Interactive Cardiovascular and Thoracic Surgery 3:254-256(2004)
© 2004 European Association of Cardio-Thoracic Surgery
Case report - Thoracic general |
Incorporated airway stent: a useful option for treating tracheal stenosis after metallic stenting
Yun-Hen Liu,
Po-Jen Ko,
Yi-Cheng Wu and
Hui-Ping Liu*
Division of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5 Fu-Hsing Street, Kweishan, Taoyuan, Taiwan, ROC
* Corresponding author. Tel.: +886-3-328-1200x2118; fax: +886-3-328-5818
hpliu125{at}ms21.hinet.net
Received April 15, 2003;
received in revised form November 7, 2003;
accepted November 17, 2003
 |
Abstract
|
|---|
This study incorporated a silicone tracheal stent into a metallic stent in a complicated airway stenosis patient. The silicone tracheal stent provided a stable and patent airway. The patient was discharged smoothly after the procedure. At 5 months after surgery, the patient remained stable and resumed all daily activities without any respiratory symptoms.
Key Words: Airway stenosis; Airway stent
|
1. Introduction
|
|---|
The gold standard of therapeutic method for central airway stenosis is segmental resection and reconstruction with primary anastomosis [1–3]. However, in situations where surgery is impossible, bronchoscopic procedures such as laser ablation, dilation, endoscopic resection, brachytherapy, and stent insertion are all useful options [4,5]. This study describes a successful experience of using a silicone tracheal stent to treat a case of tracheal stenosis in which treatment with metallic stenting failed.
|
2. Case report
|
|---|
A 66-year-old male with laryngeal cancer (squamous cell carcinoma, stage IV) was treated with laryngopharyngectomy, ileocolic free graft, and tracheostomy. The man suffered severe tracheal stenosis 45 days following tracheostomy and required multiple bronchoscopic procedures (Diode laser (Diomed 60, GaAIAs Diode Laser, Cambridge research park, Cambridge, United Kingdom), electrocoagulation, dilation, and metallic stenting (40x20 mm)) for adequate ventilation. Despite temporary improvement in his respiratory function, the man was still complicated with intermittent dyspenea and severe limitation of daily activity following metallic stent insertion performed elsewhere. The man thus was transferred to our unit for evaluation of possibility of airway reconstruction 10 months after tracheostomy (6 months after metallic stenting).
A flexible bronchoscope was used to examine the airway via the tracheostomy tube under local anesthesia. Examination revealed 4 cm of Ultraflex (Boston Scientific, Natick, MA) stent located immediately distal to the tracheostomy tube. Severe stenosis with 80% airway obstruction owing to granulation tissue was found at the distal end of the stent (1 cm in length, 2 cm from carina), compatible with the computerized tomography (CT) image (Fig. 1A–C). A rigid bronchoscope was introduced via the trachea stoma under general anesthesia. With adequate ventilation, the blunt-tip of Dumon scopes was used to manipulate and dilate the stricture region. The stenosis segment was adequately dilated by changing the scope with outer diameter from 5 to 14 mm. To prevent recurrence of stenosis, a silicone stent (16x60 mm) was introduced via the previous metallic stent using a rigid bronchoscope technique (Fig. 1D). The silicone stent was intussuscepted in the metallic stent with 5 mm protruding proximally and 15 mm protruding distally, and the distance between the silicone stent and carina was 15 mm as measured by bronchoscope following the procedure. The uncuffed Portex tracheostomy tube (size 8) was inserted into the proximal end of the silicone stent (Fig. 2). The patient regained respiratory function immediately after the operation and was discharged smoothly.
View larger version (114K):
[in this window]
[in a new window]
|
Fig. 1 (A) Airway obstruction over distal tip of tracheostomy tube. (B) Persisted obstruction after metallic stent insertion. (C) Chest CT revealed airway stricture at lower third of trachea, just distal to the end of metallic stent. (D) Patent airway lumen from lower trachea to carina after silicone stent insertion.
|
|
One week after surgery, the patient returned for a checkup displaying good health status but complaining of foul smelling secretions from the tracheostomy tube. The symptoms improved following 3 days of oral antibiotic. As an outpatient at 2 weeks post-surgery, the flexible bronchoscopy displayed good patent of airway and good position of silicone stent without any granulation over the distal trachea. The patient remained stable and resumed all daily activities without respiratory symptoms 11 months after our surgery.
|
3. Discussion
|
|---|
Rigid bronchoscopy enables simultaneous ventilation and manipulation of airway lesions. Dilation of airway stenosis enables temporary improvement in airway symptoms. Dilation can be performed via angioplasty balloon, or rigid bronchoscopes [6,7]. In our patient, the rigid scope was used to palpate and manipulate the stenosis region. The stenosis region was adequately dilated by changing the bronchoscopes to increase their nominal size. The beveled tip of the rigid scope is considered safe and ideal for insinuation via a tiny airway opening.
Easy insertion of metallic stent via flexible bronchoscope explains the current tendency of physicians to treat surgically resectable stenosis with stents. Grillo et al. did not see stenting as a benign procedure and noted that metallic stent regularly and irreversibly converts wholly resectable lesions into lesions of irresectable length [8,9].
In our patient, numerous granulations occurred and the ring of granulation tissue over the distal end of the stent caused tracheal lumen obstruction. We believe that it is difficult or impossible to remove the stent bronchoscopically or via open tracheostomy and moreover may cause airway laceration or bleeding. The stricture segment was dilated with rigid bronchoscope and another stent was introduced to prevent airway restenosis.
Using a longer tracheostomy tube to extend through the area of stenosis was the standard approach for this kind of patient. In our opinion, the use of incorporated stents which inserted the silicone stent into metallic stent has various advantages. Notably, this procedure provides a safe and patent airway. The tracheostomy tube can be introduced into the proximal end of silicone stent and provides sufficient ventilation while cleaning the inner tracheostomy tube. Although migration is a major limitation of silicone stent, it did not occur in this patient owing to accommodation between the metallic interstices and the stud of silicon stent.
In the subject patient, the rigid bronchoscope was inserted via tracheostoma. We feel that this method is a technically simple, quick, and reliable method of establishing the airway. Additionally, this procedure does not suffer from the complication of subglottic edema. For patients with cervical spine disease complicated with positioning difficulty, the use of a rigid bronchoscope should not be a contraindication for the use of this approach.
Airway reconstruction was not suitable for our patient owing to the presence of total laryngectomy, and granulation tissue ingrowths around the stent suggesting difficult removal and possibility of bleeding. Given the good outcome of incorporated stents in this patient, we believe that the technique described here may be useful for treating central airway stenosis following metallic stenting.
doi:10.1016/j.icvts.2003.11.009
|
References
|
|---|
- Mathisen DJ. Tracheal tumors. Chest Surg Clin N Am. 1996;6:875–898[Medline]
- Grillo HC, Donahue DM, Mathisen DJ, Wain JC, Wright CD. Postintubation tracheal stenosis. J Thorac Cardiovasc Surg. 1995;109:486–493[Abstract/Free Full Text]
- Donahue DM, Grillo HC, Wain JC, Wright CD, Mathisen DJ. Reoperative tracheal resection and reconstruction for unsuccessful repair of postintubation stenosis. J Thorac Cardiovasc Surg. 1997;114:934–939[Abstract/Free Full Text]
- Cavaliere S, Venuta F, Foccoli P, Toninelli C, Face La B. Endoscopic treatment of malignant airway obstructions in 2,008 patients. Chest. 1996;110:1536–1542[Abstract/Free Full Text]
- Stephens KE Jr., Wood DE. Bronchoscopic management of central airway obstruction. J Thorac Cardiovasc Surg. 2000;119:289–296[Abstract/Free Full Text]
- Wain JC. Rigid bronchoscopy: the value of a venerable procedure. Chest Surg Clin N Am. 2001;11:691–699[Medline]
- Wood DE. Airway stenting. Chest Surg Clin N Am. 2001;11:841–860[Medline]
- Grillo HC. Stents and sense. Ann Thorac Surg. 2000;70:1142[Free Full Text]
- Gaissert HA, Grillo HC, Wright CD, Donahue DM, Wain JC, Mathisen DJ. Complication of benign tracheobronchial strictures by self-expanding metal stents. J Thorac Cardiovasc Surg. 2003;126:744–747[Abstract/Free Full Text]
|
|
Top
Abstract
1. Introduction