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Ann Thorac Surg 2000;70:1803-1807
© 2000 The Society of Thoracic Surgeons

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Original article: general thoracic

Double stenting for esophageal and tracheobronchial stenoses

^a Department of Thoracic Surgery, Saiseikai Central Hospital, Tokyo, Japan

Accepted for publication May 14, 2000.

Address reprint requests to Dr Nomori, Department of Surgery, Saiseikai Central Hospital, 1-4-17 Mita, Minato-ku, Tokyo 108-0073, Japan
e-mail: hnomori{at}qk9.su-net.ne.jp

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. We examined the complications and outcomes of placing stents for both esophageal and tracheobronchial stenoses.

Methods. We placed stents for both esophageal and tracheobronchial stenoses in 8 patients (7 with esophageal cancer and 1 with lung cancer). Covered or noncovered metallic stents were used for the esophageal stenoses, except in 1 patient treated with a silicone stent. Silicone stents were used for the tracheobronchial stenoses. The grades of esophageal and tracheobronchial stenoses were scored.

Results. All patients experienced improvement of grades of both dysphagia and respiratory symptoms after stent therapy. The complications were: (1) 2 patients suffered respiratory distress after placement of the esophageal stent because of compression of the trachea by the stent; and (2) 3 patients developed new esophagotracheobronchial fistulae, and 2 patients had recurring fistula symptoms because of growth of preexisting fistulae after the stent placement, which were caused by pressure from the 2 stents. Despite the fistulae, the 5 patients treated with covered metallic stents did not complain of fistula symptoms, but 2 patients treated with noncovered metallic or silicone stents did complain.

Conclusions. For patients with both esophageal and tracheobronchial stenoses, a stent should be introduced into the tracheobronchus first. Because placement of stents in both the esophagus and tracheobronchus has a high risk of enlargement of the fistula, a covered metallic stent is preferable for esophageal cancer involving the tracheobronchus.

	Introduction

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Recent advances in stent therapy have increased the quality of life of patients with inoperable cancer. Tracheobronchial stenoses have been treated by expandable metallic stent [1, 2] and silicone stent such as Dumon or dynamic stents [3–5]. Esophageal stenoses have classically been treated with plastic or silicone stent, but self-expandable metallic stent have recently been introduced for this purpose [5, 6]. Patients with advanced esophageal cancer often have respiratory distress as a result of tracheobronchial invasion, and this necessitates stent therapy not only for esophageal stenosis but also for tracheobronchial stenosis. In this report we examine the outcomes of stent therapy for both esophageal and tracheobronchial stenoses in 8 patients and recommend some management techniques that can be used to prevent complications.

	Material and methods

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From 1991 to 1999, we performed stent therapy for 28 patients with esophageal stenoses and 45 patients with tracheobronchial stenoses. Of these, 8 patients received stent therapy for both esophageal and tracheobronchial stenoses (Table 1). The causes of the stenoses were esophageal cancer in 7 patients and lung cancer in 1. The mean length of esophageal stenoses in the esophageal cancer patients was 5.7 cm (range: 3–9). The sites of airway stenoses were the trachea in 5 patients, the left main bronchus in 2, and the right main bronchus in 1. All patients underwent chemoradiotherapy before the stent placements. In addition, one patient (patient 1) underwent also radiotherapy after the stent placement. Four patients (patient 5, 6, 7 and 8) already had fistulae before stent therapy. For tracheobronchial stenosis, we used silicone stents but not metallic stents to prevent a recurrence of stenosis due to tumor growth between the wires of the metallic stents [2]. Six Dumon stents (Novatech Co, Aubagne, France) were placed in 6 patients and 2 dynamic stents (Willy Rüsch AG, Kernen, Germany) in 2. Dumon stents were placed via an endotracheal tube under general anesthesia as described previously [4]. The dynamic stents were placed using specialized forceps under general anesthesia. The esophageal metallic stents were placed using the regular method under local anesthesia [5–7]. For esophageal stenosis, we generally used metallic stents but not silicone stents, because silicone stents tend to have a higher risk of esophageal injury and are also easily packed with food. Nine covered self-expandable metallic stents (Covered Ultraflex Esophageal Stent System, Microinvasive, Boston Scientific Co, Boston, MA) were placed in 6 patients, 2 noncovered Ultraflex metallic stents in 2 patients, and 1 silicone stent (Flexible Artificial Esophagus, Sumitomo Bakelite Co, Ltd, Tokyo, Japan) in 1.

In 5 patients (patients 1, 2, 3, 4 and 5), we placed the esophageal stent first, followed by the tracheobronchial stent, because the symptoms of esophageal stenosis or fistula were more conspicuous than those of airway stenosis. In the remaining 3 patients (patients 6, 7 and 8), who had both esophageal and tracheobronchial stenoses before the stent therapy, we placed the tracheobronchial stents first, followed by the esophageal stents, because, if the esophageal stents had been placed first, we would have risked deterioration of the tracheobronchial stenoses from compression by the esophageal stent. All patients except one (patient 7) underwent two-staged stent placements. Patient 7 underwent the placement of an airway stent followed by an esophageal stent on the same day. The mean periods between the diagnosis of the disease and stent placements were 9 months (range, from 2–20 months) for the airway stents and 6 months (range, from 0–18 months) for the esophageal stents.

To assess the results of stent therapy, we classified tracheobronchial stenosis into 4 grades as follows: grade 0, few complaints; grade 1, medium-grade stenosis; grade 2, high-grade stenosis without cyanosis; and grade 3, subtotal stenosis with cyanosis. Esophageal stenoses were classified into 4 grades as follows: grade 0, a patient can consume any kind of food; grade 1, a patient can consume soft foods without the nutritional support; grade 2, a patient can consume liquid food without the nutritional support; and grade 3, a patient needs some nutritional supports by either tube feeding or intravenous hyperalimentation because of an insufficient oral intake.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
Immediate improvement of grades of both respiratory symptoms and dysphagia was achieved in all patients after stent placements (Table 2). The symptoms of tracheobronchial stenoses did not recur in any of our cases until the patients’ death. The symptoms of esophagotracheobronchial fistulae also improved after the placement of esophageal covered metallic stent. The mean period of taking meals without the nutritional support after esophageal stent placements was 5 months (range, from 2–16 months). The major complications were: (1) respiratory distress in 2 patients because of severe tracheal stenosis from compression by a single esophageal stent; (2) occurrence of a fistulae after double-stent placement in 2 patients; (3) occurrence of a fistula at the time of placement of a Dumon stent in 1 patient; and (4) recurrence of fistula symptoms due to growth of fistula after double-stent placement in 2 patients. In the next, we present these complications in detail.

View larger version (62K): [in this window] [in a new window]   Fig 1. CT showing stenoses of both the esophagus and trachea.

View larger version (68K): [in this window] [in a new window]   Fig 2. (A) CT showing an esophagotracheal fistula beside the stents (arrow). (B) Chest X-ray showing a silicone stent in the esophagus (arrows) and a dynamic stent in the trachea.

View larger version (131K): [in this window] [in a new window]   Fig 3. Dumon stent and covered metallic stent placed in the trachea and esophagus, respectively.

Seven patients died of their tumors from 38 to 96 days (mean: 72 days) after placement of the stents in both the esophagus and tracheobronchus. Patient 6 died of massive bleeding from the tumor 76 days after the double stenting. The remaining patient is now still alive 211 days after the double stenting without dysphagia or dyspnea.

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
Although our study showed that double stenting for esophageal and tracheobronchial stenoses effectively relieved symptoms, we discovered 2 main complications: (1) in patients with both esophageal and tracheal stenoses, the tracheal stenoses can deteriorate if they are compressed by the esophageal stents; and (2) with double stents, there is a high risk of fistula occurring or growing because of necrosis of both the esophageal and tracheobronchial walls from the pressure of the stents.

Two of our patients suffered the first complication, that is, deterioration of tracheal stenosis because of compression by the esophageal stent. They had both esophageal and tracheal stenoses, but did not complain of respiratory symptoms before placement of the esophageal stent. Placement of the esophageal stents compressed the trachea, resulting in severe tracheal stenosis and necessitating prompt removal of the esophageal stents. There have been no reports regarding this complication, but we recommend that: (1) tracheal stenoses should be examined by CT and bronchoscopy before placement of esophageal stents; and (2) for patients with both the esophageal and tracheal stenoses, the tracheal stent should be placed before the esophageal stent even if the patients does not have respiratory symptoms.

Five of our patients suffered the second complication listed above, that is, development or growth of esophagotracheobronchial fistulae after placement of both the esophageal and tracheobronchial stents. Of these, 4 patients underwent esophageal stent placement first and the remaining 1 underwent the tracheobronchial stent placement first. None of the patients suffered development or growth of fistulae during single-stent placement in the esophagus or tracheobronchus: these problems occurred after double stenting. In all the patients except 1, we used self-expandable metallic stents for esophageal stenoses, which gradually expand to its final outer diameter of 22 mm after placement, without extensive compression to the esophageal wall [6, 7]. Although the Dumon stent and dynamic stent are more rigid than the self-expandable metallic stent, their diameters are selected to match the lumen of tracheobronchus, avoiding excessive compression of the tracheobronchial wall. However, the pressure from both the stents placed at the esophagus and tracheobronchus can cause extensive necrosis of the walls, leading to the development or growth of fistulae. For esophageal cancer with fistula but with little tracheobronchial stenosis, we therefore recommend that only a covered metallic stent should be placed into the esophagus at first to block the fistula, whereas additional tracheobronchial stents should not be used to prevent the growth of the fistula as long as the tracheobronchial stenosis does not become more severe.

Maier and associates reported that 4 of 11 patients (36.3%) suffered esophageal rupture during single-stent placement for esophagus, and their patients had undergone excessive endoluminal pretreatment, such as photodynamic therapy followed by endoluminal high-dose brachyradiotherapy, before stent therapy, making the esophageal wall prone to be ruptured [8]. Our patients underwent chemoradiotherapy before stent therapy, but they did not receive locally excessive endoluminal treatment such as the Maier’s method, which could be a cause of no problems for fistula occurring or growing during single-stent placement in the present study.

We recommend the use of a covered metallic stent in esophageal cancer invading the tracheobronchus, even for patients without esophagotracheobronchial fistulae, because there is a high risk of fistula occurring in the future, especially if double stents need to be placed. Three of our patients (patients 4, 6 and 8) did not complain of fistula symptoms despite having fistulae, because they had been pretreated with covered metallic stents. Because a covered metallic stent can prevent or minimize fistula symptoms [9, 10], it is the treatment of choice for esophageal cancer invading the tracheobronchus, even for patients without fistulae.

In conclusion, although the placement of stents in both the esophagus and tracheobronchus can effectively relieve symptoms of dysphagia and airway stenosis, it should be kept in mind that: (1) for patients with both the esophageal and tracheobronchial stenoses, the tracheobronchial stent should be placed first to prevent worsening of the airway stenosis from compression by the esophageal stent; and (2) a covered metallic stent should be used for esophageal tumors involving tracheobronchus even for patients without the fistulae, because the double stents increases the risk of development or growth of esophagotracheobronchial fistulae.

	References

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1. Wallace M.J., Charnsangavej D., Ogawa K., Carrasco C.H., Wright K.C., McKenna R., McMurtrey M., Gianturco C. Tracheobronchial tree: expandable metallic stents used in experimental and clinical applications. Work in progress. Radiology 1986;158:309-312.[Abstract/Free Full Text]
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3. Dumon J.F. A dedicated tracheobronchial stent. Chest 1990;97:328-332.[Abstract/Free Full Text]
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