Abstract
Anastomotic airway complications, such as necrosis with dehiscence of the anastomotic site, may cause morbidity after lung transplant (LT). In rare cases, sloughing and necrosis of the anastomotic site can mask partial, asymptomatic dehiscence.
We present the case of a masked, partial anastomotic dehiscence in a 71-year-old man after bilateral LT (06/2021) for COPD. His postoperative course was complicated by PGD grade 1 and positive crossmatch with the donor, requiring plasma exchange and IVIG. During the transplant stay, he also required frequent bronchoscopies given thick secretions in the bilateral anastomotic sites. We initiated inhaled antibiotics with tobramycin and amphotericin; donor cultures were positive for MRSA, for which the recipient was also adequately covered. Chest CT showed small, bilateral pneumothoraces, more pronounced on the right (Figure 1A), but no evidence of dehiscence (Figure 1B). At 2 weeks posttransplant, secretions were slowing, but a fifth bronchoscopy showed continued sloughing (Figure 1C) with need for forceps to remove the necrotic debris. He was ultimately discharged in stable condition, without bronchoscopic findings of dehiscence. Two months later, surveillance bronchoscopy showed resolution of sloughing. However, a small hole near the anastomotic site was seen, suspicious for partial dehiscence. Because there was no evidence of allograft dysfunction or pneumothorax, we lowered his steroid dose and monitored healing with frequent bronchoscopies. Alongside aggressive antibiotic therapy and airway clearance, a repeat bronchoscopy performed 10 days later showed pseudomembrane formation and healed dehiscence (Figure 1D). Fortunately, the patient had no issues with initial chest tube removal after transplant.
Partial, asymptomatic anastomotic dehiscence can be masked in the immediate posttransplant period. Careful inspection of the bilateral anastomosis with repeat bronchoscopies may be necessary to rule out dehiscence with certainty.