Sandeep J. Khandhar

Native lung complications in single-lung transplant recipients and the role of pneumonectomy.

Single-lung transplant recipients may develop complications in their native lungs that may have an impact on outcomes. One potential therapeutic option is native lung pneumonectomy. The purpose of this study was to assess the impact of native lung complications on post-transplant survival in single-lung transplant recipients. We also aimed to determine the morbidity and mortality associated with native lung pneumonectomy (NLP). A retrospective review of all single-lung transplant recipients at our institution from January 1, 1998 to July 15, 2008 was performed. Patients were stratified to one of three groups: no native lung complications; native lung complications requiring native lung pneumonectomy; and native lung complications not managed with native lung pneumonectomy. Survival post-transplant and post-native lung complication were the primary end-points of the study. Significant native lung complications developed in 25 of 180 single-lung transplants (13.8%). Median post-transplant survival was lower in single-lung transplant recipients with significant native lung complications (3.2 years vs 5.3 years, p = 0.002). NLP was performed in 11 patients. Post-operative complications developed in 4 of 11 cases (36.4%), but all patients survived to hospital discharge. There was no significant difference in median survival between single-lung transplant recipients undergoing native lung pneumonectomy and single-lung transplant recipients without native lung complications (4.3 years vs 5.1 years, p = 0.478). Native lung complications impact post-transplant survival in single-lung transplant recipients and may partly explain why outcomes with single-lung transplantation are inferior to those of bilateral lung transplantation. NLP can be performed with acceptable morbidity and mortality.

The Diagnosis and Management of Airway Complications Following Lung Transplantation

&NA; Airway complications following lung transplantation result in considerable morbidity and are associated with a mortality of 2% to 4%. The incidence of lethal and nonlethal airway complications has decreased since the early experiences with double‐ and single‐lung transplantation. The most common risk factor associated with post‐lung transplantation airway complications is anastomotic ischemia. Airway complications include the development of exophytic granulation tissue, bronchial stenosis, bronchomalacia, airway fistula, endobronchial infection, and anastomotic dehiscence. The broadening array of bronchoscopic therapies has enhanced treatment options for lung transplant recipients with airway complications. This article reviews the risk factors, clinical manifestations, and treatments of airway complications following lung transplantation and provides our expert opinion when evidence is lacking.

Constrictive pleuropericarditis: a dominant clinical manifestation in Whipple's disease.

BackgroundWhipple’s disease is a rare, multisystemic, chronic infectious disease which classically presents as a wasting illness characterized by polyarthralgia, diarrhea, fever, and lymphadenopathy. Pleuropericardial involvement is a common pathologic finding in patients with Whipple’s disease, but rarely causes clinical symptoms. We report the first case of severe fibrosing pleuropericarditis necessitating pleural decortication in a patient with Whipple’s disease.Case presentationOur patient, an elderly gentleman, had a chronic inflammatory illness dominated by constrictive pericarditis and later severe fibrosing pleuritis associated with a mildly elevated serum IgG4 level. A pericardial biopsy showed dense fibrosis without IgG4 plasmacytic infiltration. The patient received immunosuppressive therapy for possible IgG4-related disease. His poor response to this therapy prompted a re-examination of the diagnosis, including a request for the pericardial biopsy tissue to be stained for Tropheryma whipplei.ConclusionsDespite a high prevalence of pleuropericardial involvement in Whipple’s disease, constrictive pleuropericarditis is rare, particularly as the dominant disease manifestation. The diagnosis of Whipple’s disease is often delayed in such atypical presentations since the etiologic agent, Tropheryma whipplei, is not routinely sought in histopathology specimens of pleura or pericardium. A diagnosis of Whipple’s disease should be considered in middle-aged or elderly men with polyarthralgia and constrictive pericarditis, even in the absence of gastrointestinal symptoms. Although Tropheryma whipplei PCR has limited sensitivity and specificity, especially in the analysis of peripheral blood samples, it may have diagnostic value in inflammatory disorders of uncertain etiology, including cases of polyserositis. The optimal approach to managing constrictive pericarditis in patients with Whipple’s disease is uncertain, but limited clinical experience suggests that a combination of pericardiectomy and antibiotic therapy is of benefit.

Successful endobronchial treatment of a non-healing tracheoesophageal fistula from a previous histoplasmosis capsulatum infection using decellularized porcine urinary bladder matrix†

Abstract Tracheoesophageal fistulas (TEF) are pathologic communications between the esophagus and the trachea or bronchi. The development of a TEF can result from malignant or benign etiologies. A common approach for the treatment of TEFs is the placement of endobronchial and esophageal stents to facilitate healing of the communication. This case report describes the successful treatment of a TEF resulting from calcified mediastinal lymphadenopathy due to a previous Histoplasmosis capsulatum infection. In addition to placement of endobronchial and esophageal stents, the non-healing TEF was treated with ACell (Gentrix®) decellularized porcine urinary bladder matrix to facilitate complete closure of the fistulous tract.

Bronchoscopic valves for prolonged air leak: current status and technique

Unidirectional airway valves are devices used for the treatment of persistent air leaks (PALs) secondary to alveolar-pleural fistulas (APF) or bronchopleural fistulas (BPFs). These valves were originally developed as a non-surgical alternative to lung volume reduction surgery (LVRS) for patients with chronic obstructive pulmonary disease (COPD). Randomized trials investigating the use of valves for bronchoscopic LVRS did not lead to the Federal Drug Administration (FDA) approval, but stemming from these studies a Humanitarian Device Exemption (HDE) was granted to Spiration intrabronchial valves (IBVs) for the treatment of PALs. These valves are being increasingly utilized due to the effectiveness of IBVSs in reducing PALs, thus shortening duration of hospitalizations and minimizing the risk of hospital associated complications. The literature supporting the use of unidirectional airway valves for the bronchoscopic treatment of PALs is grounded primarily in case reports. While the current body of literature available to justify the use of unidirectional valves is limited to case series, current multicenter, randomized trials should provide further guidance regarding patient selection and effectiveness.