysis due to metastasis of leiomyosarcoma. Complications occurred in 47% of the non-salvage SP cases and 53% of the salvage SP cases. The 30-day mortality rates were zero in the non-salvage cases and 11% in the salvage cases. The 90-day mortality rates were 20% and 16% in the non-salvage and salvage groups, respectively. Conclusions: The salvage of SP after chemoradiotherapy or in the presence of urgent symptoms is feasible. We believe that it can be an option that improves quality of life (QOL) through longer desease-free survival (DFS) and alleviation of symptoms, rather than waiting for tumor growth progression and exacerbation of symptoms.

Treatment of bronchial anastomotic fistula using autologous platelet-rich plasma post lung transplantation.

BACKGROUND: Bronchial anastomotic dehiscence is considered one of the most catastrophic early airway complications post-transplant. The presence of a partial dehiscence can also cause further complications such as a fistula between the bronchus and the pleural membrane. Platelet-rich plasma (PRP) is known to significantly enhance the healing process and is being used in the treatment of various conditions, however, so far, there are no reports of the use of PRP in the treatment of bronchial anastomotic dehiscence fistula. CASE PRESENTATION: We present a 37-year-old male, with non-cystic fibrosis bronchiectasis underwent bilateral lung transplantation. The patient developed partial dehiscence of the right bronchial anastomosis that was complicated by a small bronchopleural fistula. Two bronchoscopic applications of autologous platelet-rich plasma were carried out. Follow-up a few weeks later showed complete closure and healing of the fistula. CONCLUSIONS: This case report suggests that the treatment of post-lung transplant small bronchial anastomotic partial dehiscence fistula with PRP is safe and effective.

Taking a Deep Breath: an Examination of Current Controversies in Surgical Procedures in Lung Transplantation.

Purpose of Review: This article reviews controversial questions within the field of lung transplantation, with a focus on data generated within the last 3 years. We aim to summarize differing opinions on a selection of topics, including bridge-to-transplantation, intraoperative machine circulatory support, bronchial anastomosis, size mismatch, delayed chest closure, and ex vivo lung perfusion. Recent Findings: With the growing rate of lung transplantations worldwide and increasing numbers of patients placed on waiting lists, the importance of determining best practices has only increased in recent years. Factors which promote successful outcomes have been identified across all the topics, with certain approaches promoted, such as ambulation in bridge-to-transplant and widespread intraoperative ECMO as machine support. Summary: While great strides have been made in the operative procedures involved in lung transplantation, there are still key questions to be answered. The consensus which can be reached will be instrumental in further improving outcomes in recipients.

Prophylaxis and management of postoperative complications after tracheobronchial surgery.

Prevention of bronchial complications after airway surgery must be our primary goal. Understanding bronchial and anastomotic healing is the first step to success. This can be improved by standardizing operating technique (bronchial closure and end-to-end anastomosis) as well as postoperative care. Bronchopleural fistula after pneumonectomy still remains a feared complication with a high mortality rate. Especially after sleeve resection interpretation of endobronchial healing and postoperative measures of care with the help of an algorithm, may avoid anastomotic insufficiency and therefore reduced the secondary pneumonectomy rate.

A Simplified Continuous Two-stitch Suture for Bronchial Anastomosis of Left Single Lung Transplant in Dogs.

Large animal models are essential to pre-clinical trials of pulmonary transplantation and bronchial anastomosis poses a great technical challenge to the procedure. Presented here is a simplified continuous two-stitch suture technique into bronchial anastomosis during the course of left single lung transplantation in canine. Animals were divided into three groups with each group having 6 animals. Left single lung transplantation in canine was performed to assess the feasibility of using this technique for bronchial anastomosis. In the control groups, all anastomoses were done by using traditional technique. Allograft functions and hemodynamic parameters were monitored during a 3-h reperfusion period. Quality of bronchial healing and airway complications were assessed by bronchoscopic surveillance after transplantation. We successfully completed left lung transplantation in 18 dogs, and all the dogs survived the procedures. The new technique substantially simplified the procedures for bronchial anastomosis and greatly reduced the time for bronchial anastomosis (P<<0.01) and the ischemic time of the grafts (P<0.05) compared to the control group. The continuous two-stitch suture attenuated the tissue injury to allografts and led to better blood gas exchange function as compared to the control group (P<0.05). Good bronchial healing (Grade I) was observed in all the groups. A canine left single lung transplantation model is feasible by using the novel suture technique, and the new technique is as safe as the traditional method. The technique is easy to learn, particularly for less experienced operators. Simpler and time-saving, the technique has great potential to be widely employed in clinical lung transplantation.

Indocyanine green fluorescence detects the blood flow of the bronchial anastomosis for bronchoplasty "case report".

INTRODUCTION: Bronchoplasty is widely accepted as a standard technique with a high degree of difficulty in maintaining a surgical margin for non-small-cell lung cancer (NSCLC). The key to the success of the bronchial anastomosis is both tension and the blood flow. However, local tension is inconsistent with blood distribution. CASE PRESENTATION: Operative finding of the right upper bronchoplasty after chemoradiotherapyshowed clear green staining of the upper bronchus, and afterwards, a membranous area of the truncus intermedius. The blood supply of the bronchial anastomosis judged to be enough. DISCUSSION: Indocyanine green imaging (ICG) can help a scheduled operation be performed safely, especially in extreme situations where there is concern about the blood supply during bronchoplasty. CONCLUSION: This report describes a first case concerning the blood distribution of the bronchial anastomosis for bronchoplasty after induction therapy under fluorescence navigation.

Our tips for bronchoplasty using suture holder and tourniquet.

Bronchial anastomosis is an important part of successful bronchoplasty, but it takes time to achieve stable results because of few opportunities to do it. To ensure a stable outcome, we have applied some tips for bronchial anastomosis. One of the tips is the use of a suture holder to obtain appropriate suture pitches, adjusting the discrepancy of the bronchial diameter, and another one is the use of a tourniquet to obtain an adequate tension upon tying the knots, ensuring good operative view.

Wine cup stoma anastomosis after extended sleeve lobectomy for central-type squamous cell lung cancer.

BACKGROUND: Extended sleeve lobectomy is rarely applied to pulmonary surgery for primary lung cancer to avoid a pneumonectomy. As there is a size discrepancy between main bronchus and peripheral bronchus, ingenuity to improve anastomosis is required in the bronchoplasty. We report herein a case in which successful reconstruction of extended sleeve lobectomy with bronchial wall flap. CASE PRESENTATION: We report on a 64-year-old man suffering from hemoptysis, cough, mild fever and dyspnea. His computed tomography (CT) scan showed solid tumor of 40 mm in diameter in left lower bronchus, which obstructed the lower bronchus and caused obstructive pneumonia of left lower lobe and expanded to second carina and pulmonary artery. His bronchoscopy showed that tumor was exposed in the bronchial lumen and infiltrated to left main bronchus and upper bronchus even though the scope could pass through the exposed tumor of upper bronchus. Transbronchial lung biopsy showed squamous cell carcinoma. He had undergone left sleeve lingular segmentectomy and left lower lobectomy. Reconstruction was performed with bronchial wall flap. Pathological findings revealed pT3N0M0 stage IIB according to UICC 8th edition. Postoperative bronchoscopic findings showed no troubles at the anastomotic site. He has been well for eighteen months without recurrence after surgery. CONCLUSIONS: We experienced a successful case who was reconstructed with bronchial wall flap (wine cup stoma) after extended sleeve lobectomy. This technique might be also useful for other types of extended sleeve lobectomy and lung transplantation to adjust caliber changes of bronchi.

Pathophysiology and Predictors of Bronchial Complications After Lung Transplantation.

Bronchial anastomotic breakdown was a major complication in the early days of lung transplantation. Their solution, achieved through an understanding of airway ischemia from the laboratory, was key to the initial clinical success. Subsequently, risk factors, such as prolonged ventilation in both donor and recipient, primary graft dysfunction, and recipient age, have emerged. Innovations, such as local tissue wrapping, telescoping the anastomosis, and bronchial artery revascularization, have not stood the test of time. The short donor bronchus, with a suture line at the level of the lobar bronchus carina, is a proven technique that should be adopted by surgeons.

Bronchoscopic assessment of bronchial anastomosis by visualizing local circulation status-index of hemoglobin (IHb) imaging.

BACKGROUND: Healing of airway anastomosis is largely affected by local circulation. Index of hemoglobin (IHb) imaging is a color enhancement technique that clarifies local circulation in the gastrointestinal endoscopic field. In this study, we investigated the relationship between bronchoscopic assessment of bronchial anastomosis using IHb mode and occurrence of anastomosis-related complications. METHODS: IHb was calculated by logarithmic transformation for each pixel of the electronic endoscopic images and expressed by colors of red, green, and blue. The distribution of each color area was automatically calculated by the summation of pixels. A preliminary experiment spraying vasodilator on swine was performed to confirm the relationship between bronchial mucosal circulation and the IHb image. Forty consecutive patients who underwent bronchoplasty were divided into retrospective training and prospective validation cohorts, and anastomosis-related complications and IHb images were analyzed. RESULTS: The IHb images immediately and accurately reflected the mucosal changes in the animal experiment. Among 25 cases in the retrospective training cohort, 6 cases experienced complications, with significantly lower red and higher blue values in IHb observed (P=0.03 and P=0.01, respectively). A receiver operating characteristic (ROC) curve for IHb red and blue distributions revealed the thresholds to differentiate cases with complications as 89.2 and 109.0, respectively. An analysis of the prospective validation cohort revealed that IHb blue on POD 7 was a potentially reliable predictor of complications, with 60.0% sensitivity and 90.0% specificity. CONCLUSIONS: IHb mode of bronchoscopy may be useful for assessing the local circulatory condition of bronchoplasty, which can predict anastomosis-related morbidity.

Single-lung and double-lung transplantation: technique and tips.

The first successful single-lung and double-lung transplantations were performed in the eighties. Since then both surgical and anesthesiological management have improved. The aim of this paper is to describe the surgical technique of lung transplantation: from the anesthesiological preparation, to the explantation and implantation of the lung grafts, and the preparation of the donor lungs. We will also describe the main surgical complications after lung transplantation and their management. Each step of the surgical procedure will be illustrated with photos and videos.

Application of the "continuous suture dividing and equal suture tightening" method in video-assisted thoracoscopic surgery sleeve lobectomy.

BACKGROUND: The primary focus of video-assisted thoracoscopic surgery (VATS) sleeve lobectomy is bronchial anastomosis. Both interrupted suture and continuous suture cannot overcome entanglement of the suture threads. The present study used the "continuous suture dividing and equal suture tightening" method in VATS sleeve lobectomy for bronchial anastomosis and discussed the feasibility of this approach. METHODS: A total of 17 patients underwent VATS sleeve lobectomy with bronchial anastomosis using the "continuous suture dividing and equal suture tightening" method. Four incisions were utilized in the operation as follows: (I) the pulmonary arteries and veins were cut-off using an endoscopic linear stapler. Systematic hilar and mediastinal lymph node dissection was performed; (II) the surgeon used a surgical knife for incision into the thoracic cavity and to cut the lung lobe and main bronchi. Intraoperative pathological analysis revealed negative bronchial margins; (III) the "continuous suture dividing and equal suture tightening" method was performed for anastomosis; (IV) the integrity of the anastomosis was assessed by intraoperative bronchoscopy. Computed tomography (CT), three-dimensional (3D) reconstruction and bronchoscopy assessed the anastomosis 1-week postoperatively. A follow-up was conducted using a 3-month bronchoscopy, and CT scans monitored the recurrence and stenosis of the anastomosis. RESULTS: The method was successfully completed for VATS sleeve lobectomy with bronchial anastomosis in 17 cases. Although various histological profiles were observed, the 1-week postoperative CT and bronchoscopy showed adequate healing of the anastomotic stoma as well as the absence of postoperative mortality and bronchial pleural fistula. All patients were alive and followed up for 31-49 months postoperatively; local recurrence and anastomotic stenosis were not detected. CONCLUSIONS: The continuous suture dividing and equal suture tightening method is convenient, feasible, and safe for bronchial anastomosis in VATS sleeve lobectomy. It can effectively avoid the entanglement of the suture threads, thereby enabling the widespread adoption of VATS sleeve lobectomy.

Techniques of protection and revascularization of the bronchial anastomosis.

Airway anastomosis has been traditionally considered at risk for the onset of complications, particularly dehiscence with consequent infection and erosion in the adjacent vessels. Although the modifications and improvements of the surgical technique has contributed to reduce the incidence of complications, the protection and revascularization of the anastomotic site is still considered mandatory at many centers Many techniques have been proposed for encircling the bronchial anastomosis.

Modified bronchial anastomosis in video-assisted thoracoscopic sleeve lobectomy: a report of 32 cases.

BACKGROUND: Bronchial anastomosis is a key technical challenge in sleeve lobectomy, especially when using the video-assisted thoracoscopic surgery (VATS) approach. A retrospective study was conducted to evaluate the feasibility and safety of a modified bronchial anastomosis technique developed by the authors at Fujian Union Hospital. METHODS: From October 2010 to October 2015, we performed 32 cases of VATS sleeve lobectomy through a three-port or single-port approach. All bronchial anastomoses were performed using modified bronchial anastomosis technique: the bronchial anastomosis was begun with an initial stitch on the posterior wall, and the bilateral quarters of the circumference were continuously sutured. The other two bilateral quarters were then similarly sutured, and the last knot was made outside the bronchial lumen. RESULTS: All cases were completed uneventfully. No perioperative deaths or serious complications occurred. The mean operative time, bronchial anastomosis time, and blood loss volume were 271.8±67.5, 37.6±12.0 min, and 177.5±102.9 mL, respectively. The mean follow-up time was 21.0±11.7 months, and the follow-up rate was 96.9% (31/32). An electronic bronchoscope scan was performed 6 months after surgery, and a fine healing stoma was detected in all cases. No anastomotic fistula, anastomotic stenosis, or other serious postoperative anastomotic complications occurred until the end of follow-up. CONCLUSIONS: Modified bronchial anastomosis technique applied in bronchial anastomosis was safe and feasible in three-port and single-port VATS sleeve lobectomy with good short-term and long-term therapeutic results. Adequate management of the operative process and implementation of a skilled bronchial anastomosis technique could help to reduce the difficulty of VATS sleeve lobectomy.

Surgery of the airway: historic notes.

Prior to the 20(th) century, the need for surgical procedures on the airway was infrequent and consisted mainly of tracheostomy to relieve airway obstruction or repair of tracheal injuries such as lacerations. Even the ability of tracheal suture lines to heal primarily was viewed with concern due to the rigidity of the tracheal wall, its precarious blood supply and uncertainty as to whether the cartilage components could heal without complications. In the 20(th) century the evolution of tracheal procedures on major airways evolved to meet the challenges provided by the expanding fields of thoracic surgery and advent of mechanical respiratory support with its associated complications. In the first half of the century lobar and lung resections done for tuberculosis and lung cancer required methods for safe closure of the resulting bronchial stumps and end-to-end bronchial anastomosis in the case of sleeve resections of the lung. Beginning in mid-century the advent of respiratory care units for the treatment of polio and for the expanding fields of thoracic and cardiac surgery resulted in a significant number of post-intubation tracheal stenosis requiring resection and primary repair. In the last 20 years of the century the development of lung transplantation with its requirement for successful bronchial anastomoses between the donor and recipient bronchi, created unique challenges including ischemia of the donor bronchus the adverse effects of immunosuppression, donor lung preservation and diagnosis and management of post-transplant infection and rejection.

Airway anastomosis for lung transplantation.

Lung transplantation (LT) is the only viable option for a selected group of patients with end stage pulmonary diseases. During the recent years satisfactory results in terms of long-term survival and quality of life have been achieved with improvements in surgical technique, immunosuppression and perioperative management. Since the beginning, the airway anastomosis has been considered crucial and significant efforts have been made to understand the healing process. A number of experimental studies allowed improving the surgical technique by modifying the technique of suturing, the anastomotic protection and type and dose of immunosuppression, reducing the risk of airway complications. Furthermore, a huge progress has been made in the management of such complications. Early diagnosis of bronchial complications and their prompt and correct management are crucial to achieve long-term survival.

Video-assisted thoracoscopic surgery for the central bronchogenic carcinoma with invasion of the main bronchus and pulmonary artery: A case report.

Surgical treatment for central bronchogenic carcinoma with invasion of the main bronchus and pulmonary artery often include bronchial anastomosis and pulmonary angioplasty. As a technique, video-assisted thoracoscopic surgery (VATS) lobectomy has proven to reduce the rate of occurrence of complications, and thereby obtain improved survival rates. In the present case study, its use in treating central bronchogenic carcinoma with invasion of the main bronchus and pulmonary artery is reported. A case study of a 68-year-old man with a history of smoking 15-20 cigarettes per day for 40 years is described, who presented with a cough and hemoptysis. A bronchial sleeve left upper lobectomy and pulmonary angioplasty were performed with complete VATS and routine lymph node dissection. The preoperative diagnosis of squamous cell carcinoma (SCC) of the lung (cT2, N2, M0, stage IIIA) was confirmed as SCC through the postoperative pathological examination, leading to the tumor staging: pT2, N1, M0, stage IIB. These results were obtained without sacrificing the oncological principles of thoracic surgery. It has been demonstrated that VATS may be applied for treating central bronchogenic carcinoma with invasion of the main bronchus and pulmonary artery. However, end-to-end bronchial anastomosis and continuous suture of the pulmonary artery were difficult to perform, and use of the VATS procedure is on a learning curve, which will be informative for surgeons and their assistants.