Successful surgical management of sudden acute obstruction of the bronchus intermedius via an interlobar approach following bilateral lung transplantation: a case report

Lung transplantation (LTx) is an established treatment for end-stage lung disease. However, bronchial complications after LTx remain a major challenge. Bronchial stenosis is the most common bronchial complication, for which the main treatment strategies are endoscopic and surgical interventions. This report describes a case of sudden-onset bronchial stenosis following bilateral LTx that was successfully managed by surgery. A 46-year-old man underwent bilateral LTx from a brain-dead donor for pulmonary Langerhans cell histiocytosis and pulmonary hypertension. He was discharged 1 month later without any complications. Although there were no significant abnormal findings on chest computed tomography (CT) scans obtained 3 months after LTx, he complained of sudden-onset dyspnea at 5 months following LTx. Chest radiography showed decreased lucency in the right lower lung field, and CT demonstrated severe stenosis of the right bronchus intermedius, with the stenotic segment measuring approximately 0.8 cm in length. Limited aeration remained in the middle and lower lobes. His respiratory condition deteriorated rapidly, and he was intubated and admitted to the intensive care unit. Repeat CT performed on the following day revealed complete obstruction of the bronchus intermedius and total atelectasis of the right middle and lower lobes. After urgent transfer to our hospital, bronchoscopy revealed complete obstruction of the bronchus intermedius, indicating a need for urgent surgical intervention. Right thoracotomy was performed via the fifth intercostal space. After division of the main pulmonary artery through the interlobar fissure, sleeve resection with end-to-end reconstruction was performed for the stenotic segment of the bronchus intermedius. The postoperative course was uneventful, and the patient was discharged on postoperative day 15. No restenosis has been observed on repeat CT or bronchoscopy, and he has remained well during 2.5 years since surgery. Bronchial stenosis can occur after LTx even distal to the anastomotic site, particularly in the right bronchus intermedius, and may progress rapidly to complete obstruction. Surgical intervention may be an effective strategy when endoscopic management is not feasible.