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Introduction: Lung transplantation (LTx) is the ultimate treatment for patients suffering from end-stage pulmonary conditions. Despite vast improvements in surgical techniques over the last several years, complications are still frequent. Development of an esophageal fistula after LTx is a rare complication, characterized by significant morbidity, requiring re-intervention, a prolonged stay in the intensive care unit and a long period of nil per os. Given the rarity of this complication, limited literature on this topic is available. The aim of this case series is to describe this complication in detail, its clinical presentation and treatment options as well as to discuss potential risk factors. Methods: This study is a retrospective case series on the development of an esophageal fistula after bilateral LTx at the University Hospitals Leuven Belgium between 2019 and 2020. A total of 4 patients presented with an esophageal fistula post-LTx. Case series: Case 1: A 63-year-old male received a bilateral LTx for end-stage combined pulmonary fibrosis and emphysema. 26 days after LTx, he developed a right-sided hydropneumothorax with subcutaneous emphysema. Gastroscopy revealed an esophageal fistula. The fistula was closed by an intercostal muscle flap, hemo-clips and stenting. Follow up showed no remaining fistula. He was discharged after a 156-day stay in the hospital. Case 2: a 33-year-old female underwent a bilateral lobar transplant for end-stage cystic fibrosis. 13 days after LTx, she deteriorated due to hemorrhagic shock. Bilateral redo anterior thoracotomy showed a fistula that was subsequently covered by an intercostal muscle flap. Follow up showed remaining leakage of the fistula and conservative therapy was set. Control CT confirmed a positive evolution of the fistula and after 98 days in the hospital, she was discharged home. Case 3: A 62-year-old male underwent a bilateral LTx for terminal interstitial lung disease due to systemic sclerosis with secondary severe pulmonary and right heart failure. 16 days post-LTx, he developed a pneumopericardium with bilateral pneumothorax. A week later he showed acute respiratory decline and a gastroscopy showed an esophageal fistula. A conservative management was set. However, control endoscopy showed a larger fistula and clips were placed. 109 days after LTx, CT showed a relapse of the esophageal pleural fistula and the fistula was primarily closed and covered with two intercostal muscle flaps. Follow up showed no remaining fistulas. After a 273-day hospital-stay, he was discharged to a rehabilitation center. Case 4: A 38-year-old male received a bilateral LTx because of idiopathic pulmonary arterial hypertension. 42 days after LTx, the patient presented with persistent respiratory distress. CT scan showed an esophagobronchial fistula due to bronchial dehiscence. The fistula was surgically revised with an intercostal muscle flap. Afterwards, there was limited leakage of the fistula and a conservative management was set. The fistula showed a favorable evolution. After an 88-day stay in the hospital he was discharged. Conclusion: An esophageal fistula is a rare, but severe post lung transplantation complication that presents itself in patients in poor condition with a high morbidity. A high level of clinical suspicion is required, followed by rapid diagnosis and management. If treated in time, this complication has a good short-term outcome.

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Background: Lung transplantation (LTx) is the ultimate treatment for patients with end-stage lung disease. Despite major developments, organ transplantation remains hampered by a lack of suitable organs. In countries with a legal framework for euthanasia, organ donation following euthanasia could be addressed to expand the donor pool. However, apart from the initial experience, lung donation and transplantation after euthanasia (donation after circulatory death (DCD-V)) remain relatively unacquainted and long-term outcomes have not been reported. We aim to describe our experience with lung donation after euthanasia and evaluate long-term outcome in comparison to a matched cohort of controlled donation after circulatory death (DCD-III) and donation after brain death (DBD). Methods: All sequential single-lung transplantations (SSLTx) performed at the University Hospitals Leuven between 2007 and 2020 were retrospectively analyzed. Propensity score matching was performed using recipient gender and age, indication for LTx, use of extracorporeal lung support (ECLS) and donor age as matching variables, which resulted in a one-to-two DCD-III and a one-to-three DBD matching. Chronic lung allograft dysfunction (CLAD)-free survival was the primary outcome. Results: A total of 769 SSLTx were performed of which 22 were from DCD-V donors (2.9%), accounting for 14% of all DCD cases. Thirteen women and nine men (suffering from neuromuscular disorders (n = 9), psychiatric disorders (n = 8) or unbearable pain (n = 5)) expressed their wish for organ donation after euthanasia. Donor warm ischemia time (DWIT) was 11 minutes. Twenty-two patients (13 women and 9 men) with a median age of 57 years underwent a SSLTx for chronic obstructive pulmonary disease (COPD) (n = 11), pulmonary fibrosis (n = 5), cystic fibrosis (n = 4) or bronchiolitis obliterans (n = 2). CLAD-free 3- and 5-year survival were 86.4% and 58.9%, equal to DCD-III (83.7% and 61.1%, p=0.816) and DBD (62.2% and 50.5%, p=0.120). Five-year patient survival was 90.9%, comparable to both the DCD-III (84.8%, p=0.969) and DBD (73.9%, p=0.252) cohort. Despite a significantly longer cold ischemia time in the DCD-V group compared to DBD donors (261 versus 214 minutes and 431 versus 391 minutes for the first and second lung, respectively), a trend towards less PGD was observed. Conclusion: The findings of this propensity-matched cohort study suggest for the first time that SSLTx with DCD-V grafts yield similar long-term outcome as SSLTx with DCD-III and DBD grafts. Therefore, grafts donated after euthanasia may be a justifiable option for increasing the organ donor pool.

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