Removal of Covered Self-Expandable Metallic Airway Stents in Benign Disorders

Endoscopic Removal of Uncovered Metallic Airway Stents

BACKGROUND

Self-expandable uncovered metallic stents (SEUMS) have been used in benign tracheobronchial stenosis. Stent complications may require risky removal due to SEUMS integration in the tracheobronchial wall. Our study aims to report techniques, including a novel one, and outcomes of SEUMS removal by rigid bronchoscopy.

METHODS

We studied a case series of 7 patients from a tertiary medical center, who underwent SEUMS removal from 2017 to 2022. SEUMS removals were performed through rigid bronchoscopy. We used a new technique with bronchoscopic hook scissors to gradually dissect the stent from the airway wall.

RESULTS

Nine SEUMS were removed from 7 patients. The mean duration of stenting was 7 years (5 to 12 y). Indications for stent removal included mostly recurrent pulmonary infections, obstructive granulation tissue, and stents' fractures. We used the usually described technique in the literature known as the "piecemeal fashion" without dissection in 4 SEUMS removals and a new dissection technique in 5 procedures. We reported one major intraoperative complication using the former technique in the form of tracheal tear with mediastinal breach, while we did not experience any major complications with the later one. One patient died 8 days after surgery from respiratory failure.

CONCLUSION

Dissection and "piecemeal fashion techniques" can be used to remove SEUMS by rigid bronchoscopy even after long-term stenting. SEUMS removal is a very risky procedure and must be performed by a trained operator. Patients should be aware of possible severe complications.

How risky is it to remove an airway stent?

BACKGROUND

Airway stent removal has traditionally been associated with a high complication rate. Most studies on stent removal are over a decade old, prior to newer anti-cancer therapies, and by including non-contemporary and uncovered metal stents, may not reflect the current practices. We review our experience at Mount Sinai Hospital to report outcomes of stent removal with more contemporary practices.

METHODS

A retrospective review was carried out of all the airway stent removals performed between 2018 to 2022, in adult patients with benign or malignant airway diseases. Stents inserted and removal for stent trials for tracheobronchomalacia were excluded from the final analysis.

RESULTS

Forty-three airway stents removals in 25 patients were included. Twenty-five (58%) stents were removed in 10 patients with benign diseases, and 18 (42%) stents were removed in the remaining 15 patients with malignant diseases. Patients with benign disease were more likely to have their stent removed (OR 3.88). 63% of the stents removed were silicone. The most common reasons for stent removal were migration (n = 14, 31.1%) and treatment response (n = 13, 28.9%). Rigid bronchoscopy was used in 86% of cases. Ninety-eight percent of removals were accomplished in a single procedure. The median time to removal of stents was 32.5 days. Three complications were noted: hemorrhage (n = 1, 2.3%) and stridor (n = 2, 4.6%); one not directly related to the stent removal.

CONCLUSIONS

Covered metal or silicone airway stents, in the era of contemporary stents, better cancer-directed therapies and surveillance bronchoscopies, can be removed safely with the use of rigid bronchoscopy.

The strategy of removing tracheal stents by using an interventional technique under fluoroscopy

Background

Tracheal stent implantation is widely used in clinic settings. Timely removal of tracheal stents could prevent or reduce related complications. This study was aimed at evaluating the feasibility and safety of removing tracheal stents by an interventional technique under fluoroscopy.

Methods

Clinical data of patients with self-expanding uncovered tracheal stents removed by an interventional technique under fluoroscopy were analyzed retrospectively, including medical records, imaging findings, surgical records, and follow-up results. According to the type and time of stent placement and the proliferation of granulation tissue under bronchoscopy, different tracheal stent removal techniques were used to remove the tracheal stent under fluoroscopy, and the feasibility and safety of the interventions were analyzed.

Results

In all, 148 tracheal stents were removed from 112 patients; 95.9% (142/148) of the stents were completely removed and 4.1% (6/148) had a small amount of metal residue, and foreign-body forceps were removed under fiber bronchoscopy guidance. In 78 (69.6%), 32 (21.6%), and 6 (5.4%) patients, the tracheal stent was removed by the internal stripping, direct removal, and stent-in-stent methods, respectively. The overall stent removal time ranged from 11 to 111 (28.9 ± 20.1) min. During stent removal, 16 (14.3%) and 13 (11.6%) patients developed mild and moderate complications, respectively. There were no serious complications such as massive hemorrhage, mediastinal fistula, or death.

Conclusions

An interventional technique under fluoroscopy for stent removal is a feasible, safe, and effective method and could serve as a technique for tracheal stent removal in clinical settings.

Biomechanical and functional comparison of moulded and 3D printed medical silicones

Modern 3D printing of implantable devices provides an important opportunity for the development of personalized implants with good anatomical fit. Nevertheless, 3D printing of silicone has been challenging and the recent advances in technology are provided by the systems which can print medical grade silicone via extrusion. However, the potential impacts of the 3D printing process of silicone on its biomechanical properties has not been studied in sufficient detail. Therefore, the present study compares 3D printed and moulded silicone structures for their cytotoxicity, surface roughness, biomechanical properties, and in vivo tissue reaction. The 3D printing process creates increased nanoscale roughness and noticeably changes microscale topography. Neither the presence of these features nor the differences in processes were found to result in an increase in cytotoxicity or tissue reaction for 3D printed structures, exhibiting limited inflammatory reaction and cell viability above the threshold values. On the contrary, the biomechanical properties have demonstrated significant differences in static and dynamic conditions, and in thermal expansion. Our results demonstrate that 3D printing can be used for establishing a better biomechanical microenvironment for the surrounding tissue of the implant particularly for fragile soft tissue like epithelial mucosa without having any negative effect on the cytotoxicity or in vivo reaction to silicone. For engineering of the implants, however, one must consider the differences in mechanical properties to result in correct and personalized geometry and proper physical interaction with tissues.

Y-shaped airway self-expanding covered metallic stent removal via the interventional technique

AIM

To review the removal of Y-shaped airway self-expanding covered metallic stents using the interventional technique under fluoroscopy.

MATERIALS AND METHODS

The clinical data of 33 patients who underwent removal of Y-shaped airway self-expanding covered metallic stents from March 2011 to August 2019 were analysed retrospectively.

RESULTS

A total of 35 Y-shaped stents were removed. The average indwelling duration of the tracheal stents was 101.7 ± 105.4 days. Four cases were removed via the conventional method (grasping the upper tip of the stent to collapse and adduct the proximal end of the stent), whereas 31 cases were removed using the reversal method (grasping the distal end of the stent to invert and strip out the stent). The duration of stent removal was 24.3 ± 12.4 minutes (median time, 20 minutes).

CONCLUSION

The interventional radiology technique is a feasible, safe, and effective method for removing Y-shaped airway self-expanding covered metallic stents, and can be considered for use in the clinical setting.

Long-term outcomes of tracheal stents removal under fluoroscopy guidance: comparison of tracheal fistulas and tracheal stenosis

Background

Endoscopic removal is the most common method for removal of tracheal stents. Few studies have reported the technique of fluoroscopy-guided stent removal for tracheal fistula and tracheal stenosis. We aimed to study the safety and efficacy of fluoroscopy-guided stent removal as well as the optimal duration for stent usage.

Methods

We conducted a retrospective analysis of 152 patients who underwent fluoroscopy-guided stent removal from January 2011 to June 2017. Reasons for stent implantation were tracheal fistula in 85 patients (TF group), and tracheal stenosis in 67 patients (TS group). All patients underwent tracheal CT scans before stent removal and during follow up. The technical success rate, complications, and survival rate were compared between the two groups.

Results

The technical success rate of stent removal was 98.9 and 97.4%, respectively for the TF and TS group. Removal was routine for half of patients, and in the remainder, excessive granulation tissue was the common indications for stent removal, which was found after stenting at 142.1 ± 25.9 days in the TF group, and at 89.9 ± 15.0 day in the TS group. The total incidence of complications was 21.1 and 22.4%, respectively, for the TF and TS groups. Perioperative death occurred in one patient in the TF group, and two patients in the TS group. Recurrence of fistula or stenosis requiring re-stenting was the most comment complication in both groups. The 0.5-, 3-, 6-year survival rates were 90.3, 59.6, and 36.1% for TF group, and 80.4, 75.7, 75.7% for TS group.

Conclusions

Fluoroscopic removal of tracheal stents is safe and effective for both tracheal fistula and tracheal stenosis, with no significant difference in outcomes. Clinicians should pay attention to the risk of hemoptysis for patients with malignant tumors and a combination with endoscopic hemostasis may help improve its safety.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-020-01349-7.

Fluoroscopic removal of self-expandable metallic airway stent in patients with airway stenosis

To study the safety and efficacy of fluoroscopic removal of self-expandable metallic stent for airway stenosis.We conducted a retrospective analysis of 67 consecutive patients, 39 male and 28 female, who underwent fluoroscopic stent removal from March 2011 to April 2017. The patients ranged in age from 12 to 85 years. Seventy-six airway stents were implanted, 70 covered stents and 6 bare stents, including 9 stents for second stent implantation after removal. All patients underwent chest computed tomography scans with/without bronchoscopy before stent removal. The indication of stent removal and postinterventional complications were analyzed retrospectively.Seventy-four of 76 airway stents were successfully removed, only 2 stent showed retained struts after removal, for a technical success rate of 97.4%. Two patients died of complications (1 hemorrhage and 1 respiratory failure), resulting in a clinical success rate of 94.7%. Five stents showed strut fracture and the remaining 71 stents were removed in 1 piece. Indications for stent removal include planned removal (n = 40), excessive granulation tissue (n = 15), intolerance of stenting (n = 6), inadequate expansion and deformation (n = 5), stent migration (n = 5), replacement of bare stent (n = 4), and strut fracture (n = 1). There were 17 complications of stent removal: death from massive bleeding (n = 1), restenosis requires stenting (n = 9), strut fracture or residue (n = 5), dyspnea requires mechanical ventilation (n = 2). The survival rates were 83.8%, 82.1%, and 82.1% for 0.5, 3, and 6 years.Fluoroscopic removal of airway stent is technically feasible and effective. Stents are recommended for removal within 3 months for treating airway stenosis.

A 62-Year-Old Woman With Refractory Wheezing

CASE PRESENTATION

A 62-year-old Hispanic woman, a resident of Puerto Rico, presented with symptoms of chronic cough and shortness of breath for the past 2 years that were slowly and progressively getting worse. She received a diagnosis of asthma on the basis of her history of symptomatic "wheezing" and had been on treatment with inhaled bronchodilators and corticosteroids with minimal symptomatic improvement. The peculiarity of her symptoms was that her dyspnea was worse when she was reclining in bed and she would often hear a "whistling" noise in her throat during those times. Additionally, she reported difficulty swallowing and would often drink water to aid in swallowing food. There was no prior history of endotracheal intubations or surgeries. She denied any history of joint pain, skin rashes, eye pain, hair loss, mouth ulcers, photosensitivity, diarrhea, blood-mixed stool, or blood in the urine.

Long-term follow-up of self-expandable metallic stents in benign tracheobronchial stenosis: a retrospective study

BACKGROUND

Self-expandable metallic stents (SEMSs) have enabled a approving management of malignant airway stenosis. However, the long-term efficacy and safety of this treatment in patients with benign airway stricture are unclear. We conducted this study to retrospectively determine the efficacy and long-term outcomes in patients who have undergone SEMS placement for benign tracheobronchial stenosis.

METHODS

All patients treated with SEMSs from July 2003 to June 2016 were reviewed for symptomatic response, complications, and long-term outcomes.

RESULTS

Total 131 stents were successfully deployed in 116 patients. Ninety-eight patients demonstrated clinical improvement after stent insertion (84.48%; 95% confidence interval [CI]: 77.89-91.07). Compared with uncovered stents, covered stents were associated with more sore throats complaints or chest pain (13.89% versus 28.81%, P = 0.036) and with higher incidences of major and minor granulation tissue formation and with recurrent stenosis (4.17% versus 15.25%, P = 0.029; 11.11% versus 37.29%, P < 0.0001 and 9.72% versus 28.81%, P = 0.005, respectively). Each covered and uncovered stent developing tissue hyperplasia required a median of 2 (range: 1-15) and 1(range: 1-7) fibrobronchoscope with electrocautery therapy, respectively. At follow-up (median: 1276 days; range: 2-4263), 68 patients had complete resolution, 15 remained under interventional treatment, 8 had bronchial occlusions, 7 underwent surgery, 14 were lost to follow-up, and 4 died of stent unrelated causes.

CONCLUSION

SEMS placement achieved most clinical improvement among patients in our study, if adequate endotracheal measures were used to address stent-related complications. The use of permanent SEMSs for benign tracheobronchial stenosis was effective and safe for the majority of patients in a long-term follow-up.

TRIAL REGISTRATION

The study has been retrospectively registered in the China Clinical Trial Registry on October 21, 2018 (Registry ID: ChiCTR1800019024 ).

Metallic stent insertion and removal for post-tracheotomy and post-intubation tracheal stenosis

PURPOSE

To study the safety and effectiveness of fluoroscopic insertion and removal of self-expandable metallic airway stent for post-tracheotomy tracheal stenosis (PTTS) and post-intubation tracheal stenosis (PITS).

METHODS

We conducted a retrospective analysis of 32 patients who underwent fluoroscopic stenting from September 2011 to March 2017. The patients ranged in age from 12 to 69 years. Thirty-eight airway stents were implanted, 35 covered stents and three bare stents. Nineteen airway stents were used for 16 cases of PITS or PTTS. All patients underwent chest CT scans with/without bronchoscopy prior to stent removal. The indication of stent removal and post-interventional complications were analyzed.

RESULTS

All 38 airway stents were successfully inserted. Insufficient expansion and tissue hyperplasia were most common complications after stenting. Thirty five of 38 airway stents were successfully removed fluoroscopically, with a technical success rate of 92.1%. Routine removal was performed after 2.9 ± 0.3 months, and stent restenosis was found after a mean duration of 2.7 ± 0.3 months. There were six complications of stent removal with no death. Four stents showed strut fracture after removal, of which three stent pieces retained. Two patients showed dyspnea immediately after removal and required mechanical ventilation in PTTS. One patient with PTTS lost of follow-up during a mean period of 33.7 ± 3.9 months. The one-, three- and five-year patency rates were 87.1%, 76.2% and 70.8%, respectively. There was no significant difference between PITS and PTTS.

CONCLUSIONS

Fluoroscopic insertion and removal of airway stent is safe and effective for PITS and PTTS. A three-month retention time is reasonable for airway stents.

Evaluating the interaction of a tracheobronchial stent in an ovine in-vivo model

Tracheobronchial stents are used to restore patency to stenosed airways. However, these devices are associated with many complications such as stent migration, granulation tissue formation, mucous plugging and stent strut fracture. Of these, granulation tissue formation is the complication that most frequently requires costly secondary interventions. In this study a biomechanical lung modelling framework recently developed by the authors to capture the lung in-vivo stress state under physiological loading is employed in conjunction with ovine pre-clinical stenting results and device experimental data to evaluate the effect of stent interaction on granulation tissue formation. Stenting is simulated using a validated model of a prototype covered laser-cut tracheobronchial stent in a semi-specific biomechanical lung model, and physiological loading is performed. Two computational methods are then used to predict possible granulation tissue formation: the standard method which utilises the increase in maximum principal stress change, and a newly proposed method which compares the change in contact pressure over a respiratory cycle. These computational predictions of granulation tissue formation are then compared to pre-clinical stenting observations after a 6-week implantation period. Experimental results of the pre-clinical stent implantation showed signs of granulation tissue formation both proximally and distally, with a greater proximal reaction. The standard method failed to show a correlation with the experimental results. However, the contact change method showed an apparent correlation with granulation tissue formation. These results suggest that this new method could be used as a tool to improve future device designs.

Temporary Endobronchial Stent as a Bridge to Corrective Surgery For Severe Kyphoscoliosis-associated Central-Airway Extrinsic Compression

Kyphoscoliosis is known to compromise lung function, with the primary mechanism being reduced chest wall compliance with a resultant restrictive pulmonary physiology. Severe scoliosis can also cause extrinsic compression of the central airways, leading to recurrent respiratory infections, lobar atelectasis, and potentially acute respiratory failure. Definitive therapy is corrective surgery of the spine. However, patients with severe scoliosis are at a potentially high risk of perioperative pulmonary complications. To our knowledge, we report the first successful use of retrievable endobronchial stents as a bridge to corrective surgery for kyphoscoliosis-associated complete central-airway extrinsic compression in a patient who was considered as too high risk for surgical correction due to her respiratory status. After surgery, the stents were removed and our patient experienced sustained improvement in pulmonary function and the clinical respiratory status.

Removal of Self-Expanding Metallic Stents

BACKGROUND

Despite their safety profile, self-expanding metallic stents (SEMS) have been difficult to remove. We aim to describe our experience in removal of SEMS at Henry Ford Hospital with a specific emphasis on safety.

METHODS

We reviewed the charts of all patients who underwent removal of a SEMS at Henry Ford Hospital between 2003 and 2013. We recorded demographic information, indication for initial stent placement, indication for stent removal, time to stent removal, procedure of removal, and any complications.

RESULTS

In all, 19 stents were removed in 16 separate procedures in 14 patients. The median age was 62 years, and 50% of the patients were female. Stents were removed at a median of 35 days (range, 2 to 595 d). No complications occurred in 10/16 (62.5%) procedures. In the remaining 5 patients, complications were not directly related to the stent removal, and serious complications were mostly related to severity of underlying lung disease. Of the 10 procedures done as outpatients, 70% were discharged immediately after the procedure.

CONCLUSIONS

Removal of SEMS can be done safely. Routine postoperative ventilation and intensive care unit monitoring is not required. In the absence of severe underlying lung disease, patients can safely be discharged if there are no immediate postprocedure complications.

Successful adjustment for self-expanding metallic stent migration using a flexible bronchoscope with two biopsy forceps technique

Although tracheobronchial stents are widely used for tracheal obstruction due to malignant or benign stenosis, stent migration has been reported as a major postoperative complication. A self-expandable metallic stent (SEMS) is more easily introduced compared with silicone stents. However, it is also difficult to remove or replace without complications. We report a new technique for successful SEMS adjustment using a flexible bronchoscope with two biopsy forceps.

Fully Covered Metallic Stents for the Treatment of Benign Airway Stenosis

Introduction. We herein report our experience with new fully covered self-expanding metallic stents in the setting of inoperable recurrent benign tracheobronchial stenosis. Methods. Between May 2010 and July 2014, 21 Micro-Tech® FC-SEMS (Nanjing Co., Republic of Korea) were placed in our hospital in 16 patients for inoperable, recurrent (after dilatation), and symptomatic benign airway stenosis. Their medical files were retrospectively reviewed in December 2014, with focus on stent's tolerance and durability data. Results. Twenty-one stents were inserted: 13 for posttransplant left main bronchus anastomotic stricture, seven for postintubation tracheal stenosis, and one for postlobectomy anastomotic stricture. Positioning was easy for all of them. Stents were in place for a mean duration of 282 days. The most common complications were granulation tissue development (35%), migration (30%), and sputum retention (15%). Fifty-five % of the stents (11/20) had to be removed because of various complications, without difficulty for all of them. None of the patients had life-threatening complications. Conclusion. Micro-Tech FC-SEMS were easy to position and to remove. While the rate of complications requiring stent removal was significant, no life-threatening complication occurred. Further studies are needed to better define their efficacy and safety in the treatment of benign airway disease.

Temporary placement of metallic stent could lead to long-term benefits for benign tracheobronchial stenosis

BACKGROUND

The permanent placement of metallic stent for benign tracheobronchial stenosis (BTS) was controversial. This study was conducted to evaluate the long-term outcomes of temporary placement of metallic stent for BTS.

METHODS

The BTS patients who received temporary placement of retrievable self-expanded metallic stents were included between 2008 and 2011. Pre-stenting and follow-up respiratory status was analyzed. And symptom recurrence-free survival (SRFS) was assessed.

RESULTS

A total of 49 stents were successfully temporarily placed in 40 consecutive BTS patients whose etiologies included endobronchial tuberculosis (EBTB) (n=22), post-tracheostomy stenosis (n=10), post-intubation stenosis (n=6) and post radiotherapy stricture (n=2). All stents were removed integrally after a median 18 days' stenting period, without major complications. During the median 27 months follow-up period after stent removal, a total of 22 patients were free of recurrence. And the overall 3-year SRFS rate was 52.0%. According to the etiology, the 3-year SRFS rates were 59.1% and 42.9% in the patients with EBTB and non-EBTB, respectively. Compared with pre-stenting, the follow-up internal diameter of stricture, Hugh-Jones scale, 6-minute walk test (6MWT) and percentage of forced expiratory volume in one second (FEV1%) were significantly improved. Multivariate analysis suggested that granulation tissue growth and tracheobronchial malacia might be independent factors of poor prognosis.

CONCLUSIONS

Temporary placement of retrievable metallic stent may be an alternative treatment for BTS patients.

Management of Postintubational Tracheal Injury by Endoscopic Stent Placement: Case Report and Review of the Literature

Endobronchial stent placement is a novel therapy for treatment of iatrogenic tracheal tears. A review of the available literature shows surgery and long-term intubation being the established treatment strategy.

We describe the case of a 64-year-old woman with a tracheal rupture following endotracheal intubation for routine surgery. Pneumo-mediastinum and chest pain were the predominant symptoms. She was treated with a covered self-expandable metal stent that closed the tear and led to immediate symptom relief. After six weeks and complete healing of the trachea, the stent could be explanted. No stent complications occurred. A new algorithm for the treatment of these ruptures has been proposed.

Complex metallic stent removal: decade after deployment

Endobronchial involvement is a relatively uncommon but well-described presentation in Granulomatosis with polyangiitis (GPA). Self-expandable metallic stents (SEMs) should be reserved for the malignant airway disorder to maintain airway patency, but have been used for benign disease in specific cases. We present a case of longstanding endobronchial GPA with recurrent bronchial stenosis. Three SEMs were deployed in the distal left main bronchus 10 years prior. Two were removed in the standard manner, but the remaining stent SEM was completely embedded in the bronchial mucosa making its removal extraordinarily difficult. We placed an oversized silicone stent inside the stent leading to necrosis of the mucosa allowing for a less formidable removal of the embedded stent. Another silicone stent was temporarily placed. SEMs removal can be extremely complicated and should only be performed by experienced bronchoscopists in an institution with sufficient resources.

Scoliosis and bronchial obstruction

Severe scoliosis may have a significant effect on respiratory function. The effect is most often restrictive due to severe anatomical distortion of the chest, leading to reduced lung volumes, limited diaphragmatic excursion and chest wall muscle inefficiency. Bronchial compression by the deformed spine may also occur but is more unusual. Management options include a conservative approach using bracing and physiotherapy in mild cases, as well as surgical correction of the scoliosis in more severe cases. Bronchial stenting has also been used successfully as an alternative to surgical correction, and in cases in which spinal surgery was either unsuccessful or not feasible. The authors present a case involving a 52-year-old woman who exhibited symptomatic compression of the bronchus intermedius by severe residual scoliosis despite previous corrective surgery. She was treated with an indwelling bronchial stent.

Tracheobronchial stenting

Airway stenting can be a life-preserving intervention in patients with critical airway obstruction. It may be safely performed using flexible bronchoscopy under conscious sedation as a day-case procedure in selected patients, but a high incidence of complications limits its use to palliation of malignancy or bridging treatment in benign disease.

Mechanical properties of different airway stents

Airway stents improve pulmonary function and quality of life in patients suffering from airway obstruction. The aim of this study was to compare main types of stents (silicone, balloon-dilated metal, self-expanding metal, and covered self-expanding metal) in terms of their mechanical properties and the radial forces they exert on the trachea. Mechanical measurements were carried out using a force gauge and specially designed adaptors fabricated in our lab. Numerical simulations were performed for eight different stent geometries, inserted into trachea models. The results show a clear correlation between stent diameter (oversizing) and the levels of stress it exerts on the trachea. Compared with uncovered metal stents, metal stents that are covered with less stiff material exert significantly less stress on the trachea while still maintaining strong contact with it. The use of such stents may reduce formation of mucosa necrosis and fistulas while still preventing stent migration. Silicone stents produce the lowest levels of stress, which may be due to weak contact between the stent and the trachea and can explain their propensity for migration. Unexpectedly, stents made of the same materials exerted different stresses due to differences in their structure. Stenosis significantly increases stress levels in all stents.

Serious Complications after Self-expandable Metallic Stent Insertion in a Patient with Malignant Lymphoma

An 18-year-old woman was evaluated for a chronic productive cough and dyspnea. She was subsequently diagnosed with mediastinal non-Hodgkin lymphoma (NHL). A covered self-expandable metallic stent (SEMS) was implanted to relieve narrowing in for both main bronchi. The NHL went into complete remission after six chemotherapy cycles, but atelectasis developed in the left lower lobe 18 months after SEMS insertion. The left main bronchus was completely occluded by granulation tissue. However, the right main bronchus and intermedius bronchus were patent. Granulation tissue was observed adjacent to the SEMS. The granulation tissue and the SEMS were excised, and a silicone stent was successfully implanted using a rigid bronchoscope. SEMS is advantageous owing to its easy implantation, but there are considerable potential complications such as severe reactive granulation, stent rupture, and ventilation failure in serious cases. Therefore, SEMS should be avoided whenever possible in patients with benign airway disease. This case highlights that SEMS implantation should be avoided even in malignant airway obstruction cases if the underlying malignancy is curable.

Use of lung-preserving surgery in left inflammatory bronchial occlusion and distal atelectasis: preliminary results

OBJECTIVES

Lung-preserving surgery was proved to be effective and safe to treat patients with benign bronchial strictures. However, this surgical treatment has been rarely reported in patients with complete occlusion in the left main bronchus. The aim of this study was to assess the value of this procedure and report our experience in the treatment of these patients with left atelectasis caused by inflammatory bronchial occlusion.

METHODS

We reviewed and analysed the medical records of 8 patients who had undergone left main bronchus sleeve resection for symptomatic left atelectasis caused by inflammatory bronchial occlusion from May 2007 to April 2011.

RESULTS

Eight patients (3 men and 5 women) with a medical history of active pulmonary tuberculosis were involved in this study. The median age was 23 years. Parenchyma-sparing left main bronchus resection was performed in 4 patients, 1 of whom received partial wedge resection in the lingual lobe. Left main bronchus sleeve resection plus superior lobectomy was performed in 2 patients and left main bronchus sleeve resection plus left inferior lobectomy in 2 patients, 1 of whom received additional partial wedge resection of the lingual lobe. The procedure was completed successfully in all 8 patients without postoperative deaths. The mean follow-up time was 49.3 months, ranging from 23 to 69 months. No major complications, including stenosis and atelectasis, were observed during the follow-up period. The symptoms of pulmonary atelectasis disappeared and pulmonary ventilation function improved significantly.

CONCLUSIONS

In symptomatic patients with left atelectasis caused by inflammatory bronchial occlusion, lung-preserving surgery is an effective and safe surgical treatment.

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.

Bronchoscopic management of malignant airway obstruction

Approximately one-third of patients with lung cancer will develop airway obstruction and many cancers lead to airway obstruction through meta stases. The treatment of malignant airway obstruction is often a multimodality approach and is usually performed for palliation of symptoms in advanced lung cancer. Removal of airway obstruction is associated with improvement in symptoms, quality of life, and lung function. Patient selection should exclude patients with short life expectancy, limited symptoms, and an inability to visualize beyond the obstruction. This review outlines both the immediate and delayed bronchoscopic effect options for the removal of airway obstruction and preservation of airway patency with endobronchial stenting.

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.

Self-expanding Y stents in the treatment of central airway stenosis: a retrospective analysis

BACKGROUND

Central airway obstruction (CAO) is a life-threatening situation. Stent insertion re-establishes patency of the central airways. Self-expanding metallic Y stents have been available since 2005, widening the spectrum of interventional bronchoscopic techniques.

METHODS

Retrospective analysis of all patients treated for CAO with a self-expanding metallic Y stent at the Thoraxklinik Heidelberg between May 2005 and January 2009.

RESULTS

A total of 43 patients aged 26-81 had a metallic Y stent inserted endoscopically for the treatment of CAO; 39 of these patients (90.7%) had CAO due to malignant disease, four patients (9.3%) due to benign disease. In all 43 patients, the Y stent was deployed without any complications. A longitudinal follow up was possible in 32 of the 43 patients. The stents remained in situ for an average of 107.1 days (range 1-640 days). In 29 patients with malignant CAO the stenosis was successfully overcome with a Y stent; 11 of these patients died within 6 weeks following stent insertion. On follow up the remaining 18 patients showed immediate improvement of dyspnoea. Eight out of the 18 patients (44.4%) tolerated the stent without problems, two (11.1%) required further stenting, six (33.3%) had complications such as increased secretions, cough, dyspnoea or granulation tissue formation. The stent was removed in one patient (5.6%) due to increased secretions, and in another (5.6%) as the stent was no longer required due to successful tumour-specific therapy.

CONCLUSION

Placement of Y stents in symptomatic CAO allows for quick relief of symptoms. Severe complications are rare. Stent removal is possible after successful treatment of the primary tumour. However, the prognostic indicator for survival is the underlying malignancy.

Removal of self expandable metallic airway stent: A rare case report

Covered self expandable metallic airway stents (SEMS) have been used for benign tracheal stenosis, post intubation tracheal stenosis, tracheal burn or trauma, tracheo-broncho-malacia, and extrinsic compression of trachea. Their placement is considered to be permanent, with open surgery the only way to remove the stent, though there are few cases reports of their removal with the bronchoscope, but the complications after their removal are very high. In our patient, one and a half years after placement of SEMS, she developed cough with dyspnoea, video bronchoscopy showed stenosis above the level of stent with granulation tissue inside the stent, stent fracture in lower part and stent migration to right main bronchus, thus she had all conceivable complications of stent placement. The stent was removed with the help of rigid bronchoscope under general anaesthesia. She was discharged the following day. The case is being reported because it was unique in having all the possible complications of stent placement, and rare as we could take out the stent in Toto. Thirdly, the stent could be removed without any complication.

Tracheobronchial amyloidosis treated by endobronchial laser resection and self expanding Y stent

Amyloid deposition in tracheobronchial tree is a rare presentation and counts about 1% of benign tumors in this area. Herein, we describe a case of primary tracheobronchial amyloidosis which obstructed almost completely the distal trachea and the main left bronchus. The mass was successfully resected by mechanical resection and Nd-YAG laser coagulation during rigid bronchoscopy. Afterwards, a self-expanding Y-stent of new generation was inserted to restore airway patency. Five months later, radiological and bronchoscopic findings showed the stent in site, with normal patency of the tracheo-bronchial tree.

An instant rare complication: a fractured metallic pyloric stent

Metallic pyloric stenting (also termed as metallic enteral stenting) performed endoscopically, stands as first-line treatment for malignant gastric outlet obstruction. With reported evidence, these self-expandable metallic stents (SEMS) re-enable oral food intake, preventing patients having to face invasive techniques such as surgical gastroenterostomy. We report a patient having received a covered pyloric SEMS insertion following a tumour growth causing stenosis in the gastric antropyloric region. After 3 weeks, the patient presented with a fracture of the pyloric SEMS, a rare complication, resulting in a second pyloric SEMS insertion.

Successful removal of expandable metallic stent in a patient with lung cancer

A 64-year-old man, who had received chemoradiation therapy for stage IIIB non-small-cell lung cancer, underwent stent insertion with a covered expandable metallic stent for post-radiation bronchial stenosis. Stenosis due to formation of granulation tissue at the distal stent site resulted in critical respiratory failure. The stent was removed after 43 months, using rigid bronchoscopy.

An outcome analysis of self-expandable metallic stents in central airway obstruction: a cohort study

BACKGROUND

Self-expandable metallic stents (SEMSs) have provided satisfactory management of central airway obstruction. However, the long-term benefits and complications of this management modality in patients with benign and malignant obstructing lesions after SEMS placement are unclear. We performed this cohort study to analyze the outcomes of Ultraflex SEMSs in patients with tracheobronchial diseases.

METHODS

Of 149 patients, 72 with benign and 77 with malignant tracheobronchial disease received 211 SEMSs (benign, 116; malignant, 95) and were retrospectively reviewed in a tertiary hospital.

RESULTS

The baseline characteristics of patients who received SEMS implantation for benign conditions and those who underwent implantation for malignant conditions were significantly different. These characteristics included age (mean, 63.9 vs. 58; p < 0.01), gender (male, 62% vs. 90%; p < 0.0001), smoking (47% vs. 85%; p < 0.0001), forced expiratory volume in 1 second (mean, 0.9 vs. 1.47 L/s; p < 0.0001), follow-up days after SEMS implantation (median; 429 vs. 57; p < 0.0001), and use of covered SEMS (36.2% vs. 94.7%; p < 0.0001). Symptoms improved more after SEMS implantation in patients with benign conditions than in those with malignant conditions (76.7% vs. 51.6%; p < 0.0001). The overall complication rate after SEMS implantation in patients with benign conditions was higher than that in patients with malignancy (42.2% vs. 21.1%; p = 0.001). Successful management of SEMS migration, granulation tissue formation, and SEMS fracture occurred in 100%, 81.25%, and 85% of patients, respectively.

CONCLUSIONS

Patients who received SEMS implantation owing to benign conditions had worse lung function and were older than those who received SEMS for malignancies. There was higher complication rate in patients with benign conditions after a longer follow-up period owing to the nature of the underlying diseases.

Update in airway stents

PURPOSE OF REVIEW

Malignant central airway obstruction heavily impacts patients' quality of life and its management continues to be a challenge. The current article will review the use of airway stents in this population.

RECENT FINDINGS

Airway stenting is highly effective in palliating symptoms of airway obstruction. There are several types of stents available with different advantages and disadvantages depending mainly on the material they are made from. Clinical outcomes seem to be comparable between silicone and self-expanding metal stents. Self-expanding metal stents have proven to be efficient in recanalizing 'complex' central airway obstructions. Preliminary data show that a new self-expanding 'hybrid' stent appears to be effective and safe for malignant airway obstruction. Airway stent complications vary according to the type of stent and the type of obstruction. Multidetector computed tomography seems to be a valuable adjunct to bronchoscopy in detecting and characterizing stent complications. A clear definition of airway stent-related infection is urgently needed to provide adequate diagnosis and management of this complication. Metal stent fracture is less common in patients with malignant airway obstruction as compared with benign disease, and this could be partially explained by the decreased survival and shorter exposure to stent in the former population.

SUMMARY

Airway stents are of great help in palliating symptoms of malignant central airway obstruction. Unfortunately, there have been no recent striking advances in stent technology and the ideal stent has yet to be designed.

Removal of metallic tracheobronchial stents in lung transplantation with flexible bronchoscopy

Background

Airway complications are among the most challenging problems after lung transplantation, and Self-Expandable Metallic Stents (SEMS) are used to treat airway complications such as stenosis or malacia at the bronchial anastomosis sites. Several transplantation centers are reluctant to use SEMS since their removal is sometimes needed and usually requires the use of rigid bronchoscopy under general anesthesia. The objective of the current report is to describe our experience in SEMS retrieval by flexible bronchoscopy under conscious sedation.

Methods

A retrospective review was done of patients requiring tracheobronchial stent placement after lung transplantation in which the SEMS had to be removed. The retrieval procedure was done by flexible bronchoscopy on a day-care ambulatory basis.

Results

Between January 2004 and January 2010, out of 305 lung transplantation patients, 24 (7.8%) underwent SEMS placement. Indications included bronchial stenosis in 20 and bronchomalacia in 4. In six patients (25%) the SEMS had to be removed due to excessive granulation tissue formation and stent obstruction. The average time from SEMS placement to retrieval was 30 months (range 16-48 months). The stent was completely removed in five patients and partially removed in one patient; no major complications were encountered, and all patients were discharged within 3 hours of the procedure. In all procedures, new SEMS was successfully re-inserted thereafter.

Conclusions

The retrieval of SEMS in patients that underwent lung transplantation can be effectively and safely done under conscious sedation using flexible bronchoscopy on a day-care basis, this observation should encourage increasing usage of SEMS in highly selected patients.