Tracheal Prosthesis Research Articles

Bio-Inspired Magnetically Responsive Silicone Cilia: Fabrication Strategy and Interaction with Biological Mucus.

Cilia are biological structures essential to drive the mobility of secretions and maintain the proper function of the respiratory airways. However, this motile self-cleaning process is significantly compromised in the presence of silicone tracheal prosthesis, leading to biofilm growth and impeding effective treatment. To address this challenge and enhance the performance of these devices, we propose the fabrication of magnetic silicone cilia, with the prospect of their integration onto silicone prostheses. The present study presents a fabrication method based on magnetic self-assembly and assesses the interaction behavior of the cilia array with biological mucus. This protocol allows for the customization of cilia dimensions across a wide range of aspect ratios (from 6 to 85) and array densities (from 10 to 80 cilia/mm2) by adjusting the fabrication parameters, offering flexibility for adjustments according to their required characteristics. Furthermore, we evaluated the suitability of different cilia arrays for biomedical applications by analyzing their interaction with bullfrog mucus, simulating the airways environment. Our findings demonstrate that the fabricated cilia are mechanically resistant to the viscous fluid and still exhibit controlled movement under the influence of an external moving magnet. A correlation between cilia dimensions and mucus wettability profile suggests a potential role in facilitating mucus depuration, paving the way for further advancements aimed at enhancing the performance of silicone prostheses in clinical settings.

Tracheal Reconstruction with the Scaffolded Cartilage Sheets in an Orthotopic Animal Model.

Tracheal reconstruction remains challenged in clinical. We aimed to fabricate scaffolded cartilage sheets with rigid and elastic supports for tracheal reconstruction. The chondrocyte cell infiltration activity was examined in poly-caprolactone sheet scaffolds with various thicknesses and pore sizes after seeding cells on the top surface of the sheet scaffolds. The expression of cartilage-related genes and accumulation of sulfated glycosaminoglycans were elevated in the cell-scaffold composites upon chondrogenic induction. The thicker cartilage sheets represented stronger mechanical properties than the thinner cartilage sheets. Two different cartilage sheets were orthotopically implanted into a trachea in a rabbit model for 2, 4, and 16 weeks. Cartilage-related sulfated glycosaminoglycans and type II collagen macromolecules were stably expressed in the tracheal implants. However, the invasive migration of fibrous tissue and profibrotic collagen fibers into cartilage implants and the peripheral space surrounding the implants were elevated in a time-dependent manner. At week 16 postimplantation, airway stenosis was noticed under the thicker sheet implants, but not the thinner implants, suggesting that the thinner (1 mm thick) scaffolded cartilage sheet was an optimal candidate for tracheal reconstruction in this study. Finally, cartilage sheets could be a reconstructive therapy candidate applied to reconstruct defects in the trachea and other tissues composed of cartilage. Impact statement Tissue engineering is a promising approach to generate biological substitutes. We aimed to develop cartilage sheets as tracheal prosthesis used in tracheal reconstruction or regional repairing in the animal model. The formation of microvessels and the dynamics of reepithelialization were monitored for 16 weeks in tracheal implants of the engineered cartilage sheets. In this study, it was demonstrated that the tissue-engineered cartilage sheets are potential substitutes applied in the reconstruction of the trachea and other tissues composed of cartilage tissue. The cartilage sheets were thought of as biomaterials for personalized regenerative medicine since the dimensions, thickness, and pore sizes of cartilage sheets were tunable to fit the lesions that need to be reconstructed.

Hyaluronic Acid Coating on Hydrophobic Tracheal Scaffold Enhances Mesenchymal Stem Cell Adhesion and Tracheal Regeneration.

Long segmental tracheal repair is challenging in regenerative medicine due to low adhesion of stem cells to tracheal scaffolds. Optimal transplantation of stem cells for tracheal defects has not been established. We evaluated the role of hyaluronic acid (HA) coating of tracheal scaffolds in mesenchymal stem cell (MSC) adhesion and tracheal regeneration in a rabbit model. A three-dimensionally printed tubular tracheal prosthesis was incubated with dopa-HA-fluorescein isothiocyanate in phosphate-buffered saline for 2days. MSCs were incubated with an HA-coated scaffold, and their adhesion was evaluated by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay. HA coated scaffolds with or without MSC seeding were transplanted at the circumferential tracheal defect in rabbits, and survival, rigid bronchoscopy, radiologic findings, and histologic findings were compared between the two groups. HA-coated scaffolds showed better MSC adhesion than non-coated scaffolds. The HA-coated scaffolds with MSC group showed a wider airway and greater mucosal regeneration compared to the HA-coated scaffolds without MSC group. HA coating of scaffolds can promote MSC adhesion and tracheal regeneration.

Effects of anesthesiologists awareness on the control of cuff pressure in patients submitted to cardiac surgery.

Sedatives applied to cardiac surgery patients can act on the respiratory tract, creating a demand for a tracheal prosthesis in the artificial route, whose distal part (cuff) has a recommended pressure of 20 to 25 mm Hg. The professional's lack of knowledge about procedures and adequate pressure can pose risks to patients' health. To analyze the effect of anesthesiologists awareness on the control of cuff pressure. A prospective cohort study. At the beginning of the research, cuff pressures were consecutively measured immediately after the patient's admission to the intensive care unit (ICU). After this period, anesthesiologists were trained by the responsible researchers for 1 month. In the final 2.5 months of the research, cuff pressure was again measured immediately after the patient's admission to the ICU. A total of 70 patients were evaluated, 37 of whom were pre-awareness and 33 were post-awareness. Male sex was the most prevalent with 46 (66%) patients and the mean age was 58 ± 10 years. There was a reduction from 76 ± 14 to 28 ± 9 in cuff pressure (P < .01). The training of anesthesiologists who assist cardiac surgery patients allowed a reduction in cuff pressure abnormalities.

Tranilast-loaded tubular scaffold and surgical suture for suppression of stenosis after tracheal prosthesis transplantation

Most tracheal prosthesis implantation fail because of restenosis at the anastomotic site. Tranilast, which is approved as an anti-allergic drug, has been found to inhibit the proliferation of fibroblasts. In this study, use of a tracheal scaffold and surgical suture loaded with tranilast was proposed. A three-dimensionally printed tubular scaffold was designed as an artificial tracheal implant, both ends of which were fixed with surgical sutures. The formation of granulation tissue at both ends of the scaffold were compared among four animal groups that were transplanted with a drug-loaded or bare scaffold and sutured with drug-loaded or bare thread. In animal models with a tracheal defect, the inhibitory effect of tranilast on stenosis at an anastomotic site was observed to be synergistically enhanced when both the scaffold and suture were loaded with tranilast, allowing for better survival after tracheal implantation. Histologic evaluation also revealed that more M2 phenotype macrophages, which are known to be responsible for anti-inflammation and tissue regeneration, were recruited around the scaffold than pro-inflammatory M1 macrophages that otherwise would stimulate fibrosis. Therefore, these results suggest that tracheal implantation using a tubular scaffold and suture, both loaded with tranilast, is a promising strategy for suppression of tracheal stenosis.

Long-term outcomes of 54 dogs with tracheal collapse treated with a continuous extraluminal tracheal prosthesis.

To describe the surgical placement of a continuous extraluminal tracheal prosthesis (CETP) and report the subsequent postoperative clinical outcomes in dogs with tracheal collapse. Retrospective case series. Fifty-four dogs. Medical records of dogs in which cervical and/or thoracic inlet tracheal collapse was diagnosed and treated by placement of a CETP between 2010 and 2017 were reviewed to evaluate postoperative complications, changes in respiratory function, and survival. Histological examinations of tracheal tissues performed in 2 dogs at 51 and 57 months after surgery were also reviewed. Fifty-three (98%) dogs survived to discharge. Postoperative complications included laryngeal paralysis (1 dog), disseminated intravascular coagulation (1 dog), and recurrent tracheal collapse (2 dogs). None of the dogs exhibited clinical evidence of tracheal necrosis. Preoperative dry, harsh cough resolved in 87% of the dogs after surgery. Goose honking cough was resolved in 25 of 26 (96%) dogs. Median follow-up time was 30 months (range, 16 days to 76 months). The survival rate at 36 months was 86% (CI: 75%-96%). On histological examination in 2 dogs, the tracheal tissue surrounding the prosthesis was well preserved and without evidence of chronic inflammation. Continuous extraluminal tracheal prosthesis placement in dogs with tracheal collapse resulted in low postoperative complication rates and good long-term outcomes. Continuous extraluminal tracheal prosthesis placement provides a viable alternative surgical option for managing dogs with tracheal collapse.

Treatment of tracheoesophageal fistula after laryngectomy by a customized tracheal prosthesis.

Treatment of tracheoesophageal fistula after laryngectomy by a customized tracheal prosthesis.

Collagen-conjugated tracheal prosthesis tested in dogs without omental wrapping and silicone stenting.

Artificial tracheas fabricated from collagen-conjugated mesh appear to overcome fatal postoperative complications, namely anastomotic dehiscence and prosthesis dislocation. Such prostheses are incorporated by host tissue, provided they are wrapped in omentum (necessitating an additional abdominal procedure) and a silicone tube is used as a stent (to be extracted several weeks postoperatively). To mitigate related host impact (i.e. injury, pain and distress), we investigated the feasibility of implanting this type of tracheal prosthesis (∼5 cm in length) alone, without omental wrapping and use of a silicone stent. Porous-type tracheal prostheses that were reinforced with a continuous polypropylene spiral and sealed by collagen sponge from porcine skin replaced segments of cervical trachea (∼5 cm long) in 10 dogs through the method of telescopic anastomosis. Omental wrapping and silicone stent placement were omitted. Postoperatively, bronchoscopic examination was performed periodically. When dogs died or were sacrificed, tracheal prostheses were harvested for haematoxylin and eosin staining and electron microscopic scanning of luminal surface conditions. With the exception of one death from an anaesthesia-related incident during fibre-optic bronchoscopy (postsurgical week 1), nine dogs survived uneventfully (until sacrifice), without prosthesis dislocation or anastomotic dehiscence. The longest observation period was 2 years and 8 months. Bronchoscopic examination revealed that no stenosis or local infection was evident in the prostheses of five dogs. Moderate (n = 2) and slight (n = 2) stenoses were observed in the other four animals. All four animals survived for a long time, without dyspnoea or stridor. Histological examination showed that partial inner surface of the artificial trachea was covered with the pseudostratified ciliated epithelium. Regeneration of ciliated epithelium was also confirmed by scanning electron microscopy. This pilot study revealed that implantation of a collagen-conjugated tracheal prosthesis (∼5 cm in length) is feasible without the need for omental wrapping and silicone stenting as ancillary measures. This approach considerably simplified the surgical procedures to minimize host intrusion, which indicated a possible clinical application.

Tissue Engineered Airways: A Prospects Article.

An ideal tracheal scaffold must withstand luminal collapse yet be flexible, have a sufficient degree of porosity to permit vascular and cellular ingrowth, but also be airtight and must facilitate growth of functional airway epithelium to avoid infection and aid in mucocilliary clearance. Finally, the scaffold must also be biocompatible to avoid implant rejection. Over the last 40 years, efforts to design and manufacture the airway have been undertaken worldwide but success has been limited and far apart. As a result, tracheal resection with primary repair remains the Gold Standard of care for patients presenting with airway disorders and malignancies. However, the maximum resectable length of the trachea is restricted to 30% of the total length in children or 50% in adults. Attempts to provide autologous grafts for human application have also been disappointing for a host of different reasons, including lack of implant integration, insufficient donor organs, and poor mechanical strength resulting in an unmet clinical need. The two main approaches researchers have taken to address this issue have been the development of synthetic scaffolds and the use of decellularized organs. To date, a number of different decellularization techniques and a variety of materials, including polyglycolic acid (PGA) and nanocomposite polymers have been explored. The findings thus far have shown great promise, however, there remain a significant number of caveats accompanying each approach. That being said, the possibilities presented by these two approaches could be combined to produce a highly successful, clinically viable hybrid scaffold. This article aims to highlight advances in airway tissue engineering and provide an overview of areas to explore and utilize in accomplishing the aim of developing an ideal tracheal prosthesis. J. Cell. Biochem. 117: 1497-1505, 2016. © 2016 Wiley Periodicals, Inc.

Clinical Experience of Zhao's Artificial Trachea.

The practice of artificial tracheal prosthesis has been a major challenge to the entire surgical field worldwide until now. The previously applied prosthesis is “inner stent” type, which is unable to heal biologically with native trachea.[1] The newly developed design, the Zhao's artificial trachea, uses a memory alloy mesh combined with traditional operation procedures. Following a 2-year experimental period, the device has been applied to seven patients with satisfying results. We believe this to be a successful artificial trachea that is capable of complete biologically healing with the native trachea. No rejection, infection, or major complications were present in the seven patients, and the Zhao's artificial trachea may be considered a real part of the trachea.

Design of a Nanostructured Active Surface against Gram-Positive and Gram-Negative Bacteria through Plasma Activation and in Situ Silver Reduction.

Nowadays there is an increasing focus for avoiding bacterial colonization in a medical device after implantation. Bacterial infection associated with prosthesis implantation, or even along the lifetime of the implanted prosthesis, entails a serious problem, emphasized with immunocompromised patients. This work shows a new methodology to create highly hydrophobic micro-/nanostructured silver antibacterial surfaces against Gram-positive and Gram-negative bacteria, using low-pressure plasma. PDMS (polydimethylsiloxane) samples, typically used in tracheal prosthesis, are coated with PFM (pentafluorophenyl methacrylate) through PECVD (plasma enhance chemical vapor deposition) technique. PFM thin films offer highly reactive ester groups that allow them to react preferably with amine bearing molecules, such as amine sugar, to create controlled reductive surfaces capable of reducing silver salts to a nanostructured metallic silver. This micro-/nanostructured silver coating shows interesting antibacterial properties combined with an antifouling behavior causing a reduction of Gram-positive and Gram-negative bacteria viability. In addition, these types of silver-coated samples show no apparent cytotoxicity against COS-7 cells.

Prothèse trachéobronchique dans le syndrome de Mounier-Kuhn : nouvelles perspectives

Mounier-Kuhn syndrome or tracheobronchomegaly is a rare congenital condition, the management of which is complex. We report the case of a patient who was treated with interventional endoscopy. We describe the case of a 74-year-old man with a diagnosis of tracheobronchomegaly who was admitted in 2003 with a background of deteriorating respiratory status and the occurrence of postural syncope. He initially received a tracheobronchial silicone Y prosthesis, extended with metal prostheses at the tracheal and bronchial level. This arrangement remained stable until 2011. He then began to develop episodes of asphyxia related to posterior dislocation of the tracheobronchial prosthesis, after breakage of the metallic mesh tracheal prosthesis. A new tracheobronchial prosthesis Y was then placed, custom-made from a 3D model of the airways. This was clinically and functionally effective. This case describes the management of a patient with Mounier-Kuhn syndrome by interventional bronchoscopy, with the adaptation of prosthetic materials, on an individual basis, to the anatomy of the patient's airway.

Laryngeal replacement with an artificial larynx after total laryngectomy: The possibility of restoring larynx functionality in the future

Most patients perceive total laryngectomy as a mutilation carrying with it a loss of physical and psychological integrity. Thus, an artificial larynx system that can replace the laryngeal functions would significantly improve the quality of life for the afflicted patients. This report, with accompanying video, presents the first case in an ongoing clinical trial of laryngeal rehabilitation using an artificial larynx after total laryngectomy for squamous cell carcinoma, for an 8-month follow-up period. We depict the prosthesis' features, our 2-step surgical procedure, and the outcome. The prosthesis is formed of 2 parts: (1) a tracheal prosthesis with a porous titanium junction with trachea, which was implanted in the first step to ensure its colonization, and (2) a removable part composed of concentric valves that enable inhalation and exhalation. The second part was implanted endoscopically. The implant was monitored with a retrograde nasofibroscopy of the tracheal prosthesis lumen and CT scans over a course of 8 months. The patient's functioning in the relevant postoperative problem areas, such as swallowing, breathing, and smelling, has significantly improved. The patient was able to talk in a whispering fashion while the tracheostomy was temporarily closed. The implant's porous part was in the process of being colonized by the surrounding tissue and no fistulas were observed as evidenced by barium swallow. As the current case shows, tracheotomy closure can be performed, and laryngeal functions are restored, by means of an implant. With further improvements, this system can alleviate the need for a permanent tracheostomy after total laryngectomy, while maintaining important larynx functions intact.

Reconstruction of the Trachea

This article reviews established methods of autologous tracheal reconstruction, the various synthetic prostheses that have been used in clinical practice, and briefly describes the latest developments in stem cell tracheal bioengineering and allogeneic tracheal transplantation. Reconstruction of the trachea is challenging due to its part cervical part thoracic location, proximity to major vessels, variable blood supply, and its constant colonization with bacteria. In cases of limited resection, primary anastomosis, autologous patch grafts, local advancement rotation flaps, and locoregional cutaneous and muscle flaps will often suffice. In more extensive resections, complex composite microsurgical reconstruction with a radial forearm free flap with cartilage grafts for skeletal support has proven to be viable and reliable. Synthetic tracheal prostheses, solid as well as porous, have been trialed with disappointing results. Infection, dislodgement, migration, and obstruction are not uncommon. Reconstruction with the cadaveric tracheal allografts and aortic allografts continue to be fraught with complications, specifically graft infections. Tracheal bioengineering and tracheal allotransplantation have emerged relatively recently. Despite early promising results, long-term outcome data on these new techniques are still lacking.

Superior vena cava syndrome as first presentation of an undifferentiated carcinoma with unknown origin

Introduction: The superior vena cava syndrome (SVCS) results from blood flow obstruction of superior vena cava by invasion, extrinsic compression and/or thrombosis. Clinical case: A 55 year old man, with hypertension, heavy smoker and alcohol user (100 g/d) presents at the emergency room with non-productive cough and dyspnea. On admission it is noted plethora, facial edema and jugular engorgement, upper limbs with edema and chest wall collateral circulation. Blood tests showed normocytic and normochromic anemia (10.2 g/dL), leukocytosis (33,000/μL), thrombocytosis (593,000/μL) and elevation of CRP (20.9 mg/dL). Blood gases reveled hypoxemia (44.8 mm Hg). The chest X-ray exhibits widening of the superior mediastinum; chest CT showed bulky mediastinal mass (90 × 80 × 90 mm), which involves the vascular pedicle and leads to extrinsic compression with marked reduction of the diameter of the trachea and a solitary infra-hilar nodule (24 × 26 mm). Bronchoscopy described 90% trachea occupancy by irregular tumor mass with wall destruction. A tracheal prosthesis was placed. The histological diagnosis was a poorly differentiated carcinoma, with areas of differentiation paving stone (with positive staining for CD10, CK5/6, CAM 5.2, p63, hepatocyt, AE1/3). Beta-HCG, alpha-fetal protein and carcinoma-embryonic antigen were negative. Transferred to the intensive care unit (ICU) due to invasive ventilation need. After review by the oncology and cardiothoracic surgery, and considering the stage (T3bNxMx), aggressiveness and severity in the form of presentation, we opted for palliative and comfort measures. He died in ICU, due to disease progression. Conclusions: The combination of clinical data and imaging in this case were crucial for diagnosis. Intrathoracic malignancy is responsible for nearly 60% SVCS cases. SVCS is a form of presentation of a previously undiagnosed tumor in up to 60% of these cases.

Bioengineered trachea using autologous chondrocytes for regeneration of tracheal cartilage in a rabbit model

In this study, a bioengineered trachea composed of autologous chondrocytes was developed, and its effect on cartilaginous regeneration was evaluated by implantation into tracheal defects in rabbits. Prospective controlled trial in an animal model. The tracheal prosthesis used in this study was composed of polypropylene (the frame) and collagen sponge (the scaffold). Chondrocytes were harvested from the costal cartilage of rabbits and seeded into the tracheal prosthesis. The bioengineered trachea, consisting of the tracheal prosthesis with chondrocytes, was implanted into surgically created tracheal defects of rabbits in the bioengineered group, and a tracheal prosthesis without chondrocytes was implanted in the control group. After implantation, the presence of regenerated cartilage was observed in the bioengineered trachea but not in the tracheal prosthesis without chondrocytes. It was confirmed in this study that the implanted chondrocytes proliferated in an appropriate portion of the tracheal defect and that the partially resected tracheal cartilage was repaired with regenerated cartilaginous tissue into a ring-shaped form as a whole. These results demonstrate the feasibility of cartilaginous regeneration using a bioengineered trachea with autologous chondrocytes.

Single-Staged Laryngotracheal Reconstruction for Idiopathic Tracheal Stenosis

This study retrospectively evaluated the results of surgically treated idiopathic tracheal stenosis. Of the 220 patients surgically treated for idiopathic subglottic and tracheal stenosis in the participating hospitals, we reviewed the surgical records of all patients with idiopathic tracheal stenosis. This subgroup required resection of all of the involved mucosa but frequently had undergone more conservative treatments that damaged the tracheal mucosa and cartilage and complicated the definitive surgical treatment. During the study period, 60 women (93.8%) and 4 men (6.2%), who were a mean age of 50 years (range, 19 to 77 years), were surgically treated for idiopathic tracheal stenosis, with no operative deaths. Of these 64 patients, 38 (59.3%) had undergone previous treatments in other centers: dilation, 26 (40.6%); laser only, 19 (31%); laser plus tracheal prosthesis, 5 (7.8%); tracheostomy, 7 (11.6%); T tube, 2 (3%); and laryngotracheal operations, 5 (7.8%). All patients were treated with a single-staged tracheal or laryngotracheal operation, of which 59 (98%) successful. Four of the most complex stenoses, with vocal cords and cricoid plate involvement, underwent reoperation for restenosis or larynx inconsistency. One patient was considered biologically unfit for reoperation and required a permanent T tube for restenosis. Half of the operations were temporary tracheostomies with T tube for larynx modelling. The most frequent postoperative complications were dysphonic voice in 10 patients (although in 7 instances this began months or years before the operation), granulation tissue in 10, aspiration in 3, and wound infections in 2. Idiopathic stenosis occurred predominantly (90% of cases) in women. Single-staged laryngotracheal correction was successful in 97%. Technique selection, with or without temporary laryngeal stenting, must be individualized with respect to the vocal cords' mobility, function, and distance from the stenosis.

Porous Polyurethane Scaffold as a Tracheal Prosthesis Material

Received October 28, 2011 Revised November 30, 2011 Accepted December 6, 2011 Address for correspondence Han Su Kim, MD Department of Otolaryngology, School of Medicine, Ewha Womans University, 1071 Anyangcheon-ro, Yangcheon-gu, Seoul 158-710, Korea Tel +82-2-2650-2686 Fax +82-2-2648-5604 E-mail sevent@ewha.ac.kr Background and ObjectivesZZThe purpose of this study was to confirm the usefulness of the porous polyurethane scaffold as a tracheal prosthesis for repair of partial tracheal defect. Materials and MethodZZA porous polyurethane (PU) scaffold was manufactured by saltleaching method. Polyethylene glycol (PEG) was grafted onto the surface of the PU scaffold following surface ozonation treatment. Scanning electro-microscopy (SEM) was then performed to evaluate the morphklogy. For the biocompatibility evaluation, a 5×5 mm sized PU scaffold was implanted into the rabbit’s ear. A histological examination was performed with the tissue one month later. Polymerase chain reaction for tumor necrosis factor (TNF)-α, interleukin (IL)-6, procollagen, fibromodulin, fibronectin, and actin was also performed. The tensile strength was measured and compared with beagle’s trachea to evaluate the mechanical property of the prosthesis. ResultsZZThe effect of ozonation and surface grafting with PEG was on the porous scaffold was confirmed by SEM and X-ray photoelectron spectroscopy. The histological examination showed a large amount of fibrous tissue and capillary had grown through the pores of the porous scaffold. The inflammatory reaction was not so severe. TNF-α and IL-6 were slightly elevated in the PU scaffold transplanted tissue. However, the concentration levels of the other cytokines were similar between transplanted tissue and normal tissue. The tensile strength was very similar with the beagle’s normal trachea. ConclusionZZThe polyethylene grafted polyurethane scaffold is a good candidate prosthesis for tracheal reconstruction. Korean J Otorhinolaryngol-Head Neck Surg 2012;55:30-6

Tracheoesophageal fistula associated with paracoccidioidomicosis

Paracoccidioidomycosis is a systemic fungal disease caused by Paracoccidioides brasiliensis, agent geographically distributed to certain areas of Central and South America. The infection by P. brasiliensis has been reported from north Mexico to south Argentina. Paracoccidioidomycosis presents similar clinical findings of many other diseases whatever in acute or chronic scenarios. Chronic pulmonary paracoccidioidomycosis is frequently misdiagnosed as malignancy or tuberculosis. The authors present a case of a 57 year-old man admitted to the hospital due to a chronic consumptive syndrome. He underwent anti-tuberculous treatment with rifampin, isoniazid and pyrazinamide 1 year ago without resolution of the simptoms. During the clinical investigation, pulmonary paracoccidioidomycosis with tracheoesophageal fistula was diagnosed. The systemic infection was treated with deoxicolate B amphotericin followed by sulfametoxazole and trimetoprin due to acute renal function impairment. The fistula was endoscopically treated; inittialy with the protection of left main bronchus with a tracheal prosthesis followed by the esophageal fistula’s ostium clipping.

The use of metallic expandable tracheal stents in the management of inoperable malignant tracheal obstruction

Tracheal neoplasms account for less than 1% of all malignancies. In spite of their low incidence, these tumors represent potentially lethal phenomena. In cases of airway compromise and unresectable disease, the airway may be maintained by repeated bronchoscopic debulkings, and the use of CO(2) laser, silicone Montgomery T-tube and tracheal stents. The use of metallic expandable stents to relieve airway obstruction in advanced tracheal tumors was previously reported. Our aim was to evaluate the use of metallic expandable tracheal stents as a palliative relief from severe airway obstruction in cases of locally advanced, inoperable malignant tracheal tumors. Patients suffering from severe airway obstruction secondary to locally advanced tracheal tumors, who presented to the Otolaryngology Head and Neck Surgery and Chest Diseases Departments at the Main Alexandria University Hospital, Egypt, were included in this study. After endoscopic and radiological evaluation, expandable metallic tracheal stents (SENS; Ultraflex tracheal prosthesis; Boston Scientific Corp, Watertown, MA, USA) were inserted under general anesthesia to relieve airway obstruction. Postoperative follow-up with regard to improvement of respiration, tolerability of the stent and reporting of complications was done. Twelve patients were included, eight males and four females with a mean age of 61 years. Four patients (33.3%) had primary tracheal tumors and eight (66.7%) suffered from tumors infiltrating the trachea from nearby structures. The stent was easily inserted in all patients with no significant intraoperative complications. Postoperatively, the stent was well tolerated and all patients experienced good respiration with significant improvement of respiratory function test results. The most common complication reported was granulation tissue formation. Other complications were displacement of the stent, bad breath, re-growth of tumor tissue at the lower end of the stent and retention of secretions. We concluded that Ultraflex self-expandable stent is a good alternative for palliative relief from airway obstruction in cases of inoperable malignant tracheal tumors. Strict follow-up is mandatory for early detection and management of expected complications.