Arlette Colchen Chief of broncho endoscopy unity Thoracic Surgery department

1. INTERVENTIONAL BRONCHOSCOPY FOR THE MANAGEMENT OF AIRWAYS COMPLICATIONS FOLLOWING LUNG TRANSPLANTATION Arlette Colchen Chief of broncho endoscopy unity Thoracic Surgery department Foch hospital Paris (Suresnes) France 14 th Thoracic Surgery Congress Antalya 2011

2. Interventional bronchoscopy for the management of airway complications following lung transplantation Despite the improvements in surgical techniques and immunosuppression strategies, airway stenosis or malacia still remain a major complication after lung transplant , usually as the result of anastomotic and proximal bronchi ischemia. The management of those complications is delicate and have to be carefully decided as transplant bronchi are fragile and anatomic components are modified.

3. INTERVENTIONNAL BRONCHOSCOPY Patients Anast. Int. Bron. Ksettry 1997 102 127 19 (15%) Chhazed 2001 246 375 39 (13%) Ruttmann 2005 77 125 16 (13%) Van de Wauver 2007 232 362 57 (16%) Marulli 2007 134 219 13 (6%) Weder 2009 206 391 18 (4,6%) Foch 2010 402 525 42 (8 %)

4. Foch’s experience nov.1988 – dec.2010 • 402 patients • 85 early deaths excluded ( before 6 months) • 317 transplants • 105 single lung • 212 double lung ( 4 heart lung ) • That means 525 at risk bronchial anastomosis

5. Foch’s experience nov.1988 – dec.2010 42 patients ( 8%) underwent interventional bronchoscopy 7 single lung (6,6%) 3 emphysema 2 sarcoidosis 2 fibrosis ( 1 retransplant) 35 double lung (16%) 23 cystic fibrosis 7 emphysema 5 others

6. Foch’s experience nov.1988 – dec.2010 Localization of bronchial complications in 35 double lung transplants 19 right side alone 5 left side alone 11 bilateral

7. MEDIATINAL SURROUNDING

8. RISK FACTORS FOR AIRWAY COMPLICATIONS • Donor ventilation • Ischemic time • Anastomotic type (telescoping, end to end) • Recipient lenght • Lack of bronchial arterial circulation • Reperfusion edema • Duration of recipient ventilation • Use of vaso active drugs • Early acute rejection Ruttmann J Heart Lung Transplant 2005 Van de Wauver Eur J Cardiothorac Surg 2007

9. BRONCHIAL COMPLICATIONS AFTER LUNG TRANSPLANT • Desquamation of the bronchial mucosa bloking the lumen • Granulomas • Stenosis • Malacia • Anastomotic dehiscence • Infections especially fungi

10. TECHNIQUE • Flexible bronchoscopy is performed systematically and as soon as clinical symptoms appear: dyspnea, even stridor, fall in lung function, Xray abnormalities. • It leads to interventional bronchoscopy if it discovers bronchial complications: pseudo membranous, fungi plug granulomas formations stenosis malacia

11. TECHNIQUE • Operating room • Rigid bronchoscope • General anaesthesia • Operative survey: ECG, pulse oxymetry, non invasive blood pressure, bispectral index

12. TECHNIQUE • Laser is used only to destroy granulomas Nd YAG or better Thullium • Dilation is performed with balloons, bougies and/or bronchoscopes of small diameter of increasing size • Stents are silicone ones mostly, of every type needed. Covered metallic self expanding stents are more rarely used

13. TRANSPLANT BRONCHI SPECIFICITIES As the suture line is always close to the right upper lobe or the left bifurcation, stenting is sometimes very difficult to keep open all the bronchi It is why we have used all sorts of stents: straight silicone or covered metallic, bifurcated silicone on the left side and Montgomery T tube on the right side.

14. STENT • Hood silicone prothesis is very smooth, does not generally provoke granulomas but may move easily

15. STENTS Dumon-Novatech Straight silicone able to be cutted at the good size. Numerous spikes are taken out to avoid granulomas formations Risks of migration

16. METALLIC COVERED STENT

17. MONTGOMERY T TUBE The horizontal part is introduce in the upper right lobe The inferior part in the intermediate bronchus The upper part in the main bronchus Useful on the right side

18. STENTING RIGHT SIDE

19. STENT • Bifurcated stent is useful to treat left bronchus malacia or stenosis. • The good size is nearly babie’s one • It is well tolerated

20. STENTING LEFT SIDE

21. BILATERAL STENTING

22. TECHNIQUE More seldom modalities: • Cryotherapy ( Maiwand Eur J Cardiothorac Surg 1997) • Mitomycin C (Erard Chest 2001) • Brachytherapy( Halkos Ann Thorac Surg 2003) • Gluing (Chang Eur J Cardiothorac Surg 2007) • ……

23. Foch’s experience nov.1988 – dec.2010 Treatment of 35 double lung • 6  peelings of pseudo membranous formations, succion of pus or debulking fungi • 29 dilations and stents 6 covered metallic 15 silicone straight 3 silicone bifurcated 5 silicone Montgomery T tube

24. Foch’s experience nov.1988 – dec.2010 Treatment of 7 single lung : 5 silicone 4 straight 1 Mgt T tube 2 covered metallic

25. PSEUDO MEMBRANOUS

26. MALACIA

28. COMPLICATIONS They depend of the treatment: • After dilation recurrence is unavoidable in term of 2 to 3 weeks, sessions must be repeated many times • Following stent insertion: migration,mucous blocking and drying into the stent, granuloma formations on both extremities of stent. • No complication after laser granulomas destruction

29. COMPLICATIONS 3 deaths more or less due to interventionnal endoscopy: 2 cataclysmic haemorrages 1 acute respiratory distress because of diffuse malacia

30. RESULTS All teams show nearly the same results: • Improvement of lung function 30 to 50 % amelioration • Improvement of expectoration • Improvement of quality of life

31. CONCLUSION The airway management of bronchial healing after lung transplant needs attention. Interventional endoscopy is more difficult in these indications because bronchi are fragile, anatomic conditions are different than in « normal »endoscopy. Nevertheless airway stenting and others procedures are safe and permit to the patients to round a cape waiting for a strong an durable healing.

32. NORMAL HEALING