Case report

A 49-year-old woman with emphysema secondary to α-1 antitrypsin deficiency was admitted for evaluation of lung transplantation, due to progressive worsening of disease despite optimal medical management, including monthly intravenous prolastin therapy, maximum bronchodilator therapy and oxygen.

Based on the hospital protocol and consistent with recommended guidelines double lung transplantation was performed in June 2010. Surgery was complicated by an intraoperative injury of the left pulmonary artery, which required a cardiopulmonary bypass for 4 hours. During the following 48 hours the patient required vasoactive drugs (norepinephrine 0.2 μg/kg/min and dobutamine 2 μg/kg/min) and mechanical ventilation for 7 days (tracheostomy was performed on the 3rd day). Twenty-four hours after lung transplantation a chest radiograph showed a right basal infiltrate. On computed axial tomography an oedema and congestion in the right lower lobe was diagnosed. A subsequent transoesophageal echocardiogram demonstrated absence of flow in the right inferior pulmonary vein without evidence of a thrombotic occlusion. The decision of immediate right lower lobectomy (RLL) was made, followed by an uneventful immediate postoperative course.

A week after lobectomy (9th day after transplantation) a bronchopleural fistula was diagnosed clinically and confirmed endoscopically.

Bronchoscopy revealed a 9 mm dehiscence in the stump of the right lower lobe (figure 1), the transplantation sutures were intact. …