Stents and sensibility?use of the Montgomery T-tube in tracheal stenosis

Abstract

Pereszlenyi and colleagues [1] exhaustive account of their institution’s experience with management of tracheal stenosis brings forth several important points. The first and most important issue is the choice of stent—metallic expandable or silicon stents. The ease of delivery of metallic stents through flexible bronchoscopy under topical anesthesia has unfortunately resulted in their overuse [2]. Expandable stents induce intense granulation tissue and are difficult, sometimes impossible, to remove. They frequently convert resectable lesions to lesions of irresectable length [3]. Surgery is much more demanding after prior intervention with metallic stents owing to the severe tissue reaction that they produce. Single and short segment tracheal stenosis should be treated by primary surgery in centres experienced in tracheal surgery. Stenting should be reserved for patients with terminal malignancy (where self-expandable stents may be preferred) and in an acute situation (where silicone stents may be deployed as a temporary measure) prior to referral to a centre specializing in tracheal surgery. Dumon stents and Montgomery T-tubes are invaluable in stenting lesions, which are too long for safe reconstruction [3]. We agree with the authors that though granulation tissue still may form with a silicon stent, this is considerably less compared to that caused by an expandable metallic stent. Moreover, the ease with which silicon stents can be removed if definitive surgery is being considered makes it an attractive option to tide over an acute situation. Long segment and multiple segment stenosis not suitable for surgical resection may also be managed with silicon stents. More often than not (as seen in Pereszlenyi’s series), the stent stabilizes the airway and decannulation is possible in most cases. We wonder what the authors’ criteria are to consider removal of the T-tube as some of their patients have been managed only with a T-tube for relatively prolonged periods (118 months). Generally, decannulation is possible in about 6–12 months. The pulmonologist or thoracic surgeon involved in managing complex airway problems needs to be aware of the basic pathology underlying tracheobronchial stenosis and intelligently apply the right solution to a specific problem.