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J Thorac Cardiovasc Surg 2003;126:744-747
© 2003 The American Association for Thoracic Surgery
General thoracic surgery |
a Division of Thoracic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass, USA
Presented in part at the Chest 2002 meeting of the American College of Chest Physicians, San Diego, Calif, Nov 2-7, 2002.
Received for publication December 30, 2002; revisions received February 7, 2003; revisions received February 10, 2003; accepted for publication February 14, 2003.
* Address for reprints: Henning A. Gaissert, MD, Massachusetts General Hospital, Blake 1570, Fruit Street, Boston, MA 02114, USA
hgaissert{at}partners.org
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Abstract |
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METHODS: Between 1997 and 2002, we observed recurrent airway obstruction and extension of benign inflammatory strictures after the placement of tracheobronchial Microvasive Ultraflex stents and Wallstents (Boston Scientific Corp, Natick, Mass), in 10 patients with postintubation strictures and 5 with other indications; all but 1 patient were referred to us. Patients with tracheal (9), subglottic (1), combined tracheal and subglottic (3), and bronchial (2) strictures had been treated with covered and uncovered Wallstents (6) and Microvasive Ultraflex stents (9).
RESULTS: After stent insertion, stricture and granulations within previously normal airway were seen in all patients. New subglottic strictures resulting from the stent caused hoarseness in 4 patients. A bronchoesophageal fistula was found in 1 patient at presentation and a tracheoesophageal fistula in another during extraction of a Wallstent. Primary surgical reconstruction, judged to have been feasible before wire stent insertion in 10 patients, was possible after stenting in only 7 and failed in 2. Palliative tubes were placed in 60% (9/15). Self-expanding metal stents may lengthen luminal damage, incite subglottic strictures, and cause esophagorespiratory fistula in inflammatory airway strictures. The injury is severe, occurs after a short duration of stenting, and precludes definitive surgical treatment or requires more extensive tracheal resection.
CONCLUSION: The current generation of self-expanding metal stents should be avoided in benign strictures of trachea and bronchi.
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Methods |
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Contrast esophagography was used to confirm an esophagorespiratory fistula or to define its location. All patients underwent bronchoscopic examination under general anesthesia. Airway length and condition of the tracheobronchial wall were noted and compared with original endoscopy reports before the first prosthesis. Stent extraction was attempted during endoscopy under general anesthesia unless ingrowth into the tracheal wall precluded safe removal. When endoscopic extraction proved impossible, open removal was achieved through a vertically enlarged tracheostomy. Nearly complete removal of the stent was preferred and sometimes required piecemeal extraction. The stent portion embedded in the membranous wall was left in place to avoid a tracheoesophageal fistula.
The goal of intervention was a stable airway without progression of injury. Surgical reconstruction was deferred until the true extent of airway damage became apparent, even if temporary T-tube stenting was required. When the airway could not be reconstructed by resection, a silicone T-tube or TY-tube was inserted according to methods described elsewhere.4 When an esophagorespiratory fistula was identified, oral intake was discontinued and nutrition was administered through an enteral feeding tube. Definitive repair was performed once pneumonia had resolved and the condition of the patient allowed closure of the fistula.5
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Results |
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Stents were completely or partially extracted in 13 patients. The treatment of 10 patients with lesions that were resectable before stenting is detailed in Figure 1. Of the other 5 patients, 1 patient underwent bronchial resection with closure of an esophageal fistula, 3 patients with unresectable lesions were treated with T- or tracheostomy tubes, and 1 patient underwent evaluation only.
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Discussion |
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Wire mesh prostheses covered with polyvinyl chloride had no advantage because granulations still grew over either end. Purulence is often found causing halitosis. Granulations are probably promoted by bacterial or fungal infection of inflammatory strictures and by placement of stents near the vocal cords. Indeed, 80% of our patients had positive airway cultures. Noppen and associates encountered new airway colonization in 50% of stents, but not clinical infection.11 However, their observation period was short (4 weeks). Exchanging or adding another stent did not relieve symptoms and lengthened the injury, rendering it unresectable. Removal of granulations was followed by their recurrence. A careful review of these prostheses should also include the numerous endoscopic procedures necessary, often at intervals of weeks, to keep the airway open. Complications may have a profound impact on the quality of life. In 5 patients with localized original lesions, endoluminal stenting resulted in the loss of any chance to regain a device-free airway, and in 4 patients hoarseness was caused by a new subglottic stricture.
Curative tracheal resection, predictably successful in original postintubation lesions,12 is technically difficult in these extensive, stent-induced injuries. We are concerned how easily surgical reconstruction is dismissed. Schmidt and associates,13 for example, inserted endoluminal silicone Dumon stents into 39 patients with postintubation injuries over 4 years, roughly 10 patients per year, and did not report tracheal resection. At a referral center for airway disorders, in contrast, we noted an annual rate of only 4 T-tubes (86 over 23 years, many of them temporary)4 and 18 tracheal resections (503 over 27 years) for postintubation strictures.12 In our reported experience of over 500 tracheal resections, the operative mortality was 2.4% and good or excellent results were achieved in 94% patients, including patients with advanced emphysema and heart failure and 18 patients who had previously undergone resection. In light of our experience, an enthusiastic attitude toward endoluminal stents is unfounded and a preference for stents over surgical repair in the absence of true contraindications is not supported by evidence. Tracheal strictures should not be declared unresectable unless evaluated by a surgeon experienced in tracheal reconstruction.
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Acknowledgments |
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