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Ann Thorac Surg 2004;78:1898-1902
© 2004 The Society of Thoracic Surgeons
a Department of Cardiothoracic Surgery, St. George's Hospital, London, England, UK
Accepted for publication May 20, 2004.
* Address reprint requests to Dr Madden, Department of Cardiothoracic Surgery, St. George's Hospital, London SW17 0QT, UK
brendan.madden{at}stgeorges.nhs.uk
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Abstract |
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METHODS: To date 15 patients have been followed for more than 1 year (median 41 months, range 12 to 83 months) after stent deployment. Indications for stenting in these patients were neoplasia (5), stricture (5), airway malacia (1), iatrogenic tracheal tear (1), and compression from an aortic aneurysm (1), a right interrupted aortic arch (1), and a right brachiocephalic artery aneurysm with tracheomalacia (1). Ten tracheal stents (9 covered, 1 uncovered) and 10 bronchial stents (8 uncovered, 2 covered) were inserted, and 5 patients received two stents.
RESULTS: Five of these patients experienced no long-term problems. Complications included troublesome halitosis (5), which was difficult to treat despite various antibiotic regimes; granulation tissue formation above and below the stent that was successfully treated with low-power Nd:YAG laser therapy (7); and metal fatigue (1). We did not encounter stent migration.
CONCLUSIONS: We conclude that Ultraflex expandable metallic stents have an important role in the management of selected patients with diverse endobronchial pathologies and are well tolerated in the long-term. Although associated granulation tissue can be successfully treated with Nd:YAG laser, halitosis can be a difficult problem to address.
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Introduction |
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TopAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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As experience with endobronchial stenting and availability of the procedure increases concerns have been expressed regarding the complications that might be experienced by longer-term survivors. We have deployed 80 expandable metallic stents in 69 patients. We wished to assess the long-term impact of these stents in our patients. From this population we report our experience of 15 patients who have now been followed up for more than 1 year after stent insertion. With increasing availability of this technique we believe it important to raise awareness of long-term tolerability and complications after metallic stent deployment.
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Material and Methods |
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TopAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Before stent placement all patients had rigid and flexible bronchoscopy under general anesthesia. The relevant airway portion was sized at this time and a stent was selected to bridge the lesion and overlap the normal mucosa by at least 10 mm at each end. The diameter of the stent was chosen to match the diameter of the normal proximal lumen. Stent placement was performed under direct vision by passing the delivery device through the rigid bronchoscope and retracting the nylon crotched suture when satisfied with appropriate placement, followed by removal of the delivery device. Correct positioning and deployment of the stent was then confirmed by bronchoscopy at the time of the procedure and by chest radiograph subsequently. Bronchoscopy was performed to check stent positioning at 14 days after deployment and subsequently as dictated by clinical indication.
Details of the patients stented, the stents used, the indication for stenting, and the site of stenting were recorded at the time of discharge after stent placement. These data were analyzed retrospectively to determine patients who had stents placed for more than 1 year. Data concerning the status of these patients, complications, and follow-up period were retrieved from the hospital computerized patient information and results systems, medical notes, and clinic letters. In 1 patient the type and site of stent were recorded, but the indication for stenting had not been noted and the medical notes were unavailable. The computerized hospital results system did not aid in determining the diagnosis, but did list the patient as being deceased less than 12 months after stent deployment.
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Results |
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TopAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Halitosis is a troublesome complication, and was seen in 5 patients. Seven stents were placed in these 5 patients. All had covered stents (1 bronchial, 5 tracheal), with one having both covered (tracheal) and uncovered (bronchial) stents in place. Attempts were made to determine the cause of the halitosis. Barium swallow investigations in all did not show gastroesophageal reflux; high-resolution computed tomography scanning did not reveal bronchiectasis. In addition all had microbiological samples (bronchoalveolar lavage) taken at subsequent bronchoscopies and sputum samples collected. Samples from 3 of the 5 patients did not grow any bacteria other than normal upper respiratory tract flora. The remaining 2 grew Pseudomonas aeruginosa. Treatment courses with intravenous and oral antibiotics, to which the species had proven sensitivity, were unsuccessful in eradicating the halitosis; nebulized antibiotic regimes were similarly unhelpful. Unfortunately halitosis continues to be a problem in these patients.
Some patients receiving endobronchial stenting have episodes of recurrent respiratory tract infection (RTI) early after stent deployment. Recurrent RTI was not, however, a problem for any of the 15 patients 1 year after stent deployment.
Bronchoscopy revealed evidence of epithelialization around uncovered ends of covered stents and through uncovered stents. Reassuringly we did not encounter stent migration. In one patient a stent did exhibit metal fatigue in which one of the metal struts was fragmented, but this condition did not cause any damage or compromise to the airway and has to date not required further intervention.
One patient (patient 12) gave birth to a healthy child 16 months after stent deployment.
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Comment |
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TopAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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In our series granulation tissue formation was the most common complication, mirroring the experiences of other groups [8]. We have shown that this problem can be treated easily and effectively with Ng-YAG laser therapy. In addition we have found that granulation tissue may not require continued laser treatments, but instead only a discrete number of laser treatments in some patients. Such patients should continue to be followed up to monitor for recurrence.
Halitosis proves to be a distressing and difficult complication to resolve. Previous studies have suggested that this condition is secondary to bacterial infection of the stent. All of our patients with halitosis had covered stents, which may provide a suitable environment for bacterial growth and prevent effective mucociliary clearance. Noppen and colleagues [9] showed that 78% of those receiving mainly silicone stents developed significant airways colonization with bacteria, of which 55% had potentially pathogenic organisms. Their study also found that the most common organisms found were P aeruginosa, the only potentially pathogenic organism we found to be present in our patients with halitosis. The polysaccharide glycocalyx material surrounding the outer cell wall of this organism may enhance its ability to bind to the polyvinyl chloride coating of covered stents and possibly explain our difficulty in eradicating the problem. Not only was antibiotic treatment guided by culture sensitivity ineffective, but so were empirical antibiotic regimes in patients with negative cultures. Similarly, nebulized antibiotics had no benefit in these patients. In light of the primary airway pathology and difficulty in removing the stents once deployed we did not believe that stent removal was an appropriate strategy. Only 40% of our patients with halitosis had positive microbiology from either sputum samples or bronchoalveolar lavage; therefore, bacterial growth does not appear to be the sole cause of halitosis, although this hypothesis is attractive. Halitosis can occur with prosthetic replacement of the trachea and it may be less of a problem for patients with removable stents deployed. However, these latter stents also have associated complications and furthermore it was our clinical assessment that metallic stents were appropriate for our patients. It is hoped that further research into this problem, including the structure of the covered stents themselves, will help resolve what can be a distressing issue for patients.
Stent migration did not prove a problem in our series. We believe that this is due to accurate sizing of both airway diameter and distance to be stented at the time of stent insertion. Furthermore, the ability to directly visualize stent deployment under rigid bronchoscopy and make minor adjustments as required immediately after deployment provided additional accuracy [10, 11]. We have not had any indication to remove the stents once they have been deployed.
Metal fatigue was seen in only 1 of our patients, and this did not require any further intervention. Metal fatigue does present a potentially important complication and one that should continue to be monitored with patients having stents deployed who survive for longer periods. A previous long-term follow-up study [8] also reported metal fatigue in one stent (0.89%) at 48 months after stent deployment. No clinical sequelae were reported and the stent was successfully removed.
We used covered stents to manage the airway in 3 patients who had extrinsic vascular compression of the airway. None of these patients was considered a candidate for formal vascular surgical intervention. Given the structure of the stents and the nature of the radial forces exerted by them on the airway, we did not believe that they would contribute to vascular erosion. These patients have been followed to date for 14, 15, and 39 months after stent deployment.
All of our patients gained considerable benefit in terms of clinical and respiratory status after stent insertion. Five patients had no complications in the medium-term associated with their stent, and 1 subsequently gave birth to a healthy child 16 months after stent deployment.
Our experience suggests that Ultraflex expandable metallic stents have a role to play in the management of a variety of endobronchial pathologies for carefully selected patients. Long-term complications do not necessitate stent removal and, with the exception of halitosis, can usually be managed effectively.
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References |
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