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Eur J Cardiothorac Surg 2003;23:488-493
© 2003 Elsevier Science NL

Single running suture – the new standard technique for bronchial anastomoses in lung transplantation

C. Aigner, P. Jaksch, G. Seebacher, P. Neuhauser, G. Marta, W. Wisser, W. Klepetko*

Department of Cardio-Thoracic Surgery, University of Clinic of Surgery, Vienna General Hospital, Wahringer Gurtel 18-20, 1090 Vienna, Austria

Received 15 August 2002; received in revised form 26 December 2002; accepted 7 January 2003.

* Corresponding author. Tel.: +43-1-40400-5620; fax: +43-1-40400-5642
e-mail: walter.klepetko{at}akh-wien.ac.at


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 
Objective: The aim of this retrospective study is to assess the results of a single running suture technique for bronchial anastomoses in lung transplantation. In a previous pilot study, equal results compared to the established standard technique – using single stitches on the cartilaginous part – have been described by our group. This report reviews the results obtained over a period of 3 years. Methods: Between January 1999 and December 2001, 154 consecutive lung transplantations (91 bilateral sequential, 35 right single lung and 28 left single lung) were performed in 141 patients using single running sutures for bronchial anastomoses. Thirteen transplantations (25 anastomoses) were performed in lobar or split lung technique. Bronchial healing was assessed at routine bronchoscopes performed in increasing time intervals from 7 days to 1 year postoperatively and depending upon clinical necessity. Results: Six patients (4.2%) died earlier than 7 days postoperatively and were excluded from further analysis. No bronchial complication was observed in any of them. Three months and 1-year survival rates were 82.9 and 72.7%, respectively. Two hundred and thirty-four anastomoses were subjected to examination. Mean ischemic time was 5.1 h (±1.5). In 228 anastomoses (97.4%), excellent primary airway healing was observed. In four anastomoses (1.7%), small healing defects less than 5 mm without necessity for intervention were detected. Two anastomoses (0.9%) developed a cicatriceal stenosis requiring intraluminal stenting. Conclusions: The single running suture technique for bronchial anastomoses in lung transplantation provides excellent results with regard to primary and long-term airway healing and its use as a standard suturing technique is, therefore, recommended.

Key Words: Lung transplantation • Bronchial anastomosis • Airway complication • Single running suture • Suture technique


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Results
 4. Discussion
 References
 
In the beginning of lung transplantation, problems of bronchial healing at the bronchial anastomoses were the major limiting factor for long-term success. Due to a number of different surgical techniques that were developed to overcome these problems and improvements in the management of organ preservation as well as peri- and postoperative period, the incidence of bronchial complications is now significantly diminished. However, the standard technique for bronchial anastomoses still remains a running suture on the membranous wall and single stitches on the anterior cartilaginous part. In 1998, we compared this technique with a single running suture technique in a consecutive series of patients transplanted in our institution [1]. This initial experience provided identical postoperative outcome, while being more efficient in itself. Based on this study, our center started to use the single running suture technique as the standard technique for all bronchial anastomoses in lung transplantation. The aim of this retrospective study is to assess the outcome of this method during the last 3 years.


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Results
 4. Discussion
 References
 
Between January 1999 and December 2001, 154 lung transplantations were performed in 141 patients (Figs. 1 and 2) . Ninety-one transplantations were bilateral sequential, of these, 13 were lobar transplantations or were performed in the split lung technique. The rest were single lung transplantations. Organ preservation was accomplished by perfusion and storage in a high molecular dextran solution (Perfadex®; Vitrolife, Gothenburg) and topical cooling.



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  		Fig. 1. Underlying indications for lung transplantation during 1999–2001.

 


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  		Fig. 2. Patient age distribution, 1999-2001.

 
The surgical approach for single lung transplantation was an anterolateral thoracotomy in either the fourth or fifth intercostal space depending on the individual anatomic situation. For double lung transplantation, access was gained by a bilateral transsternal anterior thoracotomy, the so called ‘Clamshell incision’ or by two separate anterolateral thoracotomies as described above.

Preparation of the donor bronchus was performed in the following manner. With strict protection of the peribronchial tissue, the bronchus was shortened so that one cartilage ring remained after the separation of the upper lobe bronchus. After performing a bacteriological swab and flushing the bronchial system with physiological sodium chloride solution the bronchus was anastomosed using double armed 4/0 polydioxanone (PDS; Ethicon Inc., Sommerville, NJ) starting at one end of the cartilaginous part and going over the membranous portion in the established single running suture technique and then using the same single running suture for the anterior cartilaginous part. In case of a bronchial size mismatch, the imbalance was adjusted over the whole circumference. No efforts for coverage of the anastomoses with whatsoever the tissue were taken except for occasional interposition of a donor pericardial flap in between the bronchus and the pulmonary artery.

In lobar and split lung transplantation, the preparation of the lobar bronchial separation was performed in a similar way with exact protection of the peribronchial tissue. The technique for the anastomosis remained identical except that 5/0 PDS was used for the suture. All patients received a triple drug immunosuppressive therapy and prophylaxis against pneumocystis carinii, cytomegalovirus and fungal infections.

Bronchial healing was retrospectively reviewed in all patients who survived at least 7 days postoperatively. Routine bronchoscopes using flexible fiberbronchoscopes were performed 7 days, 4, 8 and 12 weeks, 6 months and 1 year postoperatively and additionally depending upon clinical necessity. Bronchial healing was classified in four grades according to Table 1.


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  		Table 1. Classification of bronchial healing

 

   3. Results
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
4. Discussion
 References
 
The mean ischemic time was calculated separately for each anastomosis and averaged 5.1 h (±1.5) with a range of 2–11 h. Eight operations were performed on cardiopulmonary bypass, 49 on extracorporeal membrane oxygenation and 97 without any extracorporeal assist device. Postoperative observation period ranged from 7 to 1166 days with a mean of 476 days (±332).

During the observation period, six patients died earlier than 7 days postoperatively and so, had to be excluded. In none of them, any problem on the bronchial anastomoses was detected or was responsible for the early death. Two hundred and thirty-four bronchial anastomoses were finally subjected to examination for immediate postoperative complications and long-term outcome.

During the observation period, bronchial healing was assessed by flexible bronchoscopy and graded according to the above mentioned scheme. Two hundred and twenty-eight anastomoses (97.4%) showed excellent primary healing (grade I), although in 61 (26.1%) of them transient fibrinous coating or redness of the adjacent bronchial mucosa were seen.

In four anastomoses, in two patients (1.7%), small healing defects according to grade II occurred. However, no air leakage or subsequent bronchial stenosis was found and no therapeutic measurements were indicated in these patients.

Neither healing defects larger than 5 mm (grade III) nor distal bronchial occlusions not related to the anastomosis (grade V) occurred in any patient within the observation period. There were two cases of bronchial healing problems (0.9%), which required intraluminal stenting (grade IV). Both operations were bilateral sequential lung transplantations and both the complications occurred in the anastomosis of the right main bronchus.

In one patient, the underlying indication for bilateral lung transplantation was an end stage chronic obstructive pulmonary disease (COPD). The immediate postoperative course was uneventful and no rejection or other complications were observed. Five months postoperatively, bronchoscopy showed a cicatricial stenosis of the right main bronchus extending into the distal intermediate bronchus, which had no impact on lung function and was clinically inapparent. In the left main bronchus, there were no pathological findings. The stenosis was treated by balloon dilatation using a 12 mm balloon. Due to a re-stenosis, which was detected 4 weeks after the first intervention, a redilatation was performed and a 10 mm silicon T-stent was inserted in the main bronchus reaching into the intermediate bronchus with the median opening reaching into the upper lobe bronchus and, therefore, retaining the stent in its position. This led to a satisfying result and no further airway complications were observed.

The second patient was operated for idiopathic lung fibrosis. The postoperative course was uneventful and complete mobilization was achieved quickly. Three months postoperatively, bronchoscopy revealed a floating prominent granulomatous structure at the medial part of the right bronchial anastomosis, which partially occluded the intrabronchial lumen. For this reason, a conventional 10 mm silicone stent was inserted to obtain a sufficient intrabronchial lumen. The initial result was satisfying. After 6 days, bronchoscopy revealed a dislocation of the stent and the stent had to be removed. In the further course, a lobar pneumonia emerged. Spreading from this infiltrate, a fulminant sepsis evolved resulting in multi-organ failure and respiratory and hemodynamic instability. After a prolonged period of intensive care, hemofiltration, antibiotic treatment and transfusion therapy, the patient ultimately died due to multi-organ failure 5 months later. However, at bronchoscopes performed during that period, a sufficient lumen of the right bronchial system was repeatedly confirmed and no further stenting was required.


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
References
 
Healing problems of the bronchial anastomosis were initially the main factor precluding long-term success of lung transplantation. Whereas dehiscence played the leading role in the early days of lung transplantation, bronchial stenosis is the most common complication since the procedure gained widespread acceptance. A number of investigational and therapeutical attempts were performed to identify the factors, which influence the development of this specific problem. All of these causative factors result more or less in an impairment of bronchial microcirculation, even though the genesis can be multifactorial.

The first successful approach to overcome bronchial healing problems was, therefore, directed towards protecting the anastomosis itself and enhancing microcirculation of the donor bronchus by the so-called bronchial ‘omentum wrapping’ technique [2]. Although this approach gained a widespread use in the early days of lung transplantation, a better understanding of the underlying causative factors led to more selective techniques to approach the problem.

As a further strategy, avoidance of steroids was believed to enhance the reparative healing processes after the surgical procedure [3]. However, it soon turned out that positive virtues of steroids like prevention of rejection and potential amelioration of reperfusion injury, at least outweigh the negative effects of healing disturbances [4]. Especially during acute rejection episodes, microcirculation may be significantly impaired due to increase in pulmonary vascular resistance and decrease in pulmonary collateral blood supply [5]. Therefore, corticosteroids are now almost uniformly part of the immunosuppressive protocols used in the majority of lung transplant centers worldwide. Another attempt to improve microcirculation has been taken by introduction of heparin and prostaglandin PGI2 during the organ harvesting process as well as in the early postoperative period [6].

The variety of therapeutical approaches taken to overcome healing problems also included direct bronchial arterial revascularization. This technique was extensively used by the Copenhagen group with impressive good results [7]. It was claimed that in addition to improvement of microcirculation and avoidance of healing problems, it might also have a positive impact on long-term development of bronchiolitis obliterans [8]. However, the scientific proof for this goal has never been given so far. Due to the fact that this technique faces the surgeon with an additional considerably demanding operative effort, it has not gained a widespread use.

Furthermore, bronchial healing may be impaired by infections, especially the presence of Aspergillus, poses a risk for the occurrence of airway complications [9]. Higher complication rates have also been described in patients transplanted for cystic fibrosis [10–12].

Prolonged intubation has been reported as another potential risk factor, though this observation might be explained by other factors such as early graft dysfunction [13], since mechanical ventilation itself does reportedly not predispose to increased incidence of airway complications since positive end-expiratory pressure augments retrograde collateral bronchial mucosal flow [14].

However, besides all these factors, the technique of the anastomosis itself still has the highest influence on the development of bronchial anastomotic problems. The suture material initially used was vicryl polyfilament, which almost uniformly has been replaced now by monofilament polydioxanone, the latter leading to a substantial progress due to less traumatization of the bronchial tissue.

As depicted in Fig. 3 which illustrates the annual incidence of bronchial problems observed at our institution during our entire experience with lung transplantation, the use of the telescope technique in the early 1990s resulted in the highest incidence of anastomotic problems. During that period, the anastomosis was accomplished by telescoping the donor bronchus into the recipient bronchus and suturing with the so-called ‘figure-of-eight-technique’. Results from other groups reaffirm the deleterious effects of this technique [15].



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  		Fig. 3. Incidence of bronchial problems during 1989–2001 at Vienna University Hospital.

 
Currently the most widespread technique, which was also used at our center until 1998, is an end-to-end anastomosis with a running suture on the membranous portion of the bronchus and single stitches on the cartilaginous part. Results obtained with this technique are fairly good with complication rates repeatedly reported in an acceptable low range of below 4%.

However, some – at least theoretical – disadvantages of this method still remain. First of all, it is time consuming due to the large number of knots required; secondly, the amount of foreign material, which is placed at the anastomosis due to the multiple knots, is significant. It is, therefore, obvious that the use of a technique with one single suture line might have positive effects (Fig. 4) .



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  		Fig. 4. (a) The single running suture technique. (b) The conventional technique using single stitches on the membranous portion.

 
We started to evaluate such a technique upon initiation of the lobar transplantation technique, using a double armed suture starting at one end of the cartilaginous part, going over the membranous portion in the established single running suture technique and then using the same single running suture for the anterior cartilaginous part. This technique was especially suitable for adjusting differences in luminar diameter and small operative access via anterolateral thoracotomy. The first experience with this technique was encouraging and the results obtained during 1 year showed equal results compared to the former standard technique with an acceptable rate of complications requiring intervention of 2.3% only. Consecutively, the single running suture technique was introduced as standard technique for all bronchial anastomoses in our department (Fig. 5) . The aim of this study was, therefore, to review the results in a larger patient cohort and after a longer follow-up. As our results, obtained over 3 years demonstrate, the observed complication rate belongs to the lowest reported in literature. Several additional factors militate in favor of this technique. The simplicity of the method makes it easy to use, even when a small anterolateral thoracotomy is used for operative access. In addition to this, less suture material is needed and less tissue irritation is caused by knots resulting in potentially reduced influence on microcirculation. Differences in luminar diameter are easy to adjust, thus the excellent applicability for lobar and split lung transplantations, which led to its development, has to be especially accentuated. This also applies for standard sleeve resections in bronchial cancer operations.



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  		Fig. 5. (a) Bronchial anastomosis 3 days postoperative. (b) Bronchial anastomosis, grade I, 1 year postoperative. (c) Bronchial anastomosis with small healing defect, grade II. (d) Bronchial anastomotic stenosis, grade IV.

 
We conclude that the single running suture technique with monofilament sutures used for bronchial anastomosis in lung transplantation provides optimal results with regards to early and long-term bronchial healing. We, therefore, can recommend it as the standard technique for bronchial anastomoses in lung transplantation.


   Footnotes
 
Presented at the 16th Annual Meeting of the European Association for Cardio-thoracic Surgery, Monte Carlo, Monaco, September 22–25, 2002.


   References
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 

  1. Lischke R., Sarahrudi K., Neuhauser P., Lang P., Wisser W., Klepetko W. Bronchial anastomoses after lung transplantation: results with single running suture technique. Chirurg 2001;72:1048-1053.[CrossRef][Medline]
  2. Cooper J.D., Pearson F.G., Patterson G.A., Todd T.R., Ginsberg R.J., Goldberg M., DeMajo W.A. Technique of successful lung transplantation in humans. J Thorac Cardiovasc Surg 1987;93:173.[Abstract]
  3. Lima O., Cooper J.D., Peters W.J., Ayabe H., Townsend E., Luk S.C., Goldberg M. Effects of methylprednisolone and azathioprine on bronchial healing following lung autotransplantation. J Thorac Cardiovasc Surg 1981;82:211-215.[Abstract]
  4. Novick R.J., Menkis A.H., McKenzie F.N., Reid K.R., Pflugfelder P.W., Kostuk W.J., Ahmad D. The safety of low dose prednisone before and immediately after heart–lung transplantation. Ann Thorac Surg 1991;51:642-645.[Abstract]
  5. Calhoon J.H., Grover F.L., Gibbons W.J., Bryan C.L., Levine S.M., Bailey S.R., Nichols L., Lum C., Trinkle J.K. Single lung transplantation. Alternative indications and technique. J Thorac Cardiovasc Surg 1991;101:816.[Abstract]
  6. Shafers H.J., Haverich A., Wagner T.O., Wahlers T., Alken A., Borst H.G. Decreased incidence of bronchial complications following lung transplantation. Eur J Cardiothorac Surg 1992;6:174-179.[Abstract]
  7. Pettersson G., Norgaard M.A., Arendrup H., Brandenhof P., Helvind M., Joyce F., Stentost P., Olesen P.S., Thiis J.J., Efsen F., Mortensen S.A., Svendsen U.G. Direct bronchial artery revascularization and en bloc double lung transplantation – surgical techniques and early outcome. J Heart Lung Transplant 1997;16(3):320-333.[Medline]
  8. Norgaard M.A., Andersen C.B., Pettersson G. Does bronchial artery revascularization influence results concerning bronchiolitis obliterans syndrome and/or obliterative bronchiolitis after lung transplantation?. Eur J Cardiothorac Surg 1998;14(3):311-318.
  9. Herrera J.M., McNeil K.D., Higgins R.S., Coulden R.A., Flower C.D., Nashef S.A., Wallwork J. Airway complications after lung transplantation: treatment and long term outcome. Ann Thorac Surg 2001;71:989-993.[Abstract/Free Full Text]
  10. Shennib H., Massard G. Airway complications in lung transplantation. Ann Thorac Surg 1994;57:506-511.[Abstract]
  11. Kshettry V.R., Kroshus T.J., Hertz M.I., Hunter D.W., Shumway S.J., Bolman R.M., III Early and late complications after lung transplantation: incidence and management. Ann Thorac Surg 1997;63:1576-1583.[Abstract/Free Full Text]
  12. Nunley D.R., Ohori P., Grgurich W.F., Iacono A.T., Williams P.A., Keenan R.J., Dauber J.H. Pulmonary aspergillosis in cystic fibrosis lung transplant recipients. Chest 1998;114:1321-1329.[Abstract/Free Full Text]
  13. Alvarez A., Algar J., Santos F., Lama R., Aranda J.L., Baamonde C., Lopez-Pujol J., Salvatierra A. Airway complications after lung transplantation: a review of 151 anastomoses. Eur J Cardiothorac Surg 2001;19:381-387.[Abstract/Free Full Text]
  14. Yokomise H., Cardoso P.F.G., Kato H., Keshavjee S.H., Wada H., Slutsky A.S., Patterson G.A. The effect of pulmonary arterial blood flow and positive end-expiratory pressure on retrograde bronchial mucosal blood flow. J Thorac Cardiovasc Surg 1991;101:201-208.[Abstract]
  15. Garfein E.S., McGregor C.C., Galantowicz M.E., Schulman L.L. Deleterious effects of telescoped bronchial anastomosis in single and bilateral lung transplantation. Ann Transplant 2000;5:5-11.



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