Anastomotic dehiscence ("stump leak") post lung transplant

Case contributed by Dr Luke Danaher

Presentation

Bilateral sequential single lung transplant (BSSLTx) for severe post infectious bronchiectasis

Patient Data

Age: 55
Gender: Male
X-ray

Preoperative CXR

  • bilateral cystic bronchiectasis particularly the middle lobe
  • air-fluid levels in the cystic spaces due to chronic infection
  • architectural distortion and pleuroparenchymal scarring secondary to fibrosis
  • volume loss in the right hemithorax
  • main pulmonary artery is enlarged
  • heart size is enlarged
X-ray

Post bilateral lung transplant CXR

  • status post bilateral lung transplant (BSSLTx) with bilateral hilar surgical clips 
  • tracheostomy in situ
  • nasogastric tube (NGT) in situ
  • right dual lumen (Vascath) central venous line (CVL) appropriately positioned with its tip at the cavoatrial junction
  • left PICC line appropriately positioned with its tip at the cavoatrial junction
  • three chest tubes in situ
  • moderate right pleural effusion
  • no pneumothorax
  • surgical staples in the right chest wall
X-ray

Anastomotic dehiscence post transplant CXR

  • new right haemopneumothorax is most concerning for airway dehiscence
    • pneumothorax suggests airway dehiscence and stump-plerual fistula
    • vascular compromise can be confirmed on contrast enhanced CT
    • the term "stump" dehiscence is often used but can cause confusion as it doesn't discriminate between pulmonary arterial, bronchial arterial, or airways dehiscence
  • new left pneumothorax
  • tubes and lines appropriately positioned (see above)
    • tracheostomy
    • NGT
    • right Vascath
    • left PICC line
    • chest tubes
X-ray

Post subsequent right pneumonectomy CXR

  • subsequent right pneumonectomy for infarcted right lung post vascular and airways dehiscence (note the additional clips at the right stump to secure the pulmonary vessels and right main bronchus)
  • high density material at the right stump and adjacent to the right intercostal catheter (ICC) represents "stump glue" adhesive to further secure the right stump
  • large right haemopneumothorax (note the crisp outline of the right atrium)
  • post surgical left lower lobe atelectasis and pleural effusion
  • tubes and lines appropriately positioned
    • tracheostomy
    • right Vascath
    • left PICC line removed
    • NGT replaced with a nasojejunal tube (NJT)

Case Discussion

This case highlights the devastating consequences of "stump" dehiscence following lung transplantation.  

The presence of a new or persistent pneumothorax following a transplant should raise the suspicion of airways dehiscence.  First line treatment is directed at sealing the resultant bronchopleural fistula with with endobronchial, VATS, or open adhesive ("stump glue") or clipping.

A contrast CT is typically performed to exclude associated pulmonary arterial or bronchial arterial vascular compromise.  Resultant pulmonary infarction may necessitate a pneumonectomy (as in this case) and carries a poor prognosis.

 

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Case information

rID: 39768
Case created: 19th Sep 2015
Last edited: 19th Sep 2015
System: Chest
Inclusion in quiz mode: Included

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