Thoracoscopic Bilobectomy after Bilateral Single Sequential Lung Transplantation in a Cystic Fibrosis Patient with Post-Transplant Airway Stenosis

Introduction Airway complications following lung transplantation are associated with significant morbidity and mortality; they can result to significant functional impairment, poor quality of life and frequent hospitalizations. Anastomotic stenosis remains the commonest post-transplant airway complication with an estimated incidence between 1.6-32%. Non-anastomotic bronchial stenosis is rare and is not reported frequently. Case Report We present the case of a 46-year-old female cystic fibrosis patient requiring right lower bilobectomy following bilateral sequential lung transplant in April 2018, which was complicated by stricture of the right main bronchus requiring serial dilatations. Recurrent chest infections related to chronic Achromobacter xylosoxidans lead to complete right middle and lower lobe consolidation and collapse, with a ventilation/perfusion scan demonstrating almost complete absence of lobar ventilation and perfusion. Subsequent fibrotic narrowing of the bronchus intermedius resulted in bi-lobar failure and right lower bilobectomy in June 2020. Stenting of the bronchus intermedius was not considered feasible because the stenosis was in close proximity to the right upper lobar orifice. Thus, lung resection was undertaken utilizing a 2-port video assisted thoracoscopic technique. Intra-operatively the lung was found to be densely adhered to the chest wall and the diaphragm. Division of adhesions and lung mobilisation was challenging and utilization of various surgical techniques to avoid lacerations and prolonged leakage. Careful dissecting of the atrial cuff anastomosis was done to preserve the upper lobe venous supply. The pulmonary artery branches were dissected through their regular anatomical locations by accessing the oblique fissure. The middle and lower lobe bronchi were divided en bloc within their respective fissures to limit disruption of the vasculature of the bronchial stumps and prevent post-operative fistulae. Summary Treatment of stenotic anastomosis after lung transplantation can be challenging. Our case demonstrates that surgical management may be indicated when more conservative techniques have failed. Limits for surgery in lung failure need constant revisit; our experience shows that management in highly specialized centres improves overall outcomes.