Tracheobronchial Stents Research Articles

気道狭窄に対するラリンゲルマスクを用いたステント留置術の検討

気道ステントは悪性腫瘍による気道狭窄・閉塞の治療に有用な方法であるが，留置時の鎮静法は様々である．我々は，ラリンゲルマスクを用いた全身麻酔下に軟性気管支鏡を用いて気道ステント留置を行っており，その有用性を検討した．2005年6月～2010年11月に気道ステント（soft metallic expandable stent）留置を23症例（28回，33ステント）に行った．男性17例，女性6例，年齢中央値は61歳，原疾患は肺癌14例，食道癌7例，その他2例で，施行時間中央値は21分，麻酔時間中央値は65分であった．麻酔及びステント留置施行中に合併症及び治療関連死亡は認めず，留置後に全例で呼吸困難が改善したが，ステント内腫瘍進展を1例に認めた．悪性腫瘍による気道狭窄・閉塞症に対するラリンゲルマスクを用いた気道内ステントの留置術は，合併症も無く有効な処置であると考えられる．

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.

AB 101. Update on interventional bronchology techniques.

In recent years rapid development of technology led to the increase in number of interventional bronchology techniques available for use in respiratory endoscopy units (REU). Many of techniques are not readily available for routine use in bronchology, however their appliance significantly increases diagnostic and therapeutic efficacy of bronchoscopy. Among diagnostic interventional bronchoscopy techniques recently advanced in REU of the Institute for pulmonary diseases of Vojvodina most facilitating are autofluorescence videobronchoscopy (AFI), narrow band imaging videobronchoscopy (NBI), radial and linear endobronchial ultrasound (EBUS). In recent years REU team published several significant clinical trials in domain of AFI, NBI and EBUS. These techniques became routine diagnostic tools for detection of lung cancer, tuberculosis, sarcoidosis, and other respiratory disorders. Therapeutic interventional bronchoscopy techniques routinely used in treatment of malignant and non-malignant central airway obstruction are Nd:YAG laser resection, argon plasma coagulation, electrocautery, endobronchial brachytherapy, cryotherapy and tracheobronchial stenting. All of the techniques, except of stenting, are readily available for routine use at the REU. Large number of clinical trials in domain of therapeutic interventional pulmonology was in recent years published by the team of REU. Further development and improvement in use of diagnostic and therapeutic interventional pulmonology techniques is required in order to facilitate quality of medical care. Joint clinical trials with partners in EU and other countries would increase the quality of research and publications. Acquisition of more advanced techniques for diagnosis and treatment of respiratory diseases (electromagnetic navigation bronchoscopy, LungPoint virtual bronchoscopic navigation, technology for endobronchial lung volume reduction, bronchial thermoplatsy systems, etc) is one of the priorities of REU team at the Institute for Pulmonary Diseases of Vojvodina.

Anesthesia for Bronchoscopy

Bronchoscopic procedures are at times intricate and the patients often very ill. These factors and an airway shared with the pulmonologist present a clear challenge to anesthesiologists. The key to success lies in the understanding of both the underlying pathology and procedure being performed combined with frequent two-way communication between the anesthesiologist and the pulmonologist. Above all, vigilance and preparedness are paramount. Topics discussed in this review include anesthesia for advanced diagnostic procedures as well as for interventional/ therapeutic procedures. The latter includes bronchoscopic tracheal balloon dilation, tracheobronchial stenting, endobronchial electrocautery, bronchoscopic cryotherapy and other techniques. Special situations, such as tracheoesophageal fistula and mediastinal masses, are also considered.

Numerical analysis of airflow alteration in central airways following tracheobronchial stent placement

The computational fluid dynamics method, which provides an estimation of the pressure drop in the airway before and after the stent implantation, is proposed in this study. This method is based on the finite volume model. The pressure field was solved by the Navier-Stokes equations. The proposed methodology was evaluated in seven health people (control group) and in fourteen patients who were assigned in two groups, in which one was tracheal stenosis and the other was bronchial stenosis. The results showed that the pressure drop after tracheal stent implantation became significantly smaller. For bronchial stent implantation cases, the airway resistance improved insignificantly.

Novel Repair Technique of Transmural Tracheal Lacerations

Objective: 1) Demonstrate a novel method to repair a full thickness tracheal wall laceration. 2) Discuss the relationship of this new technique in regard to current accepted methods of treatment reported in the literature. 3) Learn that full thickness tracheal tears, although rare, are possible following routine tracheal balloon dilation. Method: We review a patient’s case of symptomatic idiopathic subglottic stenosis. One year after initial dilation, balloon dilation was performed and an 8-cm full-thickness tracheal laceration occurred. We report successful repair with a covered tracheobronchial stent and review the literature relating our repair to other accepted techniques. Results: Following tracheal balloon dilation, staying within recommended limits, a complete tear was identified. Using flexible endoscopy and fluoroscopic guidance the tear was measured to be 8 cm. An 80 × 20 mm covered tracheobronchial stent was deployed into position to overlie the area of tracheal disruption. Intraoperative computed tomography demonstrated minimal air extravasation, thus the patient was extubated. The patient’s course was uncomplicated and discharged three days later. Review of current literature demonstrates a variety of repair techniques including soft tissue reconstruction. Our technique is advantageous because it can be done at the time of surgery with excellent outcomes and less morbidity. Conclusion: Endotracheal balloon dilation is an established and safe method to restore airway volume; however full thickness lacerations can occur. This case demonstrates that deployment of an appropriate tracheobronchial stent at the time of surgery is a viable treatment option with low comorbidity. Close postoperative monitoring is vital to successful outcome.

Imaging of central airway stenting with multidetector computed tomography

Imaging of central airway stenting with multidetector computed tomography

Successful esophageal bypass surgery in a patient with a large tracheoesophageal fistula following endotracheal stenting and chemoradiotherapy for advanced esophageal cancer: case report

A 63-year-old man with esophageal achalasia for more than 20 years complained of respiratory distress. He was admitted as an emergency to the referral hospital three months previously. Computed tomography revealed tracheobronchial stenosis due to advanced esophageal cancer with tracheal invasion. He underwent tracheobronchial stenting and chemoradiotherapy. A large tracheoesophageal fistula (TEF) developed after irradiation (18 Gy) and chemotherapy, and he was unable to eat. Thereafter, he was referred to our hospital, where we performed esophageal bypass surgery using a gastric conduit. A percutaneous cardiopulmonary support system was prepared due to the risk of airway obstruction during anesthesia. A small-diameter tracheal tube inserted into the stent achieved ordinary respiratory management. No anesthesia-related problems were encountered. Oral intake commenced on postoperative day 9. He was discharged on postoperative day 23 and was able to take in sustenance orally right up to the last moment of his life. Esophageal bypass under general anesthesia can be performed in patients with large TEF with sufficient preparation for anesthetic management.

EComment. Post-pneumonectomy empyema with bronchopleural fistula

In this article by Andreetti and colleagues [1], the authors described a modification in the implantation of a tracheobronchial stent to exclude a bronchopleural fistula (PBF) by anchoring it to the tracheal mucosal surface using titanium helical fasteners. The conical-shaped, fully-covered and self-expandable stent (Tracheobronxane Silmet, Novatech SA, France) was successfully used in six patients with post-pneumonectomy BPF. Early identification of the BPF and urgent (within few hours of fistula occurrence) endoscopic implantation and anchoring of the Silmet stent ensured excellent results in all patients without distal migration of the stent. What is remarkable in their report is that none of their patients presented with empyema. We would like to ask the authors if they are disposed to implanting the Silmet stent in patients with post-pneumonectomy empyema? Traditionally in the case of post-pneumonectomy empyema, the BPF must be debrided and the bronchial stump closed and reinforced by an intrathoracic transposition of omentum or muscle flaps [2]. However, isolation of the hilar element and identification of the fistula could be difficult due to mediastinal edema and fibrosis. In the latter case, surgical management consists of an open window thoracotomy and involves daily changes of the intracavitary wound dressings over a long period of time. Negative pressure wound therapy (NPWT) such as the vacuum assisted closure (VAC) therapy device (KCI Inc, San Antonio, TX) has been adopted as an alternative method to classic wound dressings, owing to the accelerated wound healing process [3]. VAC promotes healing through the enhancement of granulation tissue formation, the removal of exudates and oedema, increased tissue perfusion and oxygenation, and wound volume reduction [4]. One major drawback in the application of VAC therapy in the thoracic cavity is the presence of air leaks. To ensure adequate functioning of the VAC system placed inside the chest, the deployment of the Silmet stent in case of a large fistula is an appropriate technique to stop air leaks. Passera et al. [5] recently published a case report concerning a patient with a large bronchopleural fistula and empyema. The surgical strategy consisted of an open window thoracostomy, surgical debridement of the bronchial stump and the deployment of an Amplatzer septal occluder device (AGA Medical Corp, Plymouth, MN) to close the BPF. Thereafter, the thoracostomy rapidly and spontaneously closed with VAC therapy. The combination of endoscopic occlusion of the PBF in the setting of post-pneumonectomy empyema (by using the Silmet stent plus anchoring system or Amplatzer septal occluder device) and application of VAC therapy through the open window thoracotomy seems not only to be safe and effective but also appears to accelerate the healing process and reduce the hospital stay. Future studies with larger numbers of patients will be required to validate the efficacy of the procedure and to draw definitive conclusions. Conflict of Interest: None declared

Abstract No. 256: Outcomes of tracheobronchial temporary partial covered stent placement for benign disease

Abstract No. 256: Outcomes of tracheobronchial temporary partial covered stent placement for benign disease

Tracheobronchial Polyflex stents for the management of benign refractory hypopharyngeal strictures

To describe a modified technique for placement of a tracheobronchial self-expanding plastic stent (SEPS) in patients with benign refractory hypopharyngeal strictures in order to improve dysphagia and allow stricture remodeling. A case series of four consecutive patients with complex hypopharyngeal strictures after combined therapy for laryngeal cancer, previously submitted to multiple sessions of dilation without lasting improvement, is presented. All patients underwent placement of a small diameter and unflared tracheobronchial SEPS. Main outcome measurements were improvement of dysphagia and avoiding of repeated dilation. The modified introducer system allowed an easy and technically successful deployment of the tracheobronchial Polyflex stent through the stricture. All four patients developed complications related to stent placement. Two patients had stent migration (one proximal and one distal), two patients developed phanryngocutaneous fistulas and all patients with stents in situ for more than 8 wk had hyperplastic tissue growth at the upper end of the stent. Stricture recurrence was observed at 4 wk follow-up after stent removal in all patients. Although technically feasible, placement of a tracheobronchial SEPS is associated with a high risk of complications. Small diameter stents must be kept in place for longer than 3 mo to allow adequate time for stricture remodeling.

A Case of Successful Natural Stenting in Tracheobronchial Restenosis with Malignant Tumor after Metallic Stenting

Tracheal tumors are very rare disease, which may cause dyspnea, obstructive pneumonia and life-threatening hypoxemia, depending on the site of the lesion and the severity of the narrowing. Such patients frequently die within hours or days due to suffocation. Patients who expressed upper airway stenosis, should be secured the airways prior to the diagnosis and treatment commonly. Then, treatment plan should be determined. For the relief of such stenosis, various modalities of therapy including surgery, laser photoresection, balloon dilatation and sometimes stent insertion have been used. Tracheobronchial stent insertion has been a good therapeutic option in these patients in point of avoiding morbidities associated with surgery. We report a case of repeated tracheobronchial stenosis by infiltrating tumor mass after metallic stent insertion in a 48-year-old man. The patient was treated successfully by Natural stent insertion with rigid bronchoscopy after removal of previous inserted metallic stent.

Summary of the British Thoracic Society Guidelines for advanced diagnostic and therapeutic flexible bronchoscopy in adults

This new guideline covers the rapidly advancing field of interventional bronchoscopy using flexible bronchoscopy. It includes the use of more complex diagnostic procedures such as endobronchial ultrasound, interventions for the...

Is There a Beneficial Role for a Flexible Bronchoscopic Approach to Oesophageal Tumour-related Tracheobronchial Stenosis?

Interventional pulmonology, in particular, tracheobronchial stent insertion, has been well described in the treatment of tracheobronchial malignant disease. Its benefits are particularly obvious in patients with inoperable malignancy or in those unfit for surgery and have been extensively described. Fewer data exist on the benefits of using self-expanding metal stents (SEMS) inserted via flexible bronchoscopy in the treatment of tracheobronchial stenosis due to extrinsic compression or infiltration from primary oesophageal malignancy. We retrospectively reviewed all patients who had stent insertion via flexible bronchoscopy from 2002 to 2010 at our institution. We found 14 patients who had Ultraflex™ self-expanding metal stent insertion for this condition. We analysed this group of patients with respect to their presentation; indications for stent insertion over surgery; size, location, and number of stents inserted; sedative dose; complications of therapy; and survival time. We conclude that insertion of SEMS via flexible bronchoscopy is a safe and effective therapy for those individuals who require palliation or are too unfit for the general anaesthesia required for surgery. Moreover, this form of stent insertion may be performed by respiratory physicians in the bronchoscopy suite, rather than by their cardiothoracic counterparts in theatre.

Use of Venovenous Extracorporeal Membrane Oxygenation Under Regional Anesthesia for a High-Risk Rigid Bronchoscopy

THERE ARE NUMEROUS indications for stent placement in the central respiratory tract. 1 Tonn H. Mall W. Schneider K.D. et al. Tracheobronchial stents: A retrospective analysis of indications, results and in particular complications. Pneumologie. 2008; 62: 611-615 Crossref PubMed Scopus (4) Google Scholar The mobilization or removal of such stents using a rigid bronchoscope may expose patients to potentially severe respiratory complications. Recently, Chen 2 Chen A. ECMO-assisted rigid bronchoscopy for tracheal obstruction. J Bronchol Intervent Pulmonol. 2009; 16: 296-297 Crossref PubMed Scopus (9) Google Scholar reported the use of venoarterial extracorporeal membrane oxygenation (ECMO) during withdrawal of a stent covering the lower part of the trachea and the proximal part of the left mainstem bronchus. The first attempt resulted in almost complete obstruction of the trachea requiring resuscitation maneuvers. After conducting a thorough neurologic assessment of the patient, a 2nd attempt was performed on the following day. In order to ensure adequate oxygenation, the patient was put on venoarterial ECMO support under general anesthesia. The use of venovenous (VV) ECMO support set up under local anesthesia before the administration of general anesthesia in order to prevent oxygenation impairment because of the complexity of managing the airway or as a result of surgical intervention is reported.

VHM04 The Use of Small Caliber Covered Self-Expandable Metal Stents for Palliation of Severe Malignant Dysphagia

Self-expandable covered metal stents provide palliation for malignant dysphagia; however significant complication rates have been associated with currently available large diameter stents. We hypothesized that small caliber fully covered self-expandable metal stents (sccSEMS) would provide adequate palliation of dysphagia in the absence of major complications. Prospective observational study of patients presenting with severe malignant dysphagia from esophageal adenocarcinoma or squamous cell cancer. 38 sccSEMS with internal diameters ranging from 8 mm to 16 mm were placed in 23 patients with pre-stent luminal diameters of < 8 mm (n = 18) or 8-10 mm (n = 5). 8 tracheobronchial stents (shaft diameter 14 – 16 mm), 2 biliary stents (shaft diameter 8 – 10 mm), and 28 specially constructed esophageal stents (shaft diameter 12 – 16 mm) were placed. All stents were placed under direct endoscopic vision without fluoroscopic support. A small caliber pediatric endoscope (diameter 5.5mm) was used to traverse the malignant strictures in cases of near-total esophageal obstruction. The direct endoscopic placement of sccSEMS in patients presenting with severe malignant dysphagia was technically successful in all cases, significantly improved dysphagia scores, provided excellent durability, and resulted in no major complications. These small caliber stents may be viewed as an alternative to currently available stents in patients with severe malignant dysphagia.

Tracheoesophageal fistula due to migration of a self-expanding esophageal stent successfully treated with a silicone “Y” tracheobronchial stent

Tracheoesophageal fistula (TEF) due to erosion of esophageal stents into the trachea has been reported. However, the reported management strategies involve surgical stent removal and TEF repair or endoscopic removal of the esophageal stent followed by re-stenting of the esophagus. We report our successful management of this complication with a silicone Y tracheobronchial stent and without removal of the esophageal stent.

One-lung ventilation in a patient with stenting for tracheobronchial stenosis caused by esophageal cancer

We have provided general anesthesia for a 53-year-old man scheduled to undergo lymph node removal for right mediastinal lymph node metastases caused by esophageal cancer. One year prior, acute respiratory failure occurred because of stenosis of the carinal bifurcation resulting from advanced esophageal cancer with tracheal invasion. The patient underwent placement of tracheobronchial stents (Spiral Z Stent) in two locations (left main bronchus and trachea/right main bronchus), followed by radiotherapy and chemotherapy. In the present case, after an 8.5-mm-ID tracheal tube was placed under bronchoscopic guidance, a 7.0 Fr. bronchial blocker (Arndt Endobronchial Blocker; Cook, Bloomington, IN, USA) was carefully inserted into the stent in the right main bronchus. Next, 3ml air was injected into the blocker cuff, and left-sided one-lung ventilation was performed. After surgery was completed, the bronchial blocker was removed under bronchoscopic guidance. We confirmed there was no tracheobronchial injury nor stent displacement or deformation, then removed the tracheal tube. Even in patients with tracheobronchial stent placement, one-lung ventilation can be safely and reliably performed by selecting an appropriate bronchial blocker, along with careful insertion into the stent and frequent checking of the blocker position.

The use of small-caliber, covered, self-expandable metal stents for palliation of severe malignant dysphagia.

134 Background: Self-expandable covered metal stents are an important component of palliative care for malignant dysphagia; however significant complication rates have been associated with large diameter stents. We hypothesized that small-caliber, fully covered, self-expandable metal stents (sccSEMS) would prove adequate palliation of dysphagia in the absence of major complications. Methods: Prospective observational study of 17 patients presenting with severe malignant dysphagia between 12/1/08 and 7/30/10. 31 sccSEMS with internal diameters ranging from 8 mm to 16 mm were placed in 17 patients with pre-stent luminal diameters of &lt; 8 mm (n = 13) or 8-10 mm (n = 4). 7 tracheobronchial stents (internal diameter 14–16 mm), 2 biliary stents (internal diameter 8–10 mm), and 22 specially constructed esophageal stents (internal diameter 12–16 mm) were placed. All stents were placed under direct endoscopic vision without fluoroscopic support. Dysphagia scores, migration rates, and complications were identified through review of endoscopy reports, outpatient clinical encounters, and 24-hour post-procedure phone surveys. Anticipated stent migration was defined as events which occurred during chemoradiation. Unanticipated stent migration was defined as events which occurred in the absence of treatment. Results: The post-stent median dysphagia score improved (decreased) from 3 to 2 (p = 0.0003). The overall median duration of first stent placement was 64 days, IQR 32 – 110 days. The overall migration rate was 35.5% (11/31). The anticipated migration rate was 60% (9/15); the unanticipated migration rate was 18.2% (2/11) (p = 0.051). All 11 of the migrated stents were retrieved endoscopically without complication. 9.7% (3/31) of patients reported self-limited sore throat or chest pain within 24-hours of stent placement. All 3 patients were managed conservatively without need for narcotic analgesics, hospitalization, or repeat endoscopy. No other complications occurred. Conclusions: The direct endoscopic placement of sccSEMS in patients presenting with severe malignant dysphagia significantly improved dysphagia scores, provided excellent durability, and resulted in no major complications. No significant financial relationships to disclose.

Role of Palliative Tracheobronchial Stenting in Hospice Patients

Lung cancer is the leading cause of cancer mortality and morbidity. Patients with advanced lung cancer have distressful symptoms like dyspnea. It has severe negative impact on the quality of life. Airway stenting has become widespread for palliation of airway stenosis in patients with metastatic airways disease. Although it provides improvement in symptoms, actual survival benefit is limited with severe potential complications. Appropriate patient selection in terms of site of tumor, type of stent placement is needed to achieve maximum benefit for patients. Here we will discuss 2 patients with advanced lung cancer who received bronchial stent for intractable dyspnea. Although there was dramatic improvement in symptoms and quality of life, both died shortly. Was there any benefit of stenting remained unanswered.