Surgical Complications

Two complications are unique to lung transplantation: 1) lung dysfunction secondary to reperfusion injury and 2) bronchial anastomotic problems.

The surgeon must be prepared to deal with reperfusion injury of the transplanted lung which is typically manifest soon following lung reperfusion. Minor cases are manifested by relatively mild pulmonary edema and are easily treated with aggressive diuresis and mechanical ventilation using positive end-expiratory pressure (PEEP) of 5-10 cm H2O. Severe cases are notable for marked hypoxemia, severe pulmonary edema and poor pulmonary compliance. In addition to diuresis and mechanical ventilation, inhaled nitric oxide (NO) (2-20 ppm) is valuable in improving oxygenation. Extreme cases may fail to respond to inhaled NO and life-threatening hypoxemia may require extracorporeal membrane oxygenation (ECMO) for survival.

Bronchial anastomotic complications occur in fewer than 10% of cases and result from ischemia of the donor bronchus. The anastomosis may dehisce or more commonly may become stenotic; the diagnosis may be confirmed with a chest CT scan or bronchoscopy. Anastomotic dehiscence is marked by pulmonary distress and sepsis and may be life-threatening; it may be avoided by cutting the donor bronchus as short as possible at the time of implantation. Anastomotic stenosis should be suspected because of wheezing or dyspnea. Intrabronchial stent placement across the anastomosis and frequent follow-up bronchoscopy procedures should be performed. Frequent bronchoscopic procedure and balloon dilation may be required.

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