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Ann Thorac Surg 1995;59:1417-1422
© 1995 The Society of Thoracic Surgeons
Division of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Abstract |
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 TopFootnotes Abstract IntroductionMaterial and MethodsResultsCommentReferences |
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Introduction |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Endoscopic management of symptomatic tracheobronchial complications can be an important adjunct to the surgical care of patients with unresectable benign or malignant airway obstruction [1, 2]. For the majority of these patients endobronchial dilation, debridement, or stenting may offer significant palliation and improved quality of life [3–6]. Anastomotic complications also have been recognized after lung transplantation and also may require aggressive endoscopic management to assure good functional outcome [6–9]. We report the University of Pittsburgh experience with the endoscopic management of 56 patients with benign, malignant, and lung transplantation airway complications, with emphasis on our endobronchial stent selection and insertion techniques.
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Material and Methods |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Patients with benign disease ranged in age from 55 to 70 years. Benign lesions included 4 intubation strictures, 4 inflammatory lesions, 1 case of severe bronchomalacia, and 1 case of bilateral bronchopleural fistulas. Benign tracheal disease presented primarily with progressive shortness of breath. Two patients with bronchial tuberculous strictures demonstrated progressive dyspnea and lobar atelectasis. One patient was symptomatic from a bronchopleural fistula that occurred as a complication of transhiatal esophagectomy.
Significant bronchial anastomotic complications developed in 24 lung transplant recipients out of 212 transplantations performed since 1991 (11.3%). Distribution of transplants included 117 single-lung and 95 double-lung transplants. Presenting symptoms included retained secretions (14 patients), pneumonia (4 patients), dyspnea (4 patients), and wheezing (2 patients). The time course to presentation of symptoms varied according to the cause of the anastomotic complication (Table 1
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The choice of stent was dictated primarily by anatomic considerations. Tracheobronchial Y stents (Hood Laboratories, Pembroke, MA) were used for patients with distal tracheal or carinal lesions, whereas Montgomery T tubes were used in patients with existing obstructive proximal or middle tracheal lesions. Silicone bronchial stents were chosen for main bronchial lesions without carinal involvement by the obstructive airway process. The findings from the bronchoscopic examination of the airway obstruction dictated the length and diameter of the bronchial stent chosen. In general, stents with an internal diameter of 10 to 12 mm were chosen to bridge bronchial obstructions in the adult airway. We usually chose the Hood bronchial stent (Hood Laboratories) to manage tight circumferential lesions where the likelihood of stent migration was minimal. The Dumon bronchial stent (Bryan Corp, Woburn, MA) was chosen for less critically stenotic lesions in which bronchomalacia may have been a significant component to the obstruction. The unique feature of the Dumon stent design is that it incorporates numerous ``studs'' along its outer diameter, which effectively reduces postoperative stent migration (Fig 1).
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). With the chest tube in place on the endoscope, the stent then is ``loaded'' onto the distal tip of the scope. The stent is positioned so that its distal extent is just proximal to the bevel on the bronchoscope. This stent/pusher tube/bronchoscope assembly then is introduced through the vocal cords into the trachea. Once in the trachea, it is important to maintain a steady forward advance of the bronchoscope, toward the stricture without retraction, to prevent premature dislodgement of the stent. The chest tube then is stabilized in position using a Kelly forceps, and the bronchoscope is withdrawn; this action ``unloads'' the stent from the bronchoscope. Final positioning of the stent then may be adjusted using alligator forceps (Fig 2B).
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). The long limb of the Y stent then is loaded onto a rigid bronchoscope, again with a proximally loaded chest tube as described previously (Fig 3B). The bronchoscope and long limb of the Y stent then are inserted into the trachea and directed down the left main bronchus, while the short limb of the stent is guided into the right main bronchus by the Fogarty catheter (Fig 3C). This Fogarty catheter technique is used to avoid backward folding or lateral malpositioning of the short limb of the Y stent during its insertion (Fig 4).
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). An alternative method used by us to overcome the problem of stent intussusception is to narrow the proximal tracheal limb of the Y stent against the bronchoscope with a 2-0 silk suture ligature (Fig 5B). The chest tube pusher then can be advanced to seat the stent without the problem of intussusception. The silk stitch is cut and removed at the end of the procedure through the rigid bronchoscope with endoscopic scissors and forceps.
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POSTOPERATIVE AIRWAY MAINTENANCE.
After stent placement, ``heavy droplet'' saline nebulization treatments were instituted to avoid incrustation of secretions within the airway. Arrangements were made so that these treatments could be continued after discharge from the hospital.
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Results |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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In 4 patients the tumor initially was managed by debridement, with stents being placed an average of 151 days (range, 7 to 300 days) later. Two patients receiving Y stents required replacement of their first stent. Four stents required repositioning or replacement including one in a patient who initially had received a Y stent and later was given a Dumon straight bronchial stent. Three patients underwent debridement after stents became blocked by tumor. Five patients received adjuvant brachytherapy, 2 before stent placement and 3 after stenting. An average of 2.15 procedures were performed on each patient (range, 1 to 5).
Five patients had their stents removed for a variety of reasons, including ability to undergo pulmonary resection after extensive neoadjuvant therapy in 1 patient (Table 2). Complications of stenting in malignant disease included granulation tissue requiring stent removal, replacement of one stent secondary to mucus plugging, coughing out of the stents (2 patients) and replacement of the stents secondary to migration (2 patients).
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Only one major operative complication occurred, in a patient with a tuberculous stricture who required a thoracotomy to repair a lacerated bronchus. Two patients required readjustment or downsizing of their T tubes secondary to laryngeal edema. Several instances of stent encrustation required bronchoscopy to clear secretions.
Posttransplantation
Of 212 lung transplantations performed since 1991, 24 patients (11.3%) had significant bronchial anastomotic complications. Time from lung transplantation to symptomatic presentation was dependent on the cause of the stricture (see Table 1
). Among 11 double-lung transplantations, left-sided complications were significantly more common than right (10 versus 5; p = 0.0317), and 4 patients had bilateral problems. Stents were used in 19 of 24 recipients. Five patients were managed with laser debridement alone, requiring a range of two to five treatments per patient. Fifty-six procedures (range, 1 to 9 per patient) using 31 bronchial stents in combination with laser debridement and dilation were performed. Symptomatic improvement of presenting symptoms occurred in all patients undergoing endobronchial debridement or stenting. Eighteen of 31 stents required readjustment by repeat bronchoscopy.
Five patients have died with their stents in place and functioning well. Among the 14 survivors who received stents, 3 patients required only temporary stenting (6 to 15 days), whereas 11 patients required stenting for longer periods (40 to 507 days). Six recipients could only be successfully discharged from the hospital after their endobronchial problems were managed by stenting. There were no significant complications of stent insertion in the transplant group.
In our total experience, 46 bronchial stents were used. Hood stents were used more frequently in our early experience, and a total of 40 Hood stents versus six Dumon stents were placed in bronchial strictures. Twenty episodes of stent migration occurred, primarily in the transplant population, and all episodes of stent migration occurred with the use of the Hood stent. No episode of stent migration was life-threatening.
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Comment |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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The treatment approach to airway compromise is dictated by the underlying pathologic condition and the location of the obstructing lesion. Patients with malignant tracheobronchial obstruction are best approached with a multimodality treatment plan in which debridement or stenting of the lesion plays a major role. Primary debridement of exophytic endobronchial lesions has been shown to provide effective short-term management of malignant obstructions [1]. However, if significant luminal narrowing remains or if rapid tumor growth is expected, we proceed with stent placement. Lesions that primarily are causing external compression without an endobronchial component are not amenable to debridement, and for these patients primary airway stenting is used.
Adjuvant radiotherapy, either external beam or brachytherapy, was used in 16 of our patients and has been shown to help control the local disease process and reduce the rate of tumor overgrowth about the stents [5]. When tumor overgrowth is noted after stenting, subsequent periodic mechanical or laser debridement can be effective in avoiding airway obstruction. No complications were encountered in our experience with the use of the laser to debride lesions through a previously placed stent.
Patients with benign tracheobronchial stenoses that are not amenable to resection or to endoscopic debridement are best managed with either a Montgomery T tube or Y tracheobronchial stents. The Montgomery T tube is reserved for patients with primary upper or mid-tracheal stenoses, whereas Y stents are chosen for patients with distal tracheal or main bronchial lesions encroaching upon the carina. Although straight silicone stents of the Hood or Dumon variety can be used to treat tracheal obstructive lesions, migration and ``coughing out'' of the stent remains a concern. One patient in our series experienced stent migration when the stent was used to manage a conical tracheal lesion, an experience also noted in other reports [5]. Because of this problem we prefer to rely upon the Y stent to manage such lesions. Stents were otherwise well tolerated and offered significant palliative relief of symptoms.
Successful lung transplantation is now being widely practiced. Although anastomotic airway problems have been significantly reduced as the ideal suturing techniques are becoming more well defined, bronchial complications are still present in 7% to 14% of most clinical series [6, 7, 13]. The postoperative airway stenoses in these patients are usually secondary to granulation tissue or fibrous stricture formation. Both of these problems have been shown to be amenable to aggressive anastomotic debridement, dilation, and selective bronchial stenting [8]. The results of our series support such an aggressive management approach. Indeed, the endoscopic relief of obstructive obstruction was often a key factor in improving a recipient's functional status, allowing discharge after lung transplantation. As with malignant lesions, manual or laser debridement of stenotic lesions often was attempted first to regain luminal patency. Three patients in our series underwent stent placement within 2 weeks of the transplantation to acutely palliate obstructive symptoms and improve function of the graft while the airway was healing. Once remodeling occurred, stents were able to be removed and luminal patency was maintained. Bronchial stents were used predominantly as most of the lesions were distal to the carina.
Adjustment of the stents was required frequently, but the stents were otherwise well tolerated, both acutely and chronically. Minor problems with stent encrustation did occur; however, these were handled easily with flexible bronchoscopy. The occurrence of this problem has been minimized by subscribing to a nebulized saline airway humidification program and close surveillance by our thoracic surgical team. Migration can occur; however, this complication also has lessened with use of the Dumon stent for noncritical stenoses with a component of malacia that we had previously managed generically with the Hood stent. Endoscopic adjustment can be performed readily when necessary. Likewise, stent removal also is accomplished easily when this is desired.
Recent reports have proposed and encouraged the use of expandable wire stents in tracheobronchial airway obstruction [14]. Wire expandable stents are said to have the advantages of low internal to external diameter ratio, reduced impairment in mucociliary clearance of secretions, and also resistance to migration [15]. However, these stents are not able to be adjusted or removed once implanted, and do not prevent growth of tumor through the interstices of the stent. The Gianturco metal stent has been reported to cause hemorrhage secondary to airway erosion [16], and has had documented stent fractures [17].
Multiple techniques for insertion of silicone tracheobronchial stents have been described in the literature [2, 5, 18, 19]. In this report we describe and illustrate our techniques of stent insertion. These techniques involve no specialized equipment, and can be performed expeditiously with minimal morbidity. Manual and laser debridement are used in a complementary fashion, with a tendency to use laser debridement for patients with hemoptysis or circumferential scar tissue. In benign lesions that initially respond to aggressive debridement, repeat early bronchoscopy is performed to ensure that restricturing does not require stent placement. After debridement is performed, the use of a silicone stent is considered if significant luminal narrowing remains, or if rapid tissue growth is suspected. Routine repeat bronchoscopy to assess tumor response to radiotherapy, or airway remodeling in benign disease, may indicate significant healing that allows for stent removal at a later date.
The results of this clinical series demonstrate that endoscopic stenting provides effective palliation of tracheobronchial stenoses resulting from both benign and malignant causes. We consider such stenting as the primary management option for airway obstruction after lung transplantation. Silicone stents are well tolerated and may be left in place for years, but consideration should be given to removing them once airway healing has occurred. Silicone stent insertion is a safe, readily mastered technique that should be included in the armamentarium of the thoracic surgeon faced with these airway problems.
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Footnotes |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Address reprint requests to Dr Keenan, Section of Thoracic Surgery, University of Pittsburgh, Suite 300, 3471 Fifth Ave, Pittsburgh, PA 15213.
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References |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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