Cutting Balloon Treatment for Resistant Benign Bronchial Strictures: Report of Eleven Patients

Interventional Bronchoscopy

For over 150 years, bronchoscopy, especially flexible bronchoscopy, has been a mainstay for airway inspection, the diagnosis of airway lesions, therapeutic aspiration of airway secretions, and transbronchial biopsy to diagnose parenchymal lung disorders. Its utility for the diagnosis of peripheral pulmonary nodules and therapeutic treatments besides aspiration of airway secretions, however, has been limited. Challenges to the wider use of flexible bronchoscopy have included difficulty in navigating to the lung periphery, the avoidance of vasculature structures when performing diagnostic biopsies, and the ability to biopsy a lesion under direct visualization. The last 10-15 years have seen major advances in thoracic imaging, navigational platforms to direct the bronchoscopist to lung lesions, and the ability to visualize lesions during biopsy. Moreover, multiple new techniques have either become recently available or are currently being investigated to treat a broad range of airway and lung parenchymal diseases, such as asthma, emphysema, and chronic bronchitis, or to alleviate recurrent exacerbations. New bronchoscopic therapies are also being investigated to not only diagnose, but possibly treat, malignant peripheral lung nodules. As a result, flexible bronchoscopy is now able to provide a new and expanding armamentarium of diagnostic and therapeutic tools to treat patients with a variety of lung diseases. This State-of-the-Art review succinctly reviews these techniques and provides clinicians an organized approach to their role in the diagnosis and treatment of a range of lung diseases.

Tuberculous Tracheobronchial Strictures Treated with Balloon Dilation: A Single-Center Experience in 113 Patients during a 17-year Period

PURPOSE

To evaluate the safety and effectiveness of balloon dilation in the treatment of tuberculous tracheobronchial strictures (TTBSs) in a series of 113 patients at a single institution.

MATERIALS AND METHODS

The institutional review board approved the study and waived the requirement to obtain informed consent. Between 1997 and 2014, under bronchoscopic and fluoroscopic guidance, a total of 167 balloon dilation sessions were performed in 113 consecutive patients (14 male and 99 female patients; mean age, 37 years [age range, 17-73 years]), with a range of one to eight sessions per patient (mean, 1.5 sessions). Outcomes were number and/or frequency of balloon dilations, technical success, primary and secondary clinical success, improvement in respiratory status, airway patency rate, and alternative treatment after balloon dilation. A two-tailed paired t test and the Kaplan-Meier method were used to evaluate the improvement in respiratory status and airway patency rate after balloon dilation, respectively.

RESULTS

Dilation was successful in 82 patients (73%) after single (n = 67) or multiple (n = 15) balloon dilations, with a mean follow-up of 30.3 months. Clinical failure occurred in 31 patients (27%). In these 31 patients, symptoms recurred 1 day to 113 months (mean, 13 months) after repeat balloon dilations. These 31 patients required alternative treatment, including temporary stent placement (n = 12), cutting balloon dilation (n = 12), radiation-eluting balloon dilation (n = 3), and surgery (n = 4). Before, immediately after, and 1 month after the procedure, pulmonary function test results showed significant improvements in mean forced vital capacity (P < .001), forced expiratory volume in 1 second (P = .001), forced expiratory flow in the midexpiratory phase (P = .020), and peak expiratory flow (P = .005).

CONCLUSION

Balloon dilation of TTBSs is a safe, minimally invasive primary treatment that relieved symptoms in a large percentage of patients (73%). In patients with TTBSs refractory to balloon dilation, temporary stent placement, cutting balloon dilation, or radiation-eluting balloon dilation can be an alternative treatment.

Fluoroscopically guided balloon dilation for benign bronchial stricture occurring after radiotherapy in patients with lung cancer

PURPOSE

To evaluate the safety and clinical effectiveness of fluoroscopically guided balloon dilation in patients with benign bronchial stricture occurring after radiotherapy (RT).

METHODS

From March 2002 to January 2013, ten patients with benign bronchial stricture occurring after RT underwent fluoroscopically guided balloon dilation as their initial treatment. Technical success, primary and secondary clinical success, improvement in respiratory status, and complications were evaluated. The symptomatic improvement period was calculated.

RESULTS

A total of 15 balloon dilation sessions were performed in ten patients, with a range of 1-4 sessions per patient (mean 1.5 sessions). Technical success was achieved in 100 %. Six of the ten patients exhibited no symptom recurrence and required no further treatment until the end of follow-up (range 4-105 months). Four patients (40 %) experienced recurrent symptom, and two of four patients underwent repeat balloon dilations. The remaining two patients underwent cutting balloon dilation and temporary stent placement, respectively, and they exhibited symptom improvement after adjuvant treatment until the end of our study. Finally, primary clinical success was achieved in six of ten patients (60 %) and secondary clinical success was achieved in eight of ten patients (80 %). The mean symptom improvement period was 61.9 ± 16 months (95 % confidence interval 30.6-93.3).

CONCLUSION

Fluoroscopically guided balloon dilation seems to be safe and clinically effective for the treatment of RT-induced benign bronchial stricture. Temporary stent placement or cutting balloon dilation could be considered in patients with benign bronchial strictures resistant to fluoroscopically guided balloon dilation.

Management of benign tracheal strictures caused by tracheostomy

PURPOSE

To evaluate the clinical efficacy and safety of radiologic management for the treatment of benign tracheal strictures caused by tracheostomy.

MATERIALS AND METHODS

We retrospectively reviewed of 13 patients with benign tracheal stricture caused by tracheostomy that was treated with balloon dilation or stent placement. Balloon dilation had initially been performed. Stent placement was indicated in patients who showed a poor response to balloon dilation. Outcomes were assessed according to the following variables: technical and clinical success, Hugh-Jones classification scale before and after the procedures, and complications.

RESULTS

Balloon dilation and stent placement were technically successful in all patients. Nine of the 13 patients (69 %) showed no response to balloon dilation, and the remaining the four patients showed a positive response to initial balloon dilation. Six of the nine (67 %) patients showed a good response to temporary stent placement and required no further treatment. Mean Hugh-Jones grades improved from 3.6 ± 0.8 to 1.8 ± 1.1 (P < 0.001). During a follow-up period of 2.6-40.8 months (mean 16.5), overall clinical success was achieved in 10 patients (77 %) after a single balloon dilation (n = 4) and temporary stent placement (n = 6). The remaining three patients with clinical failure underwent tracheal resection (n = 3).

CONCLUSION

Radiologic management can be a safe and effective therapeutic option for treating benign tracheal stricture caused by tracheostomy. Temporary stent placement can be effective in patients with symptoms recurring soon after balloon dilation.

Outcome of Treating Airway Compromise due to Bronchial Stenosis with Intralesional Corticosteroids and Cutting-Balloon Bronchoplasty

Objectives. To determine the feasibility, safety, and efficacy of treating benign bronchial stenosis with laryngoscopy, jet ventilation, intralesional corticosteroids, and cutting-balloon bronchoplasty.

Study Design. Case series with planned data collection.

Setting. National airway unit.

Subjects and Methods. Ten adult patients with bronchial stenosis caused by Wegener’s granulomatosis (n = 6), tuberculosis (n = 2), intubation (n = 1), and photodynamic therapy (n = 1) who underwent bronchoplasty using cutting-balloon dilation via suspension laryngoscopy in 2009. Information about patient demography, etiology, lesion characteristics, and details of the interventions were recorded. Patients underwent spirometry before surgery and at last follow-up. Chest infection rate in the 6 months before bronchoplasty and from bronchoplasty to the last follow-up was ascertained.

Results. There were 3 men and 7 women. Mean age at bronchoplasty was 46 ± 20 years. Length of stay was 1 day in all cases, and no treatment-related complications occurred. One patient required a second bronchoplasty at 55 days. Mean follow-up was 7 ± 2.3 months. Forced expiratory volume in 1 second increased from a prebronchoplasty mean of 1.6 ± 0.6 to 2.2 ± 0.5 at last follow-up ( P < .0001; paired Student t test). Forced vital capacity rose from 2.7 ± 0.6 to 3.1 ± 0.6 ( P = .02), and peak expiratory flow rate increased from 3.7 ± 0.8 to 5.0 ± 0.8 ( P < .0001). Chest infection rate fell from an average of 0.7 ± 0.3 infections per month to 0.2 ± 0.2 ( P < .003; paired Student t test).

Conclusion. Cutting-balloon bronchoplasty via suspension laryngoscopy is an effective treatment for benign bronchial stenosis. It is safer than airway stenting and is less invasive than thoracotomy. The authors propose its use as first-line treatment for this condition.

Interventional management of tracheobronchial strictures

Tracheobronchial balloon dilation and stent placement have been well used in the treatment of patients with benign and/or malignant diseases. Balloon dilation is the first option in the treatment of benign airway stenosis. Although balloon dilation is simple and fast, recurrence rate is high. Stent placement promptly relieves acute airway distress from malignant extraluminal and intraluminal airway obstruction. Temporary stent placement may be an alternative for benign airway strictures refractory to balloon dilation. This article reviews the indications, pre-procedure evaluation, technique, outcomes and complications of balloon dilation and stent placement with regard to benign and malignant tracheobronchial stenoses.