Managing bronchial anastomotic complications – The influence of aspergillosis

Purpose Airway complications after lung transplantation remain a challenging problem. We reviewed our experience of managing airway complications and any causal or associated factors. Methods and Materials 170 lung transplants were performed between 2009 - 2012. Patient records were retrospectively reviewed to identify those with an airway complication. Our transplant database was utilised to determine contributing factors including age, ischaemic time, CMV status, pre –operative bacterial and fungal colonisation and early rejection. SPSS statistical analysis was performed. Results Of 170 patients, 156 (Group 1) had no anastomotic complications. 14 (8.2%) required airway intervention (Group 2). Group 1 mean age was 45.1yrs with 93 (54.7%) male recipients. 115 were bilateral lung transplants (BLT) and 41 single lung transplants Group 2 mean age was 46.7yrs with 9 (64.3%) male recipients with 7 BLT. Primary pathology in those with airway complications were IPF (35.7%), CF (28.6%), sarcoidosis (14.3%) and COPD (21.4%). 12 patients had a stenotic lesion at the anastomosis. The number of airway interventional procedures required ranged from 1-5 (mean 2.2). Time from transplant to first intervention ranged from 1- 8months with a mean of 3.8months. Interventions required were balloon dilatation (64.3%), bougie dilatation (28.6%), placement of stent (14.3%) and bronchial toilet alone (14.3%). Bronchial anastamotic stenosis was significantly higher in the presence of pre-transplant Aspergillosis positive sputum (21.7% vs5.4%, p=0.019). The presence of CMV, pseudomonas, and early rejection were comparable in both groups. Post lung transplant airway complication was associated with a mortality of 21.4% with 3 deaths at 7,8 and 13 months. Conclusions Airway complications in the modern era remain challenging to manage, often require multiple interventions and are associated with significant mortality. Our data establishes a relationship between Aspergillus and the development of airway complications. Aggressive peri-operative management with anti-fungals may lower the incidence of anastamotic stenosis.