Management of a patient with a large airway stent in situ

Abstract

To the Editor, Bronchial stents are being placed more frequently for a diverse range of benign and malignant conditions. These patients may require non-pulmonary surgery and as a part of their preoperative assessment, consideration for displaced stents should be included in the planned airway management technique. We describe the case of a 55-yrold male who was scheduled for elective laparoscopic repair of a recurrent inguinal hernia. The patient’s medical history included a 30-pack year smoking history, recurrent purulent pneumonia, and bronchiectasis. He denied any current respiratory symptoms. Eleven years earlier, the patient underwent a rigid bronchoscopy which demonstrated a proximal left main bronchus stenosis secondary to chronic lingular adenopathy. Flexible bronchoscopy was performed, and two bare metal stents were deployed at the opening and in the proximal portion of the left mainstem bronchus. The patient did not return for follow-up of his bronchial stents. His physical examination was unremarkable, except for a few scattered crackles bibasally in his lung fields. A chest radiograph (Fig. 1) showed that the proximal stent appeared to be positioned at the opening of the left main bronchus and the distal stent at an angle of 30 to the first with some bibasal atelectasis. A lateral chest film demonstrated good antero-posterior alignment of the two stents. Because of the long duration between follow-up and the propensity for metallic stent migration and granulation tissue overgrowth, it was decided to proceed cautiously with flexible fibreoptic bronchoscopy. Following induction of anesthesia and confirmation of easy ventilation, endoscopic examination of the tracheo-bronchial tree demonstrated a proximally migrated stent with soft tissue overgrowth (Fig. 2). A size 7.5 cuffed tracheal tube was mounted on an intubating fibrescope and carefully advanced into position above the carina; bilateral chest ventilation was confirmed. Following uneventful surgery, a repeat endoscopic examination and chest X-ray revealed no movement of the stent or residual pneumothorax. The patient was referred to his respiratory physician for replacement of his bronchial stent. Fig. 1 Magnified postero-anterior (PA) chest radiograph showing left mainstem bronchial stents