This case report describes a patient who developed a non-stump bronchopleural fistula (BPF) after a right lower lobectomy for lung cancer. On re-exploration, the bronchial stump was intact but the membranous portion of the bronchus intermedius was necrotic, causing a large fistula. The patient underwent a completion sleeve bilobectomy, removing the remaining middle lobe and performing a sleeve resection of the involved portion of the main bronchus. The upper lobe bronchus was re-anastomosed, and the patient recovered uneventfully with an intact bronchial anastomosis. This novel procedure successfully treated a rare case of non-stump BPF.

1. CASE REPORTS
Ex Vivo Bilateral Pulmonary
Embolectomy for Donor Lungs
Prior to Transplantation
Mohammad Shihata, MD, Nitin Ghorpade, MD,
Dale Lien, MD, and Dennis Modry, MD
Division of Cardiac Surgery, University of Alberta Hospital,
Edmonton, Alberta, Canada
Pulmonary arterial embolic disease of donor lungs is a
known entity. Its implications on the technicality, the
perioperative management, and the outcome of lung
transplantation depend on the extent of the embolic
disease and the indicators of lung function at the time of
procurement. We report a case of lung transplantation
from a donor who was known to have significant acute
pulmonary embolic disease and the perioperative man-agement
used to optimize the outcome.
(Ann Thorac Surg 2008;85:2110 –2)
© 2008 by The Society of Thoracic Surgeons
Liberalization of donor criteria has been increasingly
practiced in an attempt to overcome the shortage in
donor organs. In the current era, many donor organs with
indicators showing good lung function would not fulfill
all the classic prerequisites. In this case report we de-scribe
the use of lungs from a donor who had significant
pulmonary embolic disease that was underestimated
during the pretransplantation workup.
The patient is a 55-year-old man with end-stage emphy-sema.
He was on home oxygen therapy and had severe
physical disability due to shortness of breath at rest and
minimal exertion, and hence was listed for lung
transplantation.
The donor was a previously healthy 46-year-old truck
driver who had a sudden collapse at home and was
resuscitated and transferred to a tertiary care center.
Further investigations found that he had a large hemi-spherical
cerebral infarction and severe cerebral edema.
The cerebral infarction was believed to be secondary to a
paradoxic embolic phenomenon. A transesophageal
echocardiogram confirmed the presence of a patent fo-ramen
ovale and demonstrated severe right ventricular
dysfunction. The diagnosis of deep venous thrombosis
and pulmonary embolization was confirmed.
After 7 days of anticoagulation, the need for supple-mental
oxygen therapy was significantly reduced and
there was no evidence of a residual central or subseg-mental
pulmonary embolus on a repeat computed to-mography
scan of the chest. A repeat echocardiogram
showed marked improvement of the right ventricular
dimensions and contractility. There was no central ner-vous
system recovery, however, and cerebral perfusion
studies showed no cerebral flow.
Once the brain death criteria were established, the lungs
were assessed for possible organ donation. The result of the
chest roentgenogram was normal, and a lung perfusion
scan on day 8 after the initial presentation showed a small
perfusion defect in the right lung. The donor had a partial
pressure of oxygen of 378 on 100% oxygen, a positive
end-expiratory pressure of 5 cm H2O, and a tidal volume of
6 mL/kg. On the basis of the last imaging studies and the
pulmonary functional indicators, the lungs were accepted
for transplantation. At the time of procurement, the donor
lungs were grossly normal, and there was no evidence of
any particulate embolic washout when retrograde pneu-moplegia
was administered.
The transplantation was performed on cardiopulmo-nary
bypass. Before implantation, it was apparent on
direct inspection, once the pulmonary artery was di-vided,
that both main pulmonary arteries had a substan-tial
embolic burden extending to the segmental and
subsegmental branches.
At that time, the recipient was committed to receive the
lungs after having bilateral pneumonectomies and medi-astinal
dissection. The decision was made to perform
bilateral pulmonary embolectomy and proceed with the
implantation, bearing in mind the need to institute anti-coagulation
therapy afterwards. Extraction of the central
part of the clot was relatively easy, but there was a fair
degree of clot organization in the more distal portions.
We had to resort to a special type of suction catheters that
we usually use for pulmonary endarterectomy, the
Jamieson dissecting aspirator (MMA-7; Fehling Surgical
Instruments Inc, Acworth, GA), to make sure that all
visible clots were removed (Fig 1). The bilateral embolec-tomy
added 30 minutes of ischemic time to the operation.
The total ischemic time was 155 minutes for the right
lung and 228 minutes for the left lung.
The patient had an uneventful immediate postoperative
course in the intensive care unit and was transferred to the
ward on the second postoperative day. On day 6, the
patient’s recovery was complicated by the development of
ischemic colitis and perforation, mandating an exploratory
Accepted for publication Dec 5, 2007.
Address correspondence to Dr Shihata, Division of Cardiac Surgery,
University of Alberta, 303, 10904 - 102 Ave, NW, Edmonton, Alberta,
T5K2Y3, Canada; e-mail: mshihata@gmail.com.
Fig 1. The left and right sides of the photograph show clots re-moved,
respectively, from the left and right donor lungs before
implantation.
© 2008 by The Society of Thoracic Surgeons 0003-4975/08/$34.00
Published by Elsevier Inc doi:10.1016/j.athoracsur.2007.12.011
FEATURE ARTICLES

2. Ann Thorac Surg CASE REPORT SHIHATA ET AL 2111
2008;85:2110–2 PULMONARY EMBOLECTOMY IN DONOR LUNGS
laparotomy, hemicolectomy, and formation of an ileos-tomy.
Despite the additional septic and surgical stresses,
prolonged intubation was not needed and he remained
stable from the cardiopulmonary standpoint. He contin-ued
to recover in a timely fashion and was discharged
home on oral anticoagulation therapy. Before discharge,
the result of his chest roentgenogram was within normal
limits (Fig 2), and a lung perfusion scan showed minor
residual defects in the right lung (Fig 3).
Comment
Lung transplantation has become the treatment of choice
for end-stage lung disease caused by different underlying
pathologic entities. The main limitation, however, re-mains
the lack of enough donor organs. The exponential
increase in the number of patients awaiting lung trans-plantation
has not been met by an equivalent increase in
the donor pool. Patients on the waiting lists for lung
transplantation have an annual mortality rate of 20%
according to some recent reports [1]. Other study groups
reported a mortality rate of 50% for patients found
suitable for lung transplantation from their underlying
lung disease before an organ becomes available [2].
The concept of accepting marginal or extended donors
has become a common practice in many of the busy
transplant centers around the world [3]. Advocates of
Fig 2. Chest roentgenograms taken (left) pre-operatively
and (right) before discharge.
using lungs from living donors, older donors, donors
with history of smoking, non-heart-beating donors, or
donors with reversible underlying lung pathologies have
been increasingly reporting successful outcomes [4] that
are comparable with outcomes expected when more rigid
donor selection criteria are implemented [5].
The use of donor lungs from patients suspected or
diagnosed to have variable degrees of pulmonary em-bolic
disease at the time of brain death has been previ-ously
reported in a few anecdotal cases [6]. Unexpected
macroscopic donor-related pulmonary emboli were re-ported
in as many as 38% of lung transplantations, and
this was found to be associated with worse outcomes in
terms of primary graft failure [7].
The use of pulmonary embolectomy at the time of lung
transplantation has been previously reported in two
separate case reports [8, 9]. The patient reported in this
article is unique due to the substantial clot burden that
was removed from as distal as the subsegmental pulmo-nary
arteries and the amount of organization in portions
of the clots, indicating a subacute process. That this
problem was not fully appreciated at the time of the
pretransplant workup is probably the reason the lungs
were accepted for the transplantation.
The excellent early outcome we had with this case has
led us to a number of conclusions. First, the diagnosis of
pulmonary embolism whenever suspected in a trans-
Fig 3. Predischarge perfusion lung scan shows
minor right middle and lower lobe perfusion
defects.
FEATURE ARTICLES

3. 2112 CASE REPORT HAMAD ET AL Ann Thorac Surg
COMPLETION SLEEVE BILOBECTOMY FOR BPF 2008;85:2112–4
plant workup should be based on contrast imaging
techniques. Second, the combination of antegrade and
retrograde pneumoplegia is very useful in providing
uniform lung protection. Furthermore, the absence of
particulate or visible debris with retrograde flushing of
the pulmonary veins is not completely reliable in ruling
out pulmonary emboli, especially if any degree of clot
organization is present. Careful inspection of the pulmo-nary
arterial tree should always be performed before
implantation. Finally, this result enforces the concept of
liberalization of organ donor criteria in an attempt to
overcome the confounding shortage of organs. This lib-eralization,
however, should not be in violation of any of
the functional or gas exchange indicators.
References
1. Fischer S, Gohrbandt B, Meyer A, Simon AR, Haverich A,
Struber M. Should lungs from donors with severe acute pulmo-nary
embolism be accepted for transplantation? The Hannover
experience. J Thorac Cardiovasc Surg 2003;126:1641–3.
2. Thabut G, Mal H, Cerrina J, et al. Influence of donor charac-teristics
on outcome after lung transplantation: a multicenter
study. J Heart Lung Transplant 2005;24:1347–53.
3. Filosso PL, Turello D, Cavallo A, Ruffini E, Mancuso M, Oliaro
A. Lung donors selection criteria: a review. J Cardiovasc Surg
(Torino) 2006;47:361– 6.
4. Pierre AF, Sekine Y, Hutcheon MA, Waddell TK, Keshavjee
SH. Marginal donor lungs: a reassessment. J Thorac Cardio-vasc
Surg 2002;123:421–7.
5. Aigner C, Winkler G, Jaksch P, et al. Extended donor criteria
for lung transplantation–a clinical reality. Eur J Cardiothorac
Surg 2005;27:757– 61.
6. Frenia D, Nathan SD, Ahmad S, et al. Successful lung trans-plantation
from a donor with a saddle pulmonary embolus.
J Heart Lung Transplant 2005;24:1137–9.
7. Oto T, Rabinov M, Griffiths AP, et al. Unexpected donor
pulmonary embolism affects early outcomes after lung trans-plantation:
a major mechanism of primary graft failure?
J Thorac Cardiovasc Surg 2005;130:1446.
8. Nguyen DQ, Salerno CT, Bolman M 3rd, Park SJ. Pulmonary
thromboembolectomy of donor lungs prior to lung transplan-tation.
Ann Thorac Surg 1999;67:1787–9.
9. Smith JA, Mohajeri M, Rabinov M, Esmore DS. Maldistribu-tion
of pneumoplegia in pulmonary allografts secondary to
post-traumatic pulmonary thromboembolism. J Heart Lung
Transplant 1996;15:324 –5.
A Completion Sleeve Bilobectomy
for Nonstump Postlobectomy
Bronchopleural Fistula
Abdel-Mohsen Hamad, MD, Giuseppe Marulli, MD,
Marco Schiavon, MD, and Federico Rea, MD
Division of Thoracic Surgery, Department of Cardiologic,
Thoracic and Vascular Sciences, University of Padua, Padova,
Italy
We present a novel approach for treatment of nonstump
postlobectomy bronchial fistula. Our patient had right
lower lobectomy for T3 N2 M0 adenocarcinoma. An
increased air leak developed 8 days later, and bronchos-copy
revealed the presence of a bronchial fistula. On
reexploration, the bronchial stump was intact, and the
membranous part of the bronchus intermedius was
sloughed up to the opening of the upper lobe bronchus.
A middle lobectomy with sleeve resection of the bron-chus
intermedius and part of the right main bronchus
was performed, and the upper lobe was reanastomosed to
the right main bronchus. The patient’s postoperative
course was uneventful, and follow-up bronchoscopy
showed an intact healed anastomosis.
(Ann Thorac Surg 2008;85:2112– 4)
© 2008 by The Society of Thoracic Surgeons
Bronchopleural fistula (BPF) is a relatively rare but
feared complication of pulmonary resection. The
incidence of BPF after lobectomy was reported to be 1.1%
in a series of 1083 lobectomies [1], with higher incidence
after lower lobectomies [2]. A BPF that occurs within 7
days after operation is usually the result of a technical
failure, but when the bronchial leak occurs later in the
postoperative course, it may be caused by failure of
healing. The management approach of BPF is challenging
and includes both interventional bronchoscopic and sur-gical
procedures.
A 62-year-old man underwent en bloc resection of the
right lower lobe and the posterior segments of the right
sixth and seventh ribs with mediastinal lymphadenec-tomy
for right lower-lobe non-small cell lung cancer
(NSCLC). Air leakage increased on postoperative day 8,
and the drained pleural fluid became cloudy. A broncho-scopic
examination showed a large opening of the bron-chus
intermedius. A roentgenogram showed he had a
pneumothorax and atelectatic residual lung tissue. There
was no fever or significant leucocytosis. Histopathologic
diagnosis of the resected lobe was adenocarcinoma with
metastasis to the 4R mediastinal lymph nodes (T3 N2
M0).
The patient underwent reoperation, and the bronchial
suture line was intact. The membranous part of the
bronchus intermedius was sloughed up to the origin of
the upper lobe bronchus, resulting in large fistula with
necrotic margin (Fig 1). We performed a middle lobec-tomy,
with sleeve resection of the bronchus intermedius
and part of the right main bronchus (Fig 2). The upper
lobe bronchus was reanastomosed to the right main
bronchus with running sutures. Four sutures of 4-0
polydioxanone (Ethicon Inc, Somerville, NJ) suture were
used, and each extended for one-quarter of the circum-ference
of the anastomosis. Finally, all sutures were
tightened and the adjacent limbs were each tied together.
Decortication of the upper lobe and cleaning of the
pleural space were done.
The patient’s postoperative course after the second
operation was uneventful. There was no air leak and the
chest roentgenogram showed inflation of the upper lobe.
A bronchoscopic examination 1 week later showed an
Accepted for publication Nov 26, 2007.
Address correspondence to Dr Rea, Division of Thoracic Surgery, Uni-versity
of Padua, Via Giustiniani 2, Padova, 35128, Italy; e-mail:
federico.rea@unipd.it.
© 2008 by The Society of Thoracic Surgeons 0003-4975/08/$34.00
Published by Elsevier Inc doi:10.1016/j.athoracsur.2007.11.062
FEATURE ARTICLES