Benign Tracheal Stenosis Research Articles

Successful Management of Metallic Expandable Stent-associated Tracheal Restenosis by Montgomery T-tube Insertion

Tracheal stenosis can be life-threatening and has been seen with an increasing frequency. Metallic stent-associated stenosis remains a therapeutic challenge because of difficulty in tracheostomy. Here, we report a case with repeated episodes of restenosis after insertion of metallic stents for benign tracheal stenosis which was successfully managed by Montgomery silicone T-tube placement. We further reviewed the literature of reported cases of inappropriate use of metallic stent for benign diseases.

Therapeutic rigid bronchoscopy at a tertiary care center in North India: Initial experience and systematic review of Indian literature

Background and Aim:Rigid bronchoscopy is often an indispensable procedure in the therapeutic management of a wide variety of tracheobronchial disorders. However, it is performed at only a few centers in adult patients in India. Herein, we report our initial 1-year experience with this procedure.Materials and Methods:A prospective observational study on the indications, outcomes, and safety of various rigid bronchoscopy procedures performed between November 2009 and October 2010. Improvement in dyspnea, cough, and the overall quality of life was recorded on a visual analog scale from 0 to 100 mm. A systematic review of PubMed was performed to identify studies reporting the use of rigid bronchoscopy from India.Results:Thirty-eight rigid bronchoscopies (50 procedures) were performed in 19 patients during the study period. The commonest indication was benign tracheal stenosis followed by central airway tumor, and the procedures performed were rigid bronchoplasty, tumor debulking, and stent placement. The median procedure duration was 45 (range, 30-65) min. There was significant improvement in quality of life associated with therapeutic rigid bronchoscopy. Minor procedural complications were encountered in 18 bronchoscopies, and there was no procedural mortality. The systematic review identified 15 studies, all on the role of rigid bronchoscopy in foreign body removal.Conclusions:Rigid bronchoscopy is a safe and effective modality for treatment of a variety of tracheobronchial disorders. There is a dire need of rigid bronchoscopy training at teaching hospitals in India.

Surgical management of benign tracheal stenosis in Basrah.

Background: Tracheal stenosis is more frequent as a result of wide-spread use of endotracheal intubation and tracheostomy. Resection and tracheal reconstruction remain the treatment of choice in benign tracheal stenosis. Objectives: To report our experience in Basra and to identify the result of anastomosis after tracheal resection and management of those patients preoperatively and postoperatively. Methodology: A descriptive study of sixteen patients (aged 11–28 years, 10 male and 6 female) with tracheal stenosis who underwent tracheal resection and reconstruction in Basrah thoracic unit (Basra teaching hospital) from January 2008 to January 2011. Results: The result was excellent in 62.5%, good in 25%, and satisfactory in 12.5%. Postoperative complication occurred in 25% and treated successfully with no mortality. Follow-up was every 3 months for an average of 3.6 years. Conclusion: Resection and tracheal reconstruction is the treatment of choice in benign tracheal stenosis and achieved excellent results in management of the patients.

The cause and efficacy of benign tracheal stenosis

To analysis the causes of benign tracheal stenosis and evaluate the curative effect of intraluminal bronchoscopic treatment. 158 patients with benign tracheal stenosis in our hospital from September 2005 to September 2012 were collected to retrospectively analysis the causes and clinic features of tracheal stenosis. Interventional treatments through bronchoscopy were used to treat the benign tracheal stenosis and the curative effects were evaluated. 158 cases of benign tracheal stenosis were recruited to our study, 69.6% of them were young and middle-aged. The main causes of benign tracheal stenosis were as follows: secondary to postintubation or tracheotomy in 61.4% (97/158), tuberculosis in 16% (26/158), benign tumor in 5.1% (8/158) and other 27 cases. 94.3% patients improved in symptoms with alleviation immediately after bronchoscopic treatment, the average tracheal diameter increased form (4.22 ± 2.06) mm to (10.16 ± 2.99) mm (t = 21.48, P < 0.01), dyspnea index decreased from 2.29 ± 0.75 to 0.63 ± 0.67 (t = 19.85, P < 0.01). The recurrence rate in 1 and 3 month after interventional treatment were 38.3% and 26.8%, respectively. The cases of benign tracheal stenosis were increasing year by year. The most common cause of benign tracheal stenosis was postintubation and tracheotomy. Interventional treatments through bronchoscopy is effective in treating benign tracheal stenosis, but repeated interventional procedures may be required to maintain the favorable long-term effects.

Tracheal surgery for benign tracheal stenosis: Our experience in sixty three patients

Clinical OtolaryngologyVolume 38, Issue 4 p. 343-347 Correspondence: Our Experience Tracheal surgery for benign tracheal stenosis: Our experience in sixty three patients I.J. Kleiss, I.J. Kleiss Department of Oto-Rhino-Laryngology and Head & Neck Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, the NetherlandsSearch for more papers by this authorA.F.T.M. Verhagen, A.F.T.M. Verhagen Department of Cardio-Thoracic Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, the NetherlandsSearch for more papers by this authorJ. Honings, Corresponding Author J. Honings Department of Oto-Rhino-Laryngology and Head & Neck Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands Correspondence: J. Honings, Department of Oto-Rhino-Laryngology and Head & Neck Surgery, Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB Nijmegen, the Netherlands. Tel.: +31-24-3540251; Fax: +31-24-3540251; e-mail: [email protected]Search for more papers by this authorO.C.J. Schuurbiers, O.C.J. Schuurbiers Department of Pulmonary Diseases, Radboud University Nijmegen Medical Centre, Nijmegen, the NetherlandsSearch for more papers by this authorH.F.M. van der Heijden, H.F.M. van der Heijden Department of Pulmonary Diseases, Radboud University Nijmegen Medical Centre, Nijmegen, the NetherlandsSearch for more papers by this authorH.A.M. Marres, H.A.M. Marres Department of Oto-Rhino-Laryngology and Head & Neck Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, the NetherlandsSearch for more papers by this author I.J. Kleiss, I.J. Kleiss Department of Oto-Rhino-Laryngology and Head & Neck Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, the NetherlandsSearch for more papers by this authorA.F.T.M. Verhagen, A.F.T.M. Verhagen Department of Cardio-Thoracic Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, the NetherlandsSearch for more papers by this authorJ. Honings, Corresponding Author J. Honings Department of Oto-Rhino-Laryngology and Head & Neck Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands Correspondence: J. Honings, Department of Oto-Rhino-Laryngology and Head & Neck Surgery, Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB Nijmegen, the Netherlands. Tel.: +31-24-3540251; Fax: +31-24-3540251; e-mail: [email protected]Search for more papers by this authorO.C.J. Schuurbiers, O.C.J. Schuurbiers Department of Pulmonary Diseases, Radboud University Nijmegen Medical Centre, Nijmegen, the NetherlandsSearch for more papers by this authorH.F.M. van der Heijden, H.F.M. van der Heijden Department of Pulmonary Diseases, Radboud University Nijmegen Medical Centre, Nijmegen, the NetherlandsSearch for more papers by this authorH.A.M. Marres, H.A.M. Marres Department of Oto-Rhino-Laryngology and Head & Neck Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, the NetherlandsSearch for more papers by this author First published: 28 May 2013 https://doi.org/10.1111/coa.12131Citations: 7Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Citing Literature Volume38, Issue4August 2013Pages 343-347 RelatedInformation

Cervical tracheal resection with primary anastomosis for benign tracheal stricture in adult

To introduce the outcomes of tracheal resection with primary end to end anastomosis for benign cervical tracheal stenosis, and to discuss the strategy for prevention of surgical complications. A retrospective analysis was performed in 12 patients diagnosed as benign cervical tracheal stenosis from October 2009 to June 2012. Laryngo-tracheal endoscopic examination and computed tomography (CT) were used to assess the degree of stenosis, the grade of inflammation and edema of the subglottis and trachea, and the extent of stenosis and the remaining linear amount of normal airway. The Meyer and Cotton grading system was used to categorise the clinical severity of the stenoses. All patients underwent tracheal resection with primary end to end anastomosis. The length of cervical tracheal stenosis ranged from 2.3 to 4.1 cm. Grade II stenosis was present in three patients, Grade III stenosis was present in seven patients and grade IV stenosis in two patients. Successful extubation was achieved in all 12 cases. After surgery, temporary hoarseness occurred in 1 patient (8.3%); unilateral pulmonary atelectasis with pleural effusion occurred in 1 patient (8.3%); subcutaneous emphysema with infection occurred in 1 patient (8.3%); mild dysphagia occurred in 3 patients (25.0%); a slight deepening of the tone of voice occurred in 5 patients (41.7%), granulation tissue growth near the suture occurred in 3 patients (25.0%), and suture dehiscence did not occur in any patient. The follow-up period ranged from 6 months to 38 months, no patient developed restenosis. It presents a high success rate and good functional result of tracheal resection with primary end-to-end anastomosis. Therefore, it is an effective and reliable approach for the management of benign cervical tracheal stenosis. To avoid complications, the preoperative assessment, patients selection and postoperative management should be emphasized.

The Role of Tracheal Stenting As an Alternative Treatment in Cicatricial and Non-Operable Tracheal Stenosis

Introduction: Tracheal stenosis is normally caused by trauma, infection, benign and malignant tumors, prolonged intubation or tracheostomy. The best treatment for tracheal stenosis is resection and anastomosis of trachea. Yet the major surgical complication of tracheal surgery is postoperative stenosis. The goal of this paper is to study the result of tracheal stenting as a replacement therapy for patients suffering from tracheal stenosis who are not good candidates for surgery. Materials and Methods: This study presents the results of stenting in patients with: Inoperable tumoral stenosis,Non-tumoral stenosis being complicated due to prior surgeries,Inability to undergo a major surgery.The study was performed between September 2002 and July 2011 and poly flex stents were used by means of rigid bronchoscopy. Results: A total of 25 patients received stents during this study. Among them 15 patients suffered from benign and 10 suffered from malignant tracheal stenosis. The patients were followed up for at most 12 months after the stenting operation. The mean age of the patients was 35 years. The most common cause of stenosis was prolonged intubation (75%). The most common indication for stenting was the history of multiple tracheal operations. The most common complication of stenting and cause of stent removal was formation of granulation tissue. 30% of patients with benign tracheal stenosis were cured and about 10% improved until they could stand a major operation. Ten patients in benign group and 2 patients in malignant group (20%) needed T-Tube insertion after stent removal but other patientcure by stenting. Conclusions: In benign cases stenting is associated with recurrence of symptoms which requires other therapeutic techniqus, so the stenting may not be named as a final solution in benign cases. However, this technique is the only method with approved efficacy for malignant cases with indication.

Stenting or Surgery in Benign Tracheal Stenosis?

Background: Review of stenting in benign tracheal stenosis in the long run in comparison with surgical procedures concerning indications, tolerance of stents, efficacy, complications and follow up after removal, restenting and survival. Patients and material: In a 18 year period between July 1993 and June 2011 in tracheal stenoses 52 stents, (( 32 silicone, 12 dynamic bifurcated stents, 2 metallic covered stents, 6 t-tubes )) were inserted in 35 symptomatic patients (17 men, 18 women, age 12 till 96, mean 65,7 years, 1.3 stent per patient). Indications for stenting were: anatomic stenosis, stricture and compression, malacia and combined stenosis. Retrospective analysis was done with follow up till June 2011. Data collection: Data were provided by review of patients’ charts, interview of family doctors, external hospitals and in single cases interview of family members. Patients who came for controlling of the stent were also interviewed. Methods: Bronchoscopic procedure was done under general anaesthesia, intubation with a rigid bronchoscope, dilation by balloon, rigid scope or combination. Stent placement was mostly done under fluoroscopy. Stent removal and/or replacement were also done with a rigid bronchoscope under general anaesthesia. Only the procedures for placement of a Montgomery t-tube were done under local anaesthesia. Results: During the observation period the longest survival time so far was 18 years. In 19 patients the stent led to a relief of symptoms, mainly dyspnoea and stridor and was tolerated without major complications (Successful stenting). In 12 patients the stent had to be removed because of complications and another four patients died of stenting related complications. In 16 patients therefore stenting was called “not successful”. Conclusions: In comparison to patients with advanced malignant diseases, where stenting is supposed only palliative, patients with tracheo-bronchial diseases are not limited in their life expectancy from the local tracheal disease, if this can be treated. But often these patients are high risk patients concerning co-morbidities, technical and functional operability. In these patients a stent can therefore be an alternative to surgery. Nevertheless because of the high rate of complications, which can be also life threatening, the decision must be done carefully. Purpose: Review of stenting in benign tracheal stenosis in the long run concerning indications, tolerance of stents, efficacy, complications, follow up after removal, restenting and survival. Corresponding author: Hermann Tonn, Klinikum Region Hannover, Pneumology, Intensive Care and Sleep Medicine, Hannover, Germany, E-mail: hctonn@aol.com Received September 30, 2011; Accepted November 16, 2011; Published November 18, 2011 Citation: Tonn H (2011) Stenting or Surgery in Benign Tracheal Stenosis? J Pulmonar Respirat Med S3:002. doi:10.4172/2161-105X.S3-002 Copyright: © 2011 Tonn H. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Patients and Material In 18 year period between July 1993 and June 2011 a total of 385 tracheobronchial stents in 291 patients were inserted. 318 stents were used for malignant diseases, 67 in benign diseases [1-3]. In tracheal stenoses 52 stents, (32 silicone radiopaque Dumon stents (3 bifurcated) [4,5], 12 dynamic bifurcated Freitag stents [1], 2 metallic covered Ultraflex® stents [6], 6 Montgomery t-tubes [7] ) were inserted in 35 symptomatic patients (17 men, 18 women, age 12 till 96, mean 65,7 years, 1.3 stent per patient). Indications for stenting were: anatomic stenosis, stricture and compression, malacia and combined stenosis. Retrospective analysis was done with follow up till June 2011.

Rapid Intravenous Induction of Anesthesia for Dilatation of Severe Post-Intubation Tracheal Stenosis with Rigid Bronchoscopy: Report of 100 Cases

Background : Rigid bronchoscopic dilatation is the lifesaving method for management of severe tracheal stenosis which is carried out under general anesthesia. However, this procedure is a challenging practice for both anesthesiologist and bronchoscopist because loss of airway control and sever hypoxemia can occur following induction of anesthesia. Inhalational induction with avoiding muscle relaxants and preservation of spontaneous breathing is commonly recommended in these patients. However, this technique needs a long time to reach the appropriate levels of anesthesia and may be associated with the risk of complete airway obstruction during airway manipulation. This paper describes our experience in using rapid intravenous induction of anesthesia for dilation of severe tracheal stenosis with rigid bronchoscopy. Materials and Methods : We conducted a retrospective chart review of one hundred patients with benign severe post intubation tracheal stenosis who underwent rigid bronchoscopy for dilation of stenosis using intravenous sodium thiopental and succinylcholine for induction of general anesthesia. Results : In 97 patients adequate airway was established immediately after induction of anesthesia with the first attempt of rigid bronchoscope. In one patient, because of local bleeding and mild hypoxemia the airway was managed by a 4 mm tracheal tube and following improvement of oxygenation, dilatation of stricture was successfully done with rigid bronchoscope. In second patient, after passing the first bronchoscope, due to risk of rupturing the trachea, a small transverse cervical incision was made on the trachea and a tracheal tube was inserted through it for patient’s ventilation and dilatation of stricture was managed safely with the rigid bronchoscopes. In the third patient, due to failure of passing the bronchoscope, the trachea was intubated with a 4 mm endotracheal tube and tracheal resection and anastomosis was done successfully. Conclusion : in patients with severe post intubation tracheal stenosis, rapid intravenous induction of anesthesia is a safe method for passage of rigid bronchoscope for dilatation of stricture. Careful planning and close cooperation of the anesthesia and surgical teams is critical for safe and successful conduction of this procedure.

Early Tracheal Stenosis Causing Extubation Failure and Prolonged Ventilator Dependency

Postintubation stenosis is the most frequent cause of benign tracheal stenosis and may cause reintubation and delay in weaning of intensive care unit patients. This case study describes typical patients with tracheal stenosis and the management of these patients. Five patients requiring reintubation and mechanical ventilation due to early intubation-related stenosis are discussed. Stridor developed in three cases after extubation. In these cases, bronchoscopy revealed tracheal stenosis. Dilatation and silicone stent placement were performed using rigid bronchoscopy. The other two patients were on ventilators when they were admitted to the intensive care unit and their stenoses were also treated by rigid bronchoscopy. Hypercapnia and hypoxia resolved after intervention in three cases. Of the remaining two patients, one had the tracheostomy closed and in the other patient ventilation was stopped but the tracheostomy was maintained. Tracheal stenosis developing in the subglottic region after extubation, especially after exposure to cuff pressure, may lead to reintubation. A tracheostomy may hinder the diagnosis of progressive stenosis and may lead to unnecessary maintenance of ventilator treatment. Early intubation-related tracheal stenosis should therefore be considered in cases of weaning or extubation failure and prompt appropriate investigation and treatment.

Removal of self expandable metallic airway stent: A rare case report

Covered self expandable metallic airway stents (SEMS) have been used for benign tracheal stenosis, post intubation tracheal stenosis, tracheal burn or trauma, tracheo-broncho-malacia, and extrinsic compression of trachea. Their placement is considered to be permanent, with open surgery the only way to remove the stent, though there are few cases reports of their removal with the bronchoscope, but the complications after their removal are very high. In our patient, one and a half years after placement of SEMS, she developed cough with dyspnoea, video bronchoscopy showed stenosis above the level of stent with granulation tissue inside the stent, stent fracture in lower part and stent migration to right main bronchus, thus she had all conceivable complications of stent placement. The stent was removed with the help of rigid bronchoscope under general anaesthesia. She was discharged the following day. The case is being reported because it was unique in having all the possible complications of stent placement, and rare as we could take out the stent in Toto. Thirdly, the stent could be removed without any complication.

Management of complex benign post-tracheostomy tracheal stenosis with bronchoscopic insertion of silicon tracheal stents, in patients with failed or contraindicated surgical reconstruction of trachea.

Tracheal stenosis is a potentially life-threatening condition. Tracheostomy and endotracheal intubation remain the commonest causes of benign stenosis, despite improvements in design and management of tubes. Post-tracheostomy stenosis is more frequently encountered due to earlier performance of tracheostomy in the intensive care units, while the incidence of post-intubation stenosis has decreased with application of high-volume, low-pressure cuffs. In symptomatic benign tracheal stenosis the gold standard is surgical reconstruction (often after interventional bronchoscopy). Stenting is reserved for symptomatic tracheal narrowing deemed inoperable, due to local or general reasons: long strictures, inflammation, poor respiratory, cardiac or neurological status. When stenting is decided, silicone stent insertion is considered the treatment of choice in the presence of inflammation and/or when removal is desirable. We inserted tracheal silicone stents (Dumon) under general anaesthesia through rigid bronchoscopy in two patients with benign post-tracheostomy stenosis: a 39-year old woman with failed initial operation, and continuous relapses with proliferation after multiple bronchscopic interventions, and a 20-year old man in a poor neurological status, with a long tracheal stricture involving the subglottic larynx (lower posterior part), and inflamed tracheostomy site tissues (positive for methicillin resistant staphylococcus aureus). The airway was immediately re-establish, without complications. At 15- and 10-month follow-up (respectively) there was no stent migration, luminal patency was maintained without: adjacent structure erosion, secretion adherence inside the stents, granulation at the ends. Tracheostomy tissue inflammation was resolved (2(nd) patient), new infection was not noted. The patients maintain good respiratory function and will be evaluated for scheduled stent removal. Silicone stents are removable, resistant to microbial colonization and are associated with minimal granulation. In benign post-tracheostomy stenosis silicone stenting appeared safe and effective in re-stenosis after surgery and multiple bronchoscopic interventions, and in long stenosis, involving the lower posterior subglottic larynx in the presence on inflammation and poor neurological status.

Decannulation in Tracheal Stenosis Deemed Inoperable Is Possible After Long-Term Airway Stenting

Decannulation is the ultimate therapeutic goal for patients who undergo stenting because of inoperable benign tracheal stenosis. In this study, our objectives were to evaluate whether long-term airway stenting allows decannulation in patients with benign tracheal stenosis who were deemed inoperable and to identify possible predictive factors for successful decannulation (SD). Retrospective cohort study including all patients with inoperable benign tracheal stenosis who underwent tracheal stenting in our tertiary-care university-based institution from 1998 to 2008. For benign stenosis, we use only silicone stents (T tubes, Dumon stents, and Y stents). The main outcome was SD, which was defined as removal of the tracheal stent followed by absence of respiratory symptoms and no requirement for new dilation procedures for at least 6 months. A Kaplan-Meier curve was built to evaluate SD in 5 years, and we used a Cox model to evaluate predictors for a SD. Ninety-two patients were included, and during the study period 21 were decannulated. However, 2 of them had to undergo new airway procedures and were considered to represent failure. Therefore, 19 patients were successfully decannulated. According to the Kaplan-Meier estimate, the SD rate in 5 years was 27.5%. The mean follow-up time after SD was 34.3 ± 33.9 months (range, 6 to 108 months). Cox regression showed only 1 significant factor: tracheostomy before stent insertion caused a threefold increase in the likelihood of the patient remaining with a tracheal stent (p = 0.048). Tracheal stenting may be considered a curative therapeutic approach in as many as 27.5% of patients with inoperable benign tracheal stenosis.

Endoscopic management of post-lung transplantation anastomotic stenosis: metallic, silicone or biodegradable stents

We read with great interest and enthusiasm the paper by Lischke et al. [1] on the use of a new biodegradable stent in the treatment of stenosis after lung transplantation. The concept that a stent could act for a certain period of time and then disappear is a very promising concept in airway stenting. This first report in humans is in itself of high scientific value even if the studied population is very limited and if biodegradable stents made of bio-absorbable polydioxanone do not seem to prevent recurrences as suggested by the fact that new stent placement was necessary in almost all of the patients after degradation of the initial stent. This may be due to the fact that the stent degradation is too fast and that this kind of stenosis may require longer stent placement duration. In comparison, posttracheostomy or post-intubation tracheal stenosis, another type of benign airway stenosis, requires an average of 18 months with a silicone stent in place, to be definitely cured in almost 70% of the cases (no recurrence at 1 year after removal) [2]. The absence of silicone stents as potential alternative to metallic stents in this study is questionable for us. Indeed, we recently published our experience using silicone stents to treat anastomotic stenosis following lung transplantations [3]. We treated 23 anastomotic airway stenoses with the Dumon-type stents. Mean stent duration was 266 days (range: 24–1407 days). Stent-related complications were of mild to moderate in severity, and were appropriately managed endoscopically. Successful stent removal was achieved in 16 of 23 cases (69.5%) without recurrence of stenosis. Our conclusions fully support the idea of non-permanent stenting in anastomotic complications after lung transplantations and in benign airway stenoses in general. This does not seem to be really the case with biodegradable stents, given that new stents are regularly required in the studied population. It is always useful to be reminded of the FDA recommendations regarding metallic stenting in benign tracheal stenosis (www.fda.gov/MedicalDevices/Safety/AlertsandNotices/Public HealthNotifications/UCM062115) and the fact that non-fully covered metallic stents can actually worsen the primary stenosis [4] and may be very difficult to remove after placement [5]. Silicone stents are still considered as the gold standard in airway stenting [6] and any new type of stent should be compared with them, even biodegradable stents. As the future of airway stents clearly evolves towards active stents (drug-eluting stents, biodegradable, radioactive stents) [6], the study by Lischke et al. [1] is clearly a landmark study in this field and the authors should be acknowledged for that. Many new studies will be probably published soon with new applications and new kinds of degradable stents, the debate is just starting.

Reply to Anile et al.

We appreciate the interest showed by Anile et al. [1] in our article. We thank the authors for sharing their experience with four cases of obstructive fibrinous tracheal pseudomembrane (OFTP) removed by rigid bronchoscopy (RB) [2] and for the opportunity to clarify some of the key points regarding such issues. First, OFTP is a diagnostic challenge. In most cases, it is misdiagnosed as benign post-intubation tracheal stenosis, and the patient is referred to the thoracic surgery unit for endoscopic and/or surgical treatment. Chest CT scans show a tracheal stenosis without radiological signs for which pseudomembrane may be suspected, while its observation during flexible bronchoscopic (FB) is difficult for the reasons reported by the same authors [2]. However, last week we performed an FB in a patient who had tracheostomy. The patient presented with acute respiratory failure. We found an annular lesion with a septum that was partially torn and downwardly detached with obstruction of tracheal lumen. Remembering our previous experience, a diagnosis of OFTP was made. Thus, we believe that pseudomembrane is considered as a rare event because it is poorly known, but it might be much more common than thought. Stridor and respiratory failure are common findings after extubation due to a variety of causes. Thus, pseudomembranes may be detached and removed by tracheal suctioning and/or reintubation, and thus might remain unrecognized [3]. Secondly, the pathogenesis of OFTP remains unclear. Deslee et al. [4] postulated that ischaemic injury due to pressure at the site of the endotracheal cuff is the first step of developing pseudomembrane. However, formation of pseudomembrane has been associated with various other conditions including pulmonary infection, traumatic intubation, aspiration of gastric contents, diabetic microcirculation changes as reported by Talwar et al. [5]. Two of the four cases reported by the authors [2] had Candidal infection. However, it would be interesting to know whether the other two patients presented other predisposing factors for development of pseudomembrane. In our patient, in theory, the traumatic intubation may cause superficial damage to tracheal mucosa that, in addition to injury due to endotracheal cuff, develops pseudomembrane. Conversely, real tracheal ischaemic injury at the site of intubation, resulting from more profound tissue injury may lead to stenosis afterward [3]. Whether the use of marijuana is a risk factor of OFTP remains to be validated. Thirdly, we agree with the authors that the removal of pseudomembrane should be performed via RB. It allows the extraction of it in one piece while maintaining sufficient ventilation during the procedure. Lins et al. [3] in a recent review reported that, in only 4 of 22 cases, the ablation of membrane was made during FB. No case was reported by the authors [3] in which pseudomembrane was spontaneously coughed up to confirm that our case is unique in literature. In closure, OFTP should always be considered in the differential diagnosis of OFTP that requires immediate treatment. However, if you have experienced previous episodes of pseudomembrane, it will help you in diagnosing new cases in the future!

Management of benign tracheal stenosis by intubation dilatation under flexible bronchoscopic guidance

To evaluate the efficacy and safety of intubation dilatation under flexible bronchoscopic guidance in the management of benign tracheal stenosis. A retrospective analysis of the clinical data was performed for 12 patients with benign tracheal stenosis from March 2010 to August 2011. There were 5 males and 7 females with a mean age of 37 ± 11 years old (range: 27 - 65). They were treated by intubation dilatation with different sizes under bronchoscopic guidance. And balloon dilatation was also performed for left or right main stem bronchial stenosis. And metal stents were implanted if necessary. Airway diameter, dyspnea index, complications and blood gas analysis were evaluated in all patients. And the forced expiratory volume in one second (FEV(1)) was tested in 9 cases before and after the treatments of intubation dilation, balloon dilation and other interventions. One to five attempts of intubation dilation were required to achieve satisfactory dilatation. There was immediate postoperative relief of dyspnea for all 12 cases. And PaO2 and SaO2 rose markedly, but PaCO2 declined after intervention. The effective rate of intubation dilation was 100%. The average airway diameter increased from (5.7 ± 1.2) to (12.2 ± 2.1) mm and FEV(1) improved from (0.67 ± 0.13) to (1.73 ± 0.37) L (P < 0.01). The minimally invasive management of benign tracheal stenosis with intubation dilatation is both safe and efficacious.

Tracheal resection with end-to-end anastomosis for post-intubation cervical tracheal stenosis: study of 14 cases

The incidence of acquired laryngeal stenosis is increasing. This retrospective study aimed to assess the long term results of circumferential resection with end-to-end tracheal anastomosis for isolated post-intubation stenosis of the cervical trachea, and to review the relevant literature. Twelve male and two female patients (aged 16-30 years, mean age 24 years) treated between February 2003 and December 2008 were included. Hospital and office records were reviewed and relevant surgical details recorded. Indications for tracheal resection anastomosis were post-intubation stenosis (78.57 per cent) and trauma (21.42 per cent). One to five tracheal rings were resected (i.e. 1-2.5 cm of cervical trachea). Tracheal anastomosis was considered successful if the patient remained asymptomatic for 24 months of close follow up (involving regular flexible bronchoscopy and neck X-ray). The anastomotic success rate was 92.85 per cent. Tracheal resection and end-to-end anastomosis is relatively safe and reliable for definitive treatment of benign tracheal stenosis in appropriate patients. Local application of mitomycin C prevents granulation and aids long term airway patency.

Editorial commentAirway stenting for benign tracheal stenosis: what is really behind the choice of the stent?

Editorial commentAirway stenting for benign tracheal stenosis: what is really behind the choice of the stent?

Treatment of benign tracheal stenoses with fully covered retrievable metallic stents

气管狭窄段切除后端端吻合术是治疗良性气管狭窄的标准方法[1],然而随着气管内介入治疗技术不断发展,良性气管狭窄治疗的方法逐渐多样化、微创化,其中气管支架是介入治疗的主要方法之一.笔者旨在探讨可回收全覆膜金属支架在良性气管狭窄治疗中的临床效果、并发症的处理和取出时间,评价该方法在良性气管狭窄治疗中的应用价值。

Surgical management of benign tracheal stenosis

This chapter provides a step-by-step explanation of the indications, basic technique and pitfalls of tracheal surgery for cases of benign tracheal stenosis. Approach, trachea dissection and end-to-end anastomosis in tracheal surgery is described in detail. An algorithm for laryngotracheal technique selection according to different criteria (stenosis location, vocal cords status and tracheal mucosa and/or cartilaginous larynx involvement) is also depicted. Finally, a review of the most important reported series in tracheal surgery is presented.