Covered expandable tracheal stents in the management of benign tracheal granulation tissue formation

Radical cystectomy and subsequent ureterohysterostomy in a bitch

OBJECTIVE

To describe and report the outcome of a ureterouterine anastomosis after unilateral dehiscence of a ureterovaginal anastomosis after total cystectomy in a bitch.

STUDY DESIGN

Case report.

ANIMAL

A 10-year-old intact female border collie with a urinary bladder leiomyosarcoma.

METHODS

The dog was diagnosed with an invasive urinary bladder tumor, treated by radical cystectomy and bilateral ureterovaginal anastomosis. Postoperative necrosis of the distal ureter led to dehiscence of the anastomosis on the right side. To preserve the right kidney, the right ureter was anastomosed to the right uterine horn, and a stent was placed across the uterine cervix.

RESULTS

The dog recovered from surgery and regained satisfactory urine output. Both ureteral anastomoses were patent at 10 months postoperatively. At 12 months postoperatively, intraluminal obstruction of the uterine stent, loss of patency of the right ureter, and severe right renal hydronephrosis were noted. The owner declined nephrectomy, and the dog died 2 months later.

CONCLUSION

This is the first published report of a ureterouterine anastomosis and stenting of the uterine cervix in a dog. The functional outcome was satisfactory for 1 year postoperatively. The uterine stent and distal ureter were eventually obstructed by soft tissue.

CLINICAL SIGNIFICANCE

Ureterouterine anastomosis can be considered as a salvage procedure when other surgical techniques have failed.

Indications and interventional options for non-resectable tracheal stenosis

Non-specific presentation and normal examination findings in early disease often result in tracheal obstruction being overlooked as a diagnosis until patients present acutely. Once diagnosed, surgical options should be considered, but often patient co-morbidity necessitates other interventional options. Non-resectable tracheal stenosis can be successfully managed by interventional bronchoscopy, with therapeutic options including airway dilatation, local tissue destruction and airway stenting. There are common aspects to the management of tracheal obstruction, tracheomalacia and tracheal fistulae. This paper reviews the pathogenesis, presentation, investigation and management of tracheal disease, with a focus on tracheal obstruction and the role of endotracheal intervention in management.

Tracheal granulation as a cause of unrecognized airway narrowing

Tracheostomy is one of the most common elective surgical procedures performed in critically ill patients. The most frequent late complication after tracheostomy is the development of granulation tissue, a complication that may cause airway occlusion or result in airway stenosis. We report the successful management of a patient with tracheal granulation presenting as an unrecognised cause of difficulty breathing.

The insertion of self expanding metal stents with flexible bronchoscopy under sedation for malignant tracheobronchial stenosis: a single-center retrospective analysis

OBJECTIVE

To describe a 10-year experience of inserting Ultraflex™ self-expanding metal stents (SEMS) under sedation using flexible bronchoscopy for the treatment of malignant tracheobronchial stenosis in a tertiary referral centre.

METHODS

Medical notes were retrospectively reviewed for all patients who underwent SEMS insertion between 1999 and 2009.

RESULTS

A data analysis of 68 patients who had Ultraflex™ SEMS inserted under sedation was completed. Thirty three males and 35 females with a mean age of 67.9 years (range 35-94) presented with features including dyspnea/respiratory distress (39 patients), stridor (16 patients) and hemoptysis/dyspnea (13 patients). Etiology of stenosis included lung cancer (46 patients) esophageal cancer (14 patients) and other malignancies (8 patients). Mean dose of midazolam administered was 5mg (range 0-10mg). The trachea was the most common site of stent insertion followed by the right and left main bronchus, respectively. Adjuvant laser therapy was applied at some stage in 31% of all cases, and chemotherapy and/or radiotherapy was administered to at least 64% of patients with malignant disease. Hemoptysis and stent migration were the most frequent complications (5 and 4 patients, respectively). The mean survival time of stented non-small cell lung cancer (NSCLC) patients was 214 days (range 5-1233) and that of esophageal malignancy was 70 days (range 12-249). Mean pack-year history of individuals with lung cancer requiring stent insertion was 37 (range 2-100).

CONCLUSION

Ultraflex stents offer a safe and effective therapy for patients who are inoperable or unresectable that otherwise would have no alternative therapy. It has an immediate beneficial effect upon patients, not only through symptom relief but, in some, through prolongation of life. Survival data is no worse than other studies using different varieties of stents and insertion techniques indicating its longer-term efficacy. Moreover, this report highlights the feasibility of performing this procedure successfully in a respiratory unit, without the need for general anesthesia.

Anesthetic considerations for airway stenting in adult patients

The attributable morbidity from central airway obstruction is significant. Airway stenting provides a therapeutic option to manage these complex lesions. This article focuses on the relevant anesthetic considerations of airway stenting in adult patients.

Expandable metal stents as an alternative treatment of cuff-related tracheal stenosis in tracheostomy-dependent ventilated patients: a prospective study of nine cases and description of the complications

BACKGROUND AND AIMS

In long-term intubated patients, cuff-related tracheal injury is occasionally complicated by tracheal stricture. To keep the airway patent, bougienage and deployment of stents are adopted in patients unfit for surgery.

MATERIALS AND METHODS

Prospectively, nine episodes of cuff-related tracheal stricture in nine tracheostomy-dependent ventilated patients were treated with pre-stenting bougienage, followed by implantation of expandable metal stents (EMS). The primary endpoint of this study was the successful discharge of the patients back to the chronic care unit. The other endpoint was the re-treatment rate.

RESULTS

The mean age of the nine patients was 61.7 years. The follow-up period was 18.6 months. The first two patients received a bare stent, and the other seven patients received membrane-coated stents. They all recovered well with successful discharge back to the chronic care unit. There were two episodes of granulation formation in one bare-stent patient and in one coated-stent patient, respectively. In another coated-stent patient, complications arose from a broken stent.

CONCLUSION

EMS appears to have a role to play in tracheostomy-dependent ventilated patients with benign tracheal stenoses in whom there are no other reasonable options.

Do Expandable Metallic Airway Stents Have a Role in the Management of Patients With Benign Tracheobronchial Disease?

BACKGROUND

With increasing availability many centers are deploying expandable metallic stents to manage patients with diverse endobronchial disorders. Although these devices have an important role in malignant disease their usefulness in benign large airway disorders is less defined.

METHODS

Between 1997 and 2005, 31 patients aged 34 to 83 years with benign large airway compromise secondary to tracheomalacia (n = 7), posttracheostomy stricture (n = 8), posttracheostomy rupture (n = 2), postpneumonectomy bronchopleural fistula (n = 2), stricture after lung transplantation (n = 3), lobectomy, tuberculosis, traumatic injury to right main bronchus (n = 1 patient each), and external compression of the airway secondary to achalasia, multinodular goiter, aortic aneurysm, right brachiocephalic artery aneurysm, right interrupted aortic arch, and dissecting aneurysm (n = 1 patient each) who were medically unfit for formal surgical intervention were treated by Ultraflex stent deployment. The range of follow-up was 1 week to 96 months. Stents were deployed under anesthesia using rigid bronchoscopy.

RESULTS

Complications included granulation tissue formation (n = 11) treated with Nd: YAG laser ablation, stent migration (n = 1; stent removed, another deployed), metal fatigue (n = 1), stent removal (n = 1), mucus plugging (n = 2), and halitosis (n = 6) difficult to treat despite antibiotics. Thirteen patients died of unrelated causes between 1 week and 15 months after stent deployment.

CONCLUSIONS

Endobronchial metallic stents should be considered only for selected patients with large airway compromise secondary to benign airway diseases for whom other medical comorbidities contraindicate formal airway surgery. Once deployed, they are difficult to remove, are associated with significant complications, and require prospective bronchoscopic surveillance and often further therapeutic intervention.

Airway management of patients with tracheobronchial stents

The use of tracheobronchial stents for compromised large airways is increasing. We provide a case series highlighting some of the complications of airway management in patients with tracheobronchial stents in situ and propose an approach for dealing with this potentially complicated situation.

Medium-Term Follow-Up After Deployment of Ultraflex Expandable Metallic Stents to Manage Endobronchial Pathology

BACKGROUND

Between March 1997 and March 2004 we deployed 80 Ultraflex metallic expandable stents (Boston Scientific, Waterson, MA) in 69 patients under direct vision using rigid bronchoscopy. We report our medium- to long-term experience in patients for whom these stents were deployed.

METHODS

To date 15 patients have been followed for more than 1 year (median 41 months, range 12 to 83 months) after stent deployment. Indications for stenting in these patients were neoplasia (5), stricture (5), airway malacia (1), iatrogenic tracheal tear (1), and compression from an aortic aneurysm (1), a right interrupted aortic arch (1), and a right brachiocephalic artery aneurysm with tracheomalacia (1). Ten tracheal stents (9 covered, 1 uncovered) and 10 bronchial stents (8 uncovered, 2 covered) were inserted, and 5 patients received two stents.

RESULTS

Five of these patients experienced no long-term problems. Complications included troublesome halitosis (5), which was difficult to treat despite various antibiotic regimes; granulation tissue formation above and below the stent that was successfully treated with low-power Nd:YAG laser therapy (7); and metal fatigue (1). We did not encounter stent migration.

CONCLUSIONS

We conclude that Ultraflex expandable metallic stents have an important role in the management of selected patients with diverse endobronchial pathologies and are well tolerated in the long-term. Although associated granulation tissue can be successfully treated with Nd:YAG laser, halitosis can be a difficult problem to address.

Efficacy and Safety of a Retrieval Hook for Removal of Retrievable Expandable Tracheobronchial Stents

PURPOSE

To evaluate the efficacy and safety of use of a retrieval hook for removal of retrievable expandable tracheobronchial stents.

MATERIALS AND METHODS

With fluoroscopic guidance, a retrieval hook was used to remove 45 retrievable expandable tracheobronchial stents in 31 patients. Indications for stent removal included tissue hyperplasia (n = 16), stent migration (n = 10), stent misplacement (n = 2), tumor overgrowth (n = 2), persistent gastrobronchial fistula (n = 1), and incompletely expanded stent (n = 1). Thirteen stents were electively removed after temporary use. The success rate, causes of failure, and complications related to stent removal with a retrieval hook were analyzed.

RESULTS

Forty-one of 45 stents (91.1%) were successfully removed with a retrieval hook. The following difficulties were encountered: disruption of the polyurethane membrane (n = 3) and an untied drawstring (n = 1). The removal procedure failed in four cases (8.9%) because of excessive tissue hyperplasia (n = 4) in the proximal portion of the stent. The hook wire fractured in two of the four failed cases. The overall complication rate was 4.4% (minor bleeding, n = 2).

CONCLUSION

For complications with or temporary use of retrievable expandable tracheobronchial stents, removal with a retrievable hook shows promising initial results.

Novel approach to management of a posterior tracheal tear complicating percutaneous tracheostomy

We treated a patient who developed a posterior tracheal wall perforation and severe respiratory compromise following percutaneous tracheostomy, using a covered expandable metallic stent. The stent was deployed under direct vision using rigid and fibreoptic bronchoscopy. The defect was sealed and the right lung, which had been collapsed, was re-expanded. The patient was subsequently weaned from mechanical ventilation. Late complications included halitosis, which was treated with nebulized colistin sulphate, and the development of intratracheal granulation tissue, which was cleared using low power (10 W) Nd:YAG laser.

Endoluminal stenting for tracheal stenosis

This prospective clinical study evaluates the role of endoluminal stents in the maintenance of a tracheal lumen after management of stenosis. Tracheal stenosis may be due to a variety of causes, and it is a significant health problem. Most patients either remain tracheostomized for prolonged periods of time or undergo several major surgical interventions. The most common sequel is restenosis at the site of repair either after augmentation or resection anastomosis. In this study, 16 patients with different pathologies causing tracheal stenosis or collapse are presented. All patients had the tracheal lumen re-established either endoscopically or by an open procedure. The stent was then placed to support the site of repair and prevent restenosis. A patent well-epithelialized lumen was achieved in 11 cases with a follow-up of 3-24 months. Complications were encountered in five cases: three misplaced stents, one tracheal erosion with a Dumon stent and one granulomatous obstruction. The technique, complications and follow-up of these patients are described with recommendations for the management of such patients.

Complication of benign tracheobronchial strictures by self-expanding metal stents

OBJECTIVES

Self-expanding metal stents are used to palliate benign strictures. We examined the complications of this approach.

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.

Experience with Ultraflex expandable metallic stents in the management of endobronchial pathology

BACKGROUND

Experience with Ultraflex expandable metallic stents (Micro-invasive, Boston Scientific, Watertown, MA) in the management of endobronchial pathologies leading to airway compromise is reported.

METHODS

Between January 1999 and August 2000, twenty-eight expandable metallic stents were inserted into 25 patients (7 men and 18 women; median age, 65 years) who presented with respiratory distress. Each patient had comorbid medical conditions or end-stage malignancy that precluded formal surgical repair. Seventeen patients had intrinsic airway obstruction, 5 had extrinsic compression, 2 had a tracheal tear, and 1 had a tracheoesophageal fistula. Stents were inserted through a bronchoscope under direct vision. Eighteen patients received tracheal stents alone (1 of these patients received two tracheal stents), and 5 patients received bronchial stents only. Two patients received a tracheal and a bronchial stent. Twenty-one stents were covered and seven were uncovered.

RESULTS

All patients had successful stents with restoration of airway patency and closure of tracheal defects. One patient developed a respiratory infection early after the operation. Follow-up bronchoscopy confirmed satisfactory stent position in each patient. Late complications included sputum retention, halitosis, and granulation tissue formation.

CONCLUSIONS

Ultraflex expandable metallic stents should be considered in the management of airway compromise in selected patients for whom formal surgical repair is inappropriate or contraindicated.