Double stenting with silicone and metallic stents for malignant airway stenosis

Hybrid stenting with silicone Y stents and metallic stents in the management of severe malignant airway stenosis and fistulas

Background

Airway stenting is frequently used in the palliative treatment of patients with advanced tumor-induced airway stenosis and fistulas. However, there is paucity of studies regarding the use of airway stents in restoring patency. The aim of the study was to assess the efficacy and safety of hybrid silicon Y stents and covered self-expanding metal stents (SEMS) and in reestablishing patency in airway stenoses and fistulas.

Methods

This retrospective study included 31 patients between January 2016 to December 2019 with inoperable complex malignant airway stenoses and fistulas, managed with Silicone Y stents, and covered SEMS. The clinical details, clinical outcomes and complications up to 6 months were extracted from medical records. The improvement of performance was assessed based on modified British Medical Research Council (mMRC) dyspnea scores (t=6.892, P<0.001), Karnofsky Performance Scores (KPS) (t=-11.653, P<0.001), and performance status (PS) (t=3.503, P<0.001).

Result

A total of 31 silicon Y stents and 35 covered SEMSs were inserted. Of the 31 patients (M:F 20:11; age: 54.64±9.57), 25/31 (80.6%) experienced immediate relief of symptoms following stent placement. Patients' mMRC dyspnea scores, KPS, and PS showed significant improvement following stenting. The mean duration of stent placement was 146.3±47.7 days, and 17/31 (55%) patients were alive at 6 months. No major complications related to hybrid stenting were observed during the follow-up period.

Conclusions

Hybrid stenting is a feasible and safe palliative treatment for malignant airway stenosis and fistulas to improve quality of life and can be performed without major complications.

[Use of Hybrid Stent in Management of Complex Malignant Airway Stenosisand Fistulas]

背景与目的

气道内支架广泛应用于气管狭窄和气管瘘的治疗，但使用气道内支架重建复杂气道的临床数据仍不充足。硅酮支架杂交金属支架重建复杂气道的有效性和安全性。

方法

纳入无法手术的复杂恶性气道狭窄和气道瘘患者。使用Y型硅酮支架联合金属覆膜支架（杂交支架）重建气道。评价置入支架后6个月的疗效和并发症。

结果

共纳入23例患者，置入23枚Y型硅酮支架和25枚金属覆膜支架。19例患者（19/23, 82.6%）置入支架后症状迅速缓解。支架平均置入（153.43±9.14）d。置入支架后改良呼吸困难指数（modified British Medical Research Council, mMRC）、卡氏功能状态（Karnofsky performance status, KPS）评分和功能状态（performance status, PS）评分显著改善。12例患者带支架生存超过6个月。其余患者肿瘤进展导致6个月内死亡。无支架置入相关死亡及严重并发症。

结论

杂交支架重建恶性复杂气道疗效确切，耐受良好。

Management of tracheo-oesophageal fistula in adults

Tracheo-oesophageal fistula (TOF) is a pathological connection between the trachea and the oesophagus that is associated with various underlying conditions including malignancies, infections, inhalation injuries and traumatic damage. As the condition spans multiple organ systems with varying aetiologies and acuities, TOF poses unique diagnostic and management challenges to pulmonologists, gastroenterologists and thoracic surgeons alike. Although stents have been a cornerstone in the management of TOF, there exists a large gap in our understanding of their efficacy and precise methodology, making stenting procedure both art and science. TOFs relating to underlying oesophageal or tracheal malignancies require advanced understanding of the airway and digestive tract anatomy, dimensions of the fistula, stent characteristics and types, and the interplay between the oesophageal stent and the airway stent if dual stenting procedure is elected. In this review article, we review the most up-to-date data on risk factors, clinical manifestations, diagnostic approaches, management methods and prognosis. Consequently, this article serves to evaluate current therapeutic strategies and the future directions in the areas of 3D-printed stents, over-the-scope clipping systems, tissue matrices and atrial septal closure devices.

Preoperative tracheal resection and reconstruction simulations with patient-specific three-dimensional models

Three-dimensional (3D) printers are increasingly being used for a variety of applications. In the surgical field, patient-specific organ models are increasingly being used as preoperative simulators for complicated surgeries. In this study, we describe the use of patient-specific 3D models for tracheal resection. We performed preoperative simulations for two patients diagnosed with tracheal ganglioneuroma and adenoid cystic carcinoma; the mimic operations suggested the necessity of a short cuff intubation tube across the surgical field, indicating the recommended amount of dissection around the trachea and bilateral hilum prior to tracheal reconstruction. The postoperative courses were free from any anastomotic or pulmonary complications. We described the availability of preoperative simulations for complicated tracheal resection and reconstruction using patient-specific 3D printed models. Mimic operations using the 3D printed models allowed accurate preparation and confidence in selection of the optimal surgical strategy.

Clinical Comparison of Airway Stent Placement in Intervention Room and Operating Room

BACKGROUND

Airway stent placement is the effective regimen for central airway obstruction (CAO), while its application scenarios varied. This study aimed to make clinical comparison of airway stent placement in the intervention room and operating room.

METHODS

Patients underwent airway stent placement between 2014 and 2018 were included in this retrospective case-control study. Clinical performance of airway stent placement in intervention room and operating room were compared.

RESULTS

82 patients were included in this study, including 39 in the intervention room and 43 in the operating room. Patients treated in the intervention room had lower Charlson comorbidity index (CCI) (P=0.018) and received less Y-shaped stents (P<0.001). Better clinical response (P=0.026), more stents placed (P<0.001) and longer length of stent (P<0.001) were observed in operating room, while there was no significantly statistical difference of stent-related complications and post-stent survival rate between the two groups. Extracorporeal membrane oxygenation (ECMO) supported airway stent placement procedures were performed in the operating room, which provided definitive safety support for high-risk intervention.

CONCLUSIONS

Patients with CAO could benefit from the operating room scenario, and airway stent placement in the operating room is more suitable for patients with higher CCI scores and receiving more complicated procedures.

Single Y-shaped tracheal self-expandable metallic stent for emergent carinal stenosis combined with stenosis of the right main and intermediate bronchi

To explore the outcome of placing a single Y-shaped tracheal self-expandable metallic stent (SEMS) to treat emergent carinal stenosis combined with stenosis of the right main and intermediate bronchi.The clinical and imaging data of 10 patients (8 males, 2 females) with carinal stenosis combined with stenosis of the right main and intermediate bronchi were retrospectively analyzed. There were 4 patients with esophageal cancer and 6 patients with lung cancer. All patients underwent treatment with a single Y-shaped tracheal SEMS. The long branch was inserted into the right main and intermediate bronchi, while the short branch was inserted into the left main bronchus. A modified Borg scale score was used as the criterion for assessing dyspnea in patients before and after stenting.A total of 10 Y-shaped tracheal SEMSs were successfully placed in 10 patients without any procedure-related complications. Compared with the score before stent placement, the mean Borg score for dyspnea after stent placement decreased from 7.6 to 0.8 (P = .04). Chest computed tomography showed that the stenosis disappeared 3 to 5 days poststenting. During the follow-up period, the most common complications were tumor ingrowth (n = 5) and granulation tissue hyperplasia (n = 7). The mean survival time after tracheal stent placement was 103 ± 50 (23-172) days.The application of a single Y-shaped tracheal SEMS for emergent carinal stenosis combined with stenosis of the right main and intermediate bronchi can effectively relieve dyspnea through a simple operation.

Clinical efficacy of argon plasma coagulation combined with cryotherapy for central airway stenosis caused by lung cancer

BACKGROUND

This study aimed to study the clinical efficacy of argon plasma coagulation plus cryotherapy for central airway stenosis caused by lung cancer.

METHODS

The clinical data of 177 patients with central airway stenosis caused by lung cancer received surgery from June, 2017 to July 2018 were retrospectively analyzed. According to different treatments, 43 patients received cryotherapy were included in the control group, while 134 patients received argon plasma coagulation plus cryotherapy were in the observation group. After propensity score matching, patients in the two groups were in a 1:1 ratio. The Karnofsky score, partial pressure of oxygen (PaO₂), arterial oxygen saturation (SaO₂), partial pressure of arterial carbon dioxide (PaCO₂) and adverse reactions in patients were analyzed one week before and after treatment. Besides, the survival rates of the two groups were compared.

RESULTS

After propensity score matching, the baseline data were not significantly different between the two groups. The post-treatment Karnofsky scores in the two groups were significantly higher than those of before treatment, and the post-treatment score of the observation group was higher than that of the control group (all P < 0.05). The post-treatment PaO₂ and SaO₂ in the observation group were both higher than those of the control group; while the PaCO₂ in the observation group was significantly lower than that of the control group (all P < 0.05). In the observation group, the levels of PaO₂ and SaO₂ were significantly higher, and the level of PaCO₂ was significantly lower after treatment than those of before treatment (all P < 0.05). The rates of completely effective and mild effective in the observation group were significantly higher than those in the control group (both P < 0.05). The incidences of bleeding, arrhythmia and fever in the observation group were significantly lower than those in the control group (all P < 0.05). The survival rate was significantly higher in the observation group (72.09%) than in the control group (51.16%).

CONCLUSIONS

Argon plasma coagulation combined with cryotherapy can significantly alleviate the central airway stenosis caused by lung cancer, reduce the incidence of adverse reactions, and improve prognosis in patients.

Comparison of clinical features and stent placement outcomes between airway stenosis caused by primary pulmonary malignancies and that caused by primary non-pulmonary malignancies

Background:

Primary pulmonary malignancies (PPMs) and non-pulmonary malignancies (PNPMs) may result in airway stenosis requiring stenting. This study aimed to compare and evaluate the clinical features and stent placement outcomes of airway stenosis caused by PPMs and PNPMs.

Methods:

A total of 141 patients with malignant airway stenosis who underwent Micro-Tech stent placements between January 2004 and October 2017 at Department of Respiratory Medicine, Beijing Tian Tan Hospital, Capital Medical University were divided into PPM (n = 100) and PNPM groups (n = 41). Patients’ clinical features and stent placement outcomes were collected and analyzed. Chi-square test was used to compare the categorical variables, while independent- or paired-sample t test was used to compare the continuous variables.

Results:

There were no significant differences in age, sex, treatment history, respiratory symptoms, and incidence of obstructive pneumonia between groups. Multiple airway involvement (63.0% vs. 31.7%; χ² = 11.459, P = 0.001) and atelectasis (17.0% vs. 2.4%; χ² = 5.536, P = 0.019) were more common in the PPM group, while extraluminal obstruction (24.4% vs. 6.0%; χ² = 8.033, P = 0.005) was more common in the PNPM group. Before stenting, the American Thoracic Society Dyspnea Index (ADI) and Karnofsky Performance Scale (KPS) scores showed no significant differences between groups (all P > 0.05). After stenting, a satisfactory rate of symptom improvement was achieved in both groups (98.0% and 100.0% in the PPM and PNPM groups, respectively; χ² = 0.016, P = 0.898); ADI and KPS scores, which showed no significant differences between groups (all P > 0.05), were significantly improved in each group (all P < 0.001). Complications after stenting could be effectively managed using bronchoscopic procedures.

Conclusions:

Among cases of malignant airway stenosis requiring stenting, those caused by PPM are more likely to involve multiple airways and are associated with atelectasis, while those caused by PNPM are more likely to cause extraluminal obstruction. Micro-Tech stent placement has the same immediate effect in terms of improvement in respiratory symptoms and performance status for both malignant airway stenosis caused by PPM and that caused by PNPM.

Clinical assessment of airway stent placement in patients with malignant airway lesions

Background

Airway stent placement has been proven as a satisfactory treatment of advanced malignant airway lesions. However, stent-related complications could impact the therapeutic effect of this treatment. This study aimed to assess the application of airway stents, including the clinical effects, and to explore high-risk factors for stent-related complications.

Methods

A retrospective cohort study of lung cancer (LC) patients and esophageal cancer (EC) patients was conducted at our center. Patients who received stent placement for malignant airway lesions from January 2014 to July 2017 were included in the study. Patient clinical status and stent-related complications, including granulation tissue formation, restenosis, atelectasis, migration, mucous plugging and infection were comprehensively analyzed.

Results

Fifty-six symptomatic patients who underwent 66 stent procedures were included. There was an immediate relief of symptoms after stent placement, and the Karnofsky Performance Status (KPS) scores significantly improved (56.67±23.52 versus 79.05±20.71; P<0.001). Among all the patients, general anesthesia (P=0.038) and pre-stent non-surgical therapy (P=0.048) were risk factors for granulation. A Charlson comorbidity index (CCI) <3 (P=0.008) and a procedure duration time >110 min (P=0.005) were associated with an increased risk of restenosis. Stent placement only in the main trachea (P=0.049) increased the risk of stent migration. Stent placement in the carina or upper airways (P=0.041) increased the risk of mucous plugging. The stent length (>60 mm) had a direct correlation with both mucous plugging in LC patients (P=0.003) and granulation tissue formation in EC patients (P=0.019).

Conclusions

Airway stent placement immediately and significantly improved the clinical symptoms for patients with advanced malignant airway lesions. High-risk factors for different stent-related complications were identified, which provided evidence for further clinical improvement with airway stents.

Initial experience with a 3D printed model for preoperative simulation of the Nuss procedure for pectus excavatum

The incidence of pectus excavatum has been estimated to be between 0.1% and 0.8% though a large autopsy series reports. After publication of the Nuss procedure for pectus excavatum, it became widely accepted. However, there are still some complications, such as over-correction and recurrence. To reduce differences in the procedure due to surgeons' experience level, preoperative simulation may be useful. Thus, we performed simulated surgery using a specific patient's three-dimensional (3D) chest wall model made by a 3D printer before operation. A 13-year-old male patient with a severe deformity of the chest underwent the Nuss procedure. As in the simulation, bars were inserted into the 5^th and 7^th intercostal spaces (ICS), leading to improvement of the chest wall. This simulation can increase surgeons' confidence to improve the deformity by determination of the number and insertion sites of bars.

Three-dimensional (3D) bronchial tree model for bronchial resection with pulmonary segmentectomy

There has been an increase in pulmonary segmentectomy procedures because of increased numbers of individuals with small lung cancer. However, it is difficult to identify the correct bronchus during surgery even with pre-operative three-dimensional (3D) computed tomography. We investigated using a 3D-printed model of the bronchi to prepare for bronchus resection during pulmonary segmentectomy. The model was useful to determine pre-operatively which bronchus should be transected, and being composed of a soft material it could be mobilized similarly to the actual bronchus during surgery. This simulation can increase surgeons' confidence to identify the correct bronchus during pulmonary segmentectomy.