Benign Tracheal Stricture Research Articles

1828 CryoDilation: A Novel Treatment for Benign Esophageal Strictures Using Liquid Nitrogen Spray Cryotherapy

INTRODUCTION: Liquid nitrogen spray cryotherapy (SCT) was developed for endoscopic treatment of Esophageal Cancer and Barrett’s Esophagus. It has been shown to be a safe and effective therapy. Pulmonologists and thoracic surgeons have used SCT for treatment of benign tracheal strictures and stenoses with reduced severity of airway narrowing and symptomatic improvement. We describe the successful use of SCT in a recurrent, benign esophago-gastric anastomotic stricture, highlighting its potential as a new alternative treatment modality. CASE DESCRIPTION/METHODS: A 52-year-old female with stage T1 esophageal adenocarcinoma status-post laparoscopic thoracoscopic Ivor-Lewis esophagectomy presented to clinic 3 months following surgery for dysphagia. An esophagogastroduodenoscopy (EGD) revealed an esophago-gastric anastomotic stricture. Over the next 4 years, the stricture recurred despite monthly EGDs with dilations, steroid injections, and stent placement. Her course was complicated by dysphagia, food impactions, and severe protein-calorie malnutrition requiring total parenteral nutrition (TPN). The decision was made to perform Cryodilation. The patient then underwent seven EGDs with cryodilation over seven months. During the procedure, liquid nitrogen spray was administered for 20 seconds, followed by 60 seconds of thaw time, for a total of three freeze-thaw cycles and stricture then dilated up to 18mm. Prior to the first EGD with cryoablation, she recorded her lowest weight within 5 years at 49.4 kg (BMI 16.4). After initiating these procedures, the patient experienced marked functional and clinical improvement. After only three cycles, she began eating soft foods again. After five cycles, her weight peaked at 58.9 kg (BMI 19.7), which she maintained for 8 months. After six cycles of therapy she was able to discontinue TPN. Since cryodilation, she has had no further weight loss nor episodes of food impaction and the time between endoscopic dilation procedures has lengthened considerably. DISCUSSION: This case demonstrates a severe recurrent esophago-gastric anastomotic stricture which was unresponsive to aggressive, frequent traditional management. This novel and previously unreported method of serial cryotherapy with dilation greatly improved this patient’s symptoms and functional status. This method is a potential safe and effective primary treatment or adjunct modality for refractory benign esophageal strictures.

Role of Gum Elastic Bougie Dilatation in Benign Tracheal Stricture

Role of Gum Elastic Bougie Dilatation in Benign Tracheal Stricture

Tracheal resections and anastomosis for benign tracheal stricture. A seven-year experience in a single tertiary institute

BackgroundTracheal stenosis is one of the major complications following prolonged endotracheal intubation. Tracheal resection and anastomosis (TRA) is a definitive solution for this serious problem. This study aimed to review the experience of our institute in 7 years with patients presenting with postintubation tracheal stenosis. MethodsA retrospective analysis of patients with post-intubation tracheal stenosis who presented to the pulmonology and Thoracic Surgery departments, Ain Shams University Hospitals, Cairo, Egypt during the period from January 2009 to January 2016. All patients were subjected to diagnostic bronchoscopy, and radiological evaluation. TRA was performed as a primary treatment. Sixty patients were selected and data were collected from their files. ResultsAge range was 2–72 years with mean age of 29.76 ± 17.04 years, 42 were males (70%) and 18 were females (30%), 40 patients (66.7%) had previous bronchoscopic dilatations, 35 patients (58.33%) had tracheostomies, 4 patients (6.7%) had history of tracheal stenting. Twenty-five patients (41.67%) had cricotracheal resection (CTR) for subglottic stenosis. Patients were followed up for 6 months. Anastomotic success rate was (96.6%). Two patients died during the in-hospital stay (3.3%). ConclusionsTRA proved to be a safe and reliable solution for post-intubation tracheal stenosis. This procedure should be considered first in developing countries where there is frequent rush for tracheostomies and tracheal stenting. Quality of life improved dramatically following this definitive surgery.

Management of Benign Tracheal Strictures Caused by Tracheostomy

To evaluate the clinical efficacy and safety of radiologic management for the treatment of benign tracheal strictures caused by tracheostomy. We retrospectively reviewed of 13 patients with benign tracheal stricture caused by tracheostomy that was treated with balloon dilation or stent placement. Balloon dilation had initially been performed. Stent placement was indicated in patients who showed a poor response to balloon dilation. Outcomes were assessed according to the following variables: technical and clinical success, Hugh-Jones classification scale before and after the procedures, and complications. Balloon dilation and stent placement were technically successful in all patients. Nine of the 13 patients (69 %) showed no response to balloon dilation, and the remaining the four patients showed a positive response to initial balloon dilation. Six of the nine (67 %) patients showed a good response to temporary stent placement and required no further treatment. Mean Hugh-Jones grades improved from 3.6 ± 0.8 to 1.8 ± 1.1 (P < 0.001). During a follow-up period of 2.6-40.8 months (mean 16.5), overall clinical success was achieved in 10 patients (77 %) after a single balloon dilation (n = 4) and temporary stent placement (n = 6). The remaining three patients with clinical failure underwent tracheal resection (n = 3). Radiologic management can be a safe and effective therapeutic option for treating benign tracheal stricture caused by tracheostomy. Temporary stent placement can be effective in patients with symptoms recurring soon after balloon dilation.

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.

Post-intubation membranous trachitis after endotracheal intubation

We read with interest the paper entitled ‘Spontaneous expectoration of an obstructive fibrinous tracheal pseudomembrane after tracheal intubation’ from Fiorelli et al .[ 1]. Membraneous trachitis is a rare complication after tracheal intubation; however, it may pose several diagnostic and therapeutic problems if misdiagnosed. In particular, both benign tracheal strictures and simple granulation may be erroneously suspected. Direct endoscopic observation may be difficult due either to the presence of the endotracheal tube in place, or, in the case of spontaneously breathing patients, to respiratory distress. Radiological evaluation with computed tomography (CT) may also be difficult for the same reasons. We have observed this complication in four patients during the last years. In all cases, the intubation time was less than a week long and the suspect of tracheal obstruction was raised on the base of difficulties to extubate the patient notwithstanding optimal functional parameters. In all patients, inexperienced endoscopists made the diagnosis of fibrous tracheal strictures; in one case, the erroneous diagnosis was confirmed at CT performed with the patient still intubated. All patients were still intubated when they were referred with the diagnosis of ‘benign postintubation tracheal stricture’ to our unit for a more careful endoscopic evaluation through the rigid bronchoscope, potential initial treatment with mechanical debridement and/or laser, and subsequent tracheal or laryngo-tracheal resection [2]. In all cases, the thick fibrous membranes required careful mechanical debridement to be removed with the tip of the rigid bronchoscope, with the patient under deep sedation and spontaneously breathing; after the removal of the pseudomembranes, a bleeding airway wall was observed. All the lesions were at the level of the tracheal tube cuff. All patients were immediately extubated. Cultures showed the presence of Candida in two cases. After 1 month, fiberoptic bronchoscopy showed complete mucosal healing. This complication should always be suspected when extubation is not possible after short periods of mechanical ventilation notwithstanding adequate functional parameters. Bronchoscopy should be performed by an experienced thoracic surgeon familiar with tracheal disorders; the rigid bronchoscope should always be available for immediate treatment. Spontaneous expectoration is extremely rare due to adhesions with the tracheal wall, as reported by Fiorelli A et al. CT evaluation is not useful.

Morphologic Assessment of Extracellular Matrix Scaffolds for Patch Tracheoplasty in a Canine Model

The optimal management of benign tracheal stricture remains surgical resection. Resection is not always an option because of the challenges posed by anastomotic tension and a tenuous blood supply. Regenerative medicine approaches, such as extracellular matrix (ECM) scaffold technology, may alleviate some of the limitations to tracheal replacement. ECM scaffolds facilitate site-specific tissue remodeling when used to reconstruct a variety of soft-tissue structures. A 1-cm wide x 2-cm-long defect was created in the ventral trachea of 15 dogs and repaired with one of three acellular biologic scaffolds: urinary bladder matrix (UBM), UBM crosslinked with carbodiimide (UBMC), and decellularized tracheal matrix (DTM). The grafts were evaluated periodically using bronchoscopy and by macroscopic and microscopic morphologic examination at either 2 months or 6 months. The UBM, UBMC, and DTM groups showed no evidence of stenosis or tracheomalacia. The UBM, UBMC, and DTM groups all showed deposition of organized collagenous tissue at the site of scaffold placement and an intact epithelial layer. Scattered areas of mucociliary differentiation were present at the edges of the graft site. There was no evidence cartilage observed within the remodeled tissue at 6 months. ECM scaffolds promote healing of significantly sized tracheal defects without stricture and with some, but not all, of the necessary structures required for tracheal reconstruction, including complete coverage with ciliated epithelium and dense organized collagenous tissue.

Awake Tracheobronchial Dilation Without the Use of Rigid Bronchoscopy

Benign tracheal strictures have been treated by repeated dilations using rigid bronchoscopy and general anesthesia. An alternative approach using conscious sedation, fluoroscopy, flexible bronchoscopy, and Savary-Gilliard esophageal dilators (Cook Endoscopy, Inc, Winston-Salem, NC) is reported. All patients undergoing dilation while awake had lesions due to inflammatory disease or lesions that were not amenable to resection. This method may be less traumatic than rigid bronchoscopy and can be accomplished on an outpatient basis without the use of general anesthesia.

Covered Gianturco stent for tracheal stricture: application of polychlorovinylidene and polyurethane as covering materials.

The aim of this study was to assess the efficacy and safety of thin membranes of polychlorovinylidene (PCV) or polyurethane (PU) as covering materials for Gianturco stents in the treatment of severe tracheal stricture caused by intraluminal tumor. Manufactured Gianturco stents covered with PCV or PU membrane were used to treat six malignant and one benign tracheal stricture. The initial results, complications, clinical follow-up, bronchoscopic findings, and three autopsy microscopic examinations were reviewed. Informed consent was obtained after the nature of the treatment had been fully explained before every procedure. The stents successfully dilated the tracheal strictures, providing immediate relief of respiratory symptoms in all patients with no major complications. During the follow-up period, the covering materials prevented tumor ingrowth until death or intraluminal granuloma formation. Autopsies proved that no histological change occurs in the tracheal mucosa in response to the presence of PCV or PU; however, ulcer formation occurred in one patient and penetration of the stent struts into the tracheal wall in two. Bloody sputum with ulcer formation, minimal granuloma formation at the distal end of the stent, and abnormal bacterial load in the sputum were long-term complications. The Gianturco stent covered with PCV or PU membrane is a useful option as a palliative treatment for malignant and an emergent salvage for benign tracheal stricture, because both materials are thinner and less voluminous than the others. However, the indications for its use are limited to patients with poor prognoses, because hemoptysis, granuloma formation, and bacterial propagation remain problematic.

Nitinol Tracheobronchial stents: a word of caution

To the Editor, We would like to address a few of the points raised in the letter from Drs. Colreavy and Walsh. To our knowledge, ours was the first reported use of the nitinol stenting system for the treatment of benign strictures of the trachea. We have credited Dr. H.D. Becker for his invaluable descriptions and initial work with this stent in the treatment of malignant strictures. However, a complete search on our part failed to note his publication in Stents: State of the Art and Future Developments (Polyscience Publications, 1995). This publication is not cited in any of the databases that we have researched including MEDLINE. We certainly anticipate the forthcoming report by Dr. Colreavy et al. on nitinol stents.In their letter they seem to concur with our findings of ease of insertion and rapidity of airway improvements after nitinol stent placement as compared with other metallic stents. Unlike Drs. Colreavy et al., we have not experienced any cases of stent migration after placement in the reported patient population or in any patients treated since that time. We feel that appropriate sizing (stent diameter) is an important factor in preventing such a serious complication. We routinely have a number of stents of different diameters available at the time of surgery. A stent that is not wide enough (or long enough) may be safely removed at the initial surgery and should be replaced with one of a more appropriate dimension.As this indwelling stent does become mucosalized, removal would be quite difficult if required. We have not encountered a patient requiring this to be done to date. We feel that, in the absence of adverse effect, stent removal should not be necessary. As stated in the paper, further long-term follow-up of this patient population is required before it can be recommended as the treatment of choice in patients with benign tracheal strictures. Thus far, with an expanding personal experience, we continue to have a very positive experience with this stenting system. YADRANKO DUCIC MD, FRCS(C), REZA S. KHALAFI MD, FACS

Excision of adenoid cystic carcinoma of the cervical trachea via an anterior castellated approach

Adenoid cystic carcinoma of the cervical trachea is rare and its diagnosis and surgical management challenging. We report a case with an unusual presentation and discuss the diagnosis and management. The preferred surgical management is tracheal resection, however this is often not feasible and many alternative techniques have been used. Here an anterior castellated approach is described, a modification of that more commonly used for benign tracheal strictures. We found it gave excellent access to the posterior tracheal wall which we feel is superior to a straight vertical tracheal incision. It also facilitates a tracheal widening procedure if indicated, and safeguards the recurrent laryngeal nerves which are particularly vulnerable in the cervical part of the trachea.