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Ann Thorac Surg 1996;61:1074-1078
© 1996 The Society of Thoracic Surgeons

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Original Article: General Thoracic

Management of Malignant Tracheobronchial Stenosis With Metal Stents and Dumon Stents

Departments of Surgery III, Radiology and Oncoradiology, Nara Medical College, Nara, and National Kinki Central Hospital, Sakai, Japan

Accepted for publication December 2, 1995.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. Tracheobronchial stenosis caused by malignancy is a life-threatening problem. Stenting is one of the treatment modalities and recently has been used widely for the management of such stenosis, but we do not have a clear guide as to which stent should be selected.

Methods. We evaluated 25 patients (19 men, 6 women; mean age, 60.7 years; range, 34 to 77 years) received 24 metal stents (four covered with silicone rubber) and three Dumon stents. All 25 patients had severe dyspnea because of airway stenosis caused by malignant tumors.

Results. Among the 25 patients, airway obstruction due to extrinsic compression by tumor developed in 11 and was treated with a bare metal stent. The airway remained patent in 10 patients. In 16 patients with intraluminal tumor invasion, nine lesions were treated with a bare metal stent, four lesions with a covered metal stent, and the remaining three lesions with a Dumon stent. Recurrent stenosis did not occur in any patient with a covered metal stent or a Dumon stent. However, restenosis occurred in 4 patients with a bare metal stent, all of whom received laser therapy. In all patients, stenting immediately relieved dyspnea. Six patients lived for 32 days to 53 months after stenting, and 19 patients died of primary malignancies with a mean survival of 131.9 days.

Conclusions. Metal stents are effective in treating malignant extrinsic tracheobronchial compression. The use of covered metal stents or Dumon stents is preferable for intraluminal stenosis due to malignant growth.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Malignant tracheobronchial obstruction in end-stage cancer patients results in dyspnea, coughing, difficulty in handling sputum, and symptoms of suffocation. Various treatment modalities have been developed for the management of inoperable malignant tracheobronchial stenosis. Laser therapy has been used widely to relieve obstruction caused by intraluminal tumor growth, but airway stenosis caused by extrinsic compression or cartilaginous destruction owing to malignant tumors is not amenable to laser therapy. We describe our experience with metal stents and Dumon stents used in the patients with airway obstruction caused by malignancies.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Metal Stents
The metal stents, which expand by themselves, were handmade of stainless steel wire, fabricated into a cylindrical zigzag form. The fully expanded stent formed a tube approximately 1.0 to 1.2 times the diameter of the normal airway, and the length of the stent corresponded to that of the stenotic area. In cases of airway stenosis caused by intraluminal tumor growth, we made a metal stent covered with silicone rubber to prevent tumor growth through the stent. First, we used a modified Gianturco stent [1] to treat malignant tracheobronchial stenosis, but more recently we have used spiral zigzag stents [2]. To date, 8 modified Gianturco stents, 12 spiral stents, and 4 covered stents have been inserted for malignant stenosis (Fig 1).

View larger version (71K): [in this window] [in a new window]   Fig 1. . The expandable metallic stents. (A) Modified Gianturco stent. (B) Spiral zigzag stent. (C) Modified Gianturco zigzag stent covered with silicone rubber.

Dumon Stents
All 3 patients who received Dumon stents (Cometh, Marseille, France, and Bryan Corp, Woburn, MA) had tracheal stenoses. First they were intubated to prevent suffocation. The Dumon stents were then inserted easily without airway dilation under general anesthesia.

Patients
Between July 1990 and December 1994, 24 metal stents and 3 Dumon stents were inserted in 25 patients (19 men and 6 women) (Table 1). The mean patient age was 60.7 years (range, 34 to 77 years). All 25 patients had severe dyspnea due to airway stenosis including 23 with stenosis of trachea or main bronchus caused by lung cancer, one with tracheal stenosis by tracheal cancer, two with tracheal stenosis as a result of esophageal cancer, and one with main bronchial stenosis as a result of a leiomyosarcoma. Metal stents were inserted in 10 patients with tracheal stenoses, 4 with right main bronchial stenoses, and 10 with left main bronchial stenoses. Dumon stents were inserted in 3 patients with tracheal stenoses.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Stent placement was performed easily without any immediate complications. Dyspnea disappeared immediately after stenting in all patients, and secretions could be easily cleared. There were no problems with migration, infection due to the stent, or stent breakage.

Malignant tracheobronchial stenosis was divided into two categories: intraluminal tumor invasion (16 patients) and extrinsic compression (11 patients).

Of the 16 intraluminal tumors, nine lesions were treated with bare metal stents, four lesions were treated with covered metal stents, and three lesions were treated with Dumon stents. All nine bare metal stents were inserted without prior airway dilation. Four of these patients required laser therapy for subsequent restenosis. Four covered metal stents were inserted without prior dilation, but no restenoses occurred. After insertion of the Dumon stent, granulation tissue developed at the stent margins in 2 patients and was removed with a biopsy forceps.

Airway stenosis due to extrinsic compression developed in 11 patients. All were treated with bare metal stents and 10 had no further problems with restenosis.

Four patients had not had previous treatment for their primary malignancies, and after stenting, 3 underwent chemotherapy and radiotherapy. For example, patient 14 received a bare metal stent for intraluminal tracheal stenosis as an emergency procedure before anticancer therapy and had a complete remission with chemotherapy and radiotherapy. A week after stenting, the stent was almost covered with mucous membrane, and 41 months after stenting, the stent was completely covered with mucous membrane, maintaining good patency of the trachea (Fig 2).

View larger version (66K): [in this window] [in a new window]   Fig 2. . Endoscopic findings from patient 14 with intraluminal tracheal stenosis due to tracheal cancer. (A) One week after stenting, the stent was well covered with a mucous membrane. (B) At 41 months, the stent was completely covered with a mucous membrane.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

Montgomery [3] first reported his clinical experience with a T-shaped silicone stent, and Westaby and associates [4] have published the results of their experiences with a T-Y-shaped stent. Silicone stents have been improved and modified to overcome problems with instability and migration [5–9]. Dumon [10] has described a silicone stent with studs designed to prevent its migration, which is now widely used for benign and malignant tracheobronchial strictures. However, these tube stents have some disadvantages for long-term use. The relatively thick wall of the stent results in a small internal diameter, and mucous secretions tend to occlude the stent. Moreover, granulation tissue and tumor regrowth develop at the end of the stent. Therefore, regular bronchoscopic examination and treatment are necessary to keep the airway clear.

Daniel OK? Only 1 author in reference list[11] reported the results of his experiments with tubes made of stainless steel wire for the tracheobronchial airway, and Gebauer OK? Only 1 author in reference list[12] described the reconstruction of tuberculous bronchial stenosis using a dermal graft with stainless steel wire. Bucher and associates [13] reported reconstruction with a stainless steel wire mesh in experimental animals, and Harkins [14] described the clinical uses of an endotracheal metallic prosthesis. Pagliero and Shepherd [15] reported the clinical application of a stainless steel wire coil prosthesis. In addition, Wallace and associates [16] reported experimental and clinical uses of Gianturco-type expandable metallic stents in the tracheobronchial tree, and since then their applications have been significantly extended [17–23]. The modified Gianturco zigzag stent, the spiral zigzag stent, and the Wall stent [7] also have been used in this area.

Stenting in the tracheobronchial tree has been an important advance in the treatment of malignant tracheobronchial stenosis. We performed stenting for the following reasons: (1) to relieve distressing symptoms of dyspnea and stridor and to improve quality of life for end-stage patients who were not candidates for further curative treatment, and (2) to keep the airway patent when obstruction was imminent during anticancer therapy. Four of our patients required stenting to relieve airway obstruction as the first treatment, followed by multiple therapeutic modalities to treat the primary malignancies. For instance, patient 14 was first treated with a bare metal stent, followed by chemotherapy and radiotherapy and has survived for more than 4 years without recurrence of tracheal stenosis or stent failure.

Comparing bare metal stents, covered metal stents, and Dumon stents, the three stents have different features. Both bare and covered metal stents can be inserted under local anesthesia, but Dumon stents must be placed under general anesthesia because of the need for rigid bronchoscopic instrumentation. Metal stents can be inserted without preceding airway dilation, but severe stenoses should be dilated before the insertion of Dumon stents. Bare metal stents do not block ventilation of nonstenotic bronchi, a possibility that exists with Dumon stents or covered metal stents. Migration may occur with covered metal stents, but rarely happens with bare metal stents or Dumon stents. Dumon stents are easily removed after stenting, whereas metal stents are difficult to remove, although removal of one by rigid bronchoscopy has been reported [21].

We divided malignant stenoses into two types: those caused by intraluminal tumor invasion and those resulting from extrinsic compression. Our treatment plan is described in Figure 3. In cases of intraluminal tumor invasion, we used these three stents. We inserted nine bare metal stents into intraluminal strictures as emergency cases because they could be inserted under local anesthesia without preceding dilation, and they do not block the ventilation of nonstenotic bronchi. Four restenoses caused by either granulation tissue or tumor regrowth occurred between 7 days to 3 months after the insertion, but the other 5 patients had no airway problem in the course of their lives. However, in such stenosis, we consider covered metal stents or Dumon stents to be desirable to prevent tumor growth into the stents when stents do not block nonstenotic airway. In cases of extrinsic compression treated with bare metal stents, restenosis did not occur in 10 of 11 patients.

View larger version (25K): [in this window] [in a new window]   Fig 3. . Treatment algorithm based on our experience.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Address reprint requests to Dr Tojo, Department of Surgery III, Nara Medical College, 840 Shijo-cho, Kashihara, Nara 634 Japan.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

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