Management of airway involvement of oesophageal cancer using covered retrievable nitinol stents

CIRSE Standards of Practice on Placement of Upper Gastrointestinal Stents

BACKGROUND

Image-guided insertion of stents in the upper gastrointestinal trunk is an effective, minimally invasive treatment option to provide immediate relief of symptoms caused by upper gastrointestinal tract obstruction related to advanced-stage malignant causes or benign causes that lead to lumen narrowing.

PURPOSE

This document, as with all CIRSE Standards of Practice documents, is not intended to impose a standard of clinical patient care but will recommend a reasonable approach to best practices for performing stenting of the upper gastrointestinal tract, namely the oesophageal and gastroduodenal segments. Our purpose is to provide up-to-date recommendations for placement of upper gastrointestinal tract stents based on the previously published guidelines on this topic in 2005 and 2007.

METHODS

The writing group was established by the CIRSE Standards of Practice Committee and consisted of a group of internationally recognised experts in performing upper gastrointestinal stenting. The writing group reviewed the existing literature using PubMed to search for relevant publications in the English language up to September 2021. The final recommendations were formulated through consensus.

CONCLUSION

Insertion of stents in the oesophageal and gastroduodenal tracts has an established role in the successful management of malignant or benign obstructions. This Standards of Practice document provides up-to-date recommendations for the safe performance of upper gastrointestinal stent placement.

Retrograde Radiological Gastrostomy Technique and Retrograde Stent Placement in a Completely Occluded Cervical Esophagus

Malignant obstruction of the cervical esophagus presents some anatomical and technical challenges when considering radiologic or endoscopic intervention. This case report describes the failure of antegrade access to place a gastrostomy tube and stent due to complete luminal occlusion from an esophageal tumor. The ultrasound-guided percutaneous gastric puncture was performed to achieve retrograde pneumodistension to allow radiologic gastrostomy insertion. Subsequently, the cervical esophagus was retrogradely cannulated via insertion of a guidewire from the gastrostomy site. A distal release esophageal stent was then inserted over the wire and deployed from the mouth in an antegrade manner.

However, due to the unpredictable proximal shortening of distal release stents, this stent was eventually shortened and displaced so that it no longer covered the top of the tumor stricture, and further antegrade access failed. Once more, a retrograde access approach was adopted via the gastrostomy stoma, a guidewire and catheter were passed retrogradely through the original stent and out through the mouth. A distal release stent system was then inserted in a retrograde manner via the gastrostomy stoma, effectively making it a proximal release stent which enabled more precise positioning of the stent above the tumor. Palliation was achieved until death, and beyond expected mean survival.

3D printing for tissue engineering in otolaryngology

Airway and other head and neck disorders affect hundreds of thousands of patients each year and most require surgical intervention. Among these, congenital deformity that affects newborns is particularly serious and can be life-threatening. In these cases, reconstructive surgery is resolutive but bears significant limitations, including the donor site morbidity and limited available tissue. In this context, tissue engineering represents a promising alternative approach for the surgical treatment of otolaryngologic disorders. In particular, 3D printing coupled with advanced imaging technologies offers the unique opportunity to reproduce the complex anatomy of native ear, nose, and throat, with its import in terms of functionality as well as aesthetics and the associated patient well-being. In this review, we provide a general overview of the main ear, nose and throat disorders and focus on the most recent scientific literature on 3D printing and bioprinting for their treatment.

Self-expandable metal stent for malignant esophagorespiratory fistula: predictive factors associated with clinical failure

BACKGROUND AND AIMS

Malignant esophagorespiratory fistulas (MERFs) usually are managed by the placement of self-expandable metal stents (SEMSs) but with conflicting results. This study aimed to identify risk factors associated with clinical failure after SEMS placement for the treatment of MERFs.

METHODS

This was a retrospective analysis of a prospectively maintained database used at a tertiary-care cancer hospital, with patients treated with SEMS placement for MERFs between January 2009 and February 2016. Logistic regression was used to identify predictive factors for clinical outcomes and to estimate the odds ratio (OR) and the 95% confidence interval (CI). The Kaplan-Meier method was used for survival analysis, and comparisons were made by using the log-rank test.

RESULTS

A total of 71 patients (55 male, mean age 59 years) were included in the study, and 70 were considered for the final analysis (1 failed stent insertion). Clinical failure occurred in 44% of patients. An Eastern Cooperative Oncology Group (ECOG) performance status of 3 or 4 and fistula development during esophageal cancer treatment were associated with an increased risk of clinical failure. ECOG status of 3 or 4, pulmonary infection at the time of SEMS placement, and prior radiation therapy were predictive factors associated with lower overall survival. Dysphagia scores improved significantly 15 days after stent insertion. The overall stent-related adverse event rate was 30%. Stent migration and occlusion caused by tumor overgrowth were the most common adverse events.

CONCLUSION

SEMS placement is a reasonable treatment option for MERFs; however, ECOG status of 3 or 4 and fistula development during esophageal cancer treatment may be independent predictors of clinical failure after stent placement.

Serial Analysis of Tracheal Restenosis After 3D-Printed Scaffold Implantation: Recruited Inflammatory Cells and Associated Tissue Changes

Tracheal restenosis is a major obstacle to successful tracheal replacement, and remains the greatest challenge in tracheal regeneration. However, there have been no detailed investigations of restenosis. The present study was performed to analyze the serial changes in recruited inflammatory cells and associated histological changes after tracheal scaffold implantation. Asymmetrically porous scaffolds, which successfully prevented tracheal stenosis in a partial trachea defect model, designed with a tubular shape by electrospinning and reinforced by 3D-printing to reconstruct 2-cm circumferential tracheal defect. Serial rigid bronchoscopy, micro-computed tomography, and histology [H&E, Masson's Trichrome, IHC against α-smooth muscle actin (α-SMA)] were performed 1, 4, and 8 weeks after transplantation. Progressive stenosis developed especially at the site of anastomosis. Neutrophils were the main inflammatory cells recruited in the early stage, while macrophage infiltration increased with time. Recruitment of fibroblasts peaked at 4 weeks and deposition of α-SMA increased from 4 weeks and was maintained through 8 weeks. During the first 8 weeks post-transplantation, neutrophils and macrophages played significant roles in restenosis of the trachea. Antagonists to these would be ideal targets to reduce restenosis and thus play a pivotal role in successful tracheal regeneration.

Management of Post-traumatic Laryngotracheal Stenosis: Our Experience

To describe our experience in management of post-traumatic laryngo-tracheal stenosis by study of various surgical methods. To compare our results with different studies. To find out best surgical procedure. Retrospective study. 13 patients of LTS were analyzed within the period of 2009-2013 highlighting the important causes of stenosis, management based on type and severity of stenosis and outcome following the treatment given. Cases were diagnosed in detail with help of flexible laryngoscopy. Finer details of stenosis like site, length, associated injuries were studied with help of CT scan. Various modalities of treatment were used and outcome was assessed. There were 13 patients 9 males and 4 females. Of these 54 % had iatrogenic stenosis and 46 % had traumatic stenosis. 46 % had true stenosis, remaining cases suffered from either soft stenosis or had associated injuries rendering the stenosis as a complex one. The patients underwent a combined surgical approach which included treatment modalities like T-tube insertion, endoscopic dilatation, laser, and open surgical intervention (tracheal resection and anastomosis). Of all the patient treated 69.2 % were successfully decannulated and recovered well with a satisfactory airway outcome, (23.07 %) cases remained T-tube dependent, 8 % case died due to septicemia. It was evident that prolonged intubation remained most common cause of tracheal stenosis and the management varied depending on the type of stenosis. Simple soft stenosis could be managed well by endoscopic dilatation and laser while complete, complex stenosis required surgical intervention in form of T-tube stenting or open surgical intervention. Tracheal stenosis is a life threatening complication and difficult to manage. It requires multiple approaches and the successful outcome is assessed by patent airway and voice quality.

The use of self-expandable metallic stents in the airways in the adult population

The airway stents restore patency in the face of luminal compromise from intrinsic and/or extrinsic pathologies. Luminal compromise beyond 50% often leads to debilitating symptoms such as dyspnea. Silicone stents remain the most commonly placed stents worldwide and have been the "gold standard" for the treatment of benign and malignant airway stenoses over the past 20 years. Nevertheless, silicone stents are not the ideal stents in all situations. Metallic stents can serve better in some selected conditions. Unlike silicone stents, there are large and increasing varieties of metallic stents available on the market. The lack of prospective or comparative studies between various types of metallic stents makes the choice difficult and expert-opinion based. International guidelines are sorely lacking in this area.

Tracheal stenosis: our experience at a tertiary care centre in India with special regard to cause and management

Tracheal stenosis (TS), a challenging problem, is a known complication of prolonged intubation and tracheostomy. The management involves a multidisciplinary approach with multiple complex procedures. In this study we discuss our experience with severe TS with regards to patient characteristics, cause and management. A retrospective analysis of 20 patients of severe TS treated at a tertiary care centre was evaluated. Inclusion criteria were all patients with severe TS who required surgical intervention. Exclusion criteria were patients with associated laryngeal stenosis and TS due to cancer. Demographic data was recorded and findings relating to aetiology, characteristics of stenosis and the various aspects of therapeutic procedures performed are discussed with review of literature. Descriptive analysis of data were performed SPSS 18. Results of the 20 patients, 17 patients (85 %) developed TS post tracheostomy, or post intubation and subsequent tracheostomy. 13 Patients (65 %) had true stenosis of which 7 patients (35 %) had simple web or circumferential fibrosis and 6 patients (30 %) had complex stenosis. Seven patients (35 %) had granulations causing severe TS which were mostly suprastomal (5 patients), stomal (5 patients) and combined stomal and suprastomal (3 patients). The average length of stenosis was 3.57 cm (0.5-8 cm). Montgomery t tube insertion was a common procedure in 18 patients (90 %) pre or post intervention. Each patient underwent an average of 3.4 procedures during their course of treatment which included rigid bronchoscopy and mechanical debulking, Nd YAG laser, KTP laser, balloon dilatation and use of stents. Among the 7 patients with granulations 100 % successful decanulation was noted with endoscopic management whereas in 13 patients with true stenosis, 10 patients (76.9 %) required open surgical management (8 tracheal resection and anastomosis and 2 tracheoplasty) with 80 % successful decanulation, 2 patients (15.4 %) were treated with endoscopy with 100 % successful decanulation and 1 patient (7.7 %) was a non surgical candidate on stent. Of the total 20 patients with severe TS in this series, 17 (85 %) of patients who were decanulated, asymptomatic on routine daily activities with normal FFB were considered cured. TS is a challenging condition requiring a highly skilled multidisciplinary team for adequate management. Prolonged intubation and tracheostomy are the common causes leading to tracheal stenosis. Simple tracheal stenosis is easier to manage than a complex stenosis which usually requires an open surgical procedure for successful management. Presence of conditions like tracheoesophageal fistula and long segment tracheomalacia are poor factors for successful management. In our cases successful decanulation was possible in 85 % of the patients following a systematic multidisciplinary approach.