Metallic stent placement for the management of tracheal carina strictures and fistulas: technical and clinical outcomes

Self-Expandable Metal Stent in the Management of Malignant Airway Disorders

Background

Self-expanding metallic stent (SEMS) is a palliative therapy for patients with malignant central airway obstruction (CAO) or tracheoesophageal fistula (TEF). Despite this, many patients experience death shortly after SEMS placement.

Aims

We aimed to investigate the effect of SEMS on the palliative treatment between malignant CAO and malignant TEF patients and investigate the associated prognostic factors of the 3-month survival.

Methods

We performed a single-center, retrospective study of malignant CAO or TEF patients receiving SEMS placement. Clinical data were collected using the standardized data abstraction forms. Data were analyzed using SPSS 22.0. A two-sided P-value <0.05 was statistically significant.

Results

106 malignant patients (82 CAO and 24 TEF) receiving SEMS placement were included. The body mass index (BMI), hemoglobin levels, and albumin levels in the malignant TEF group were lower than in the malignant CAO group (all P < 0.05). The procalcitonin levels, C-reactive protein levels, and the proportion of inflammatory lesions were higher in the malignant TEF group than in the malignant CAO group (all P < 0.05). The proportion of symptomatic improvement after the SEMS placement was 97.6% in the malignant CAO group, whereas 50.0% in the malignant TEF group, with a significant difference (P = 0.000). Three months after SEMS placement, the survival rate at was 67.0%, significantly lower in the malignant TEF group than in the malignant CAO group (45.8% vs. 73.2%, P = 0.013). Multivariate analysis revealed that BMI [odds ratio (OR) = 1.841, 95% certificated interval (CI) (1.155-2.935), P = 0.010] and neutrophil percentage [OR = 0.936, 95% CI (0.883–0.993), P = 0.027] were the independent risk factors for patients who survived three months after SEMS placement.

Conclusions

We observed symptom improvement in malignant CAO and TEF patients after SEMS placement. The survival rate in malignant TEF patients after SEMS placement was low, probably due to aspiration pneumonitis and malnutrition. Therefore, we recommend more aggressive treatment modalities in patients with malignant TEF, such as strong antibiotics, nutrition support, and strategic ventilation. More studies are needed to investigate the prognostic factors in patients with malignant airway disorders receiving SEMS placement.

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。

Customization of stent design for treating malignant airway stenosis with the aid of three-dimensional printing

Background

The treatment of malignant stenosis involving the carina or bronchi is challenging due to complicated anatomy with individual variation, which makes it necessary to customize stents for each patient. Therefore, this study aims to evaluate the feasibility of a novel metallic segmented airway stent customized with the aid of three-dimensional (3D) printing for such cases.

Methods

The stents were individually customized with the aid of a 3D printed mold based on computed tomography (CT) images according to the anatomical features of the airway. A segmented design was applied on the junction part of the main stem and the branches to fit the dynamic changes of the carina angle. In 12 patients with airway stenosis caused by malignancies including esophageal cancer (EC) and lung cancer (LC), the stents were implanted. The technical and clinical success of the stenting procedure, Hugh-Jones (HJ) classification, Karnofsky performance status (KPS), and stent-related complications of patients were evaluated.

Results

The stenting procedure was technically successful in all patients, and 11 patients showed significant palliation of dyspnea after stenting. The HJ and KPS classification of patients after stent insertion improved significantly compared with those before stenting (P=0.003 and P=0.006, respectively). During follow-up, granulation tissue proliferation and sputum retention were found in two and four patients, respectively.

Conclusions

This study shows that the implantation of a novel stent designed with the aid of 3D printing is feasible for relieving dyspnea and improving performance status of patients with inoperable malignant stenosis involving the carina or bronchi.

Clinical Outcomes of Complications Following Self-Expandable Metallic Stent Insertion for Benign Tracheobronchial Stenosis

Background and Objectives: The use of metallic stents in benign TBS is controversial. Here, we report the clinical outcomes of patients who developed complications due to self-expandable metallic stent (SEMS) insertion for benign TBS. Materials and Methods: Our institution, which is the largest and most active referral hospital for airway stenosis in South Korea, only uses silicone stents. We conducted a retrospective review of 20 patients referred after the insertion of SEMS for benign TBS from 2006 to 2015. Results: All 20 patients underwent rigid bronchoscopy for SEMS removal due to airway obstruction from granulation tissue overgrowth. All but one (95%) experienced successful removal of the SEMS. During a median follow-up period of 40 months, a median of seven rigid bronchoscopies per patient was needed to maintain airway patency. Three (15%) patients suffered acute complications during SEMS removal (bleeding (10%) and fistula (5%)). All patients suffered chronic complications (granulation tissue (80%), stent migration (58%), mucostasis (55%), and restenosis (43%)). Eventually, 15 patients (75%) needed airway prostheses (silicone stent (75%) and tracheostomy (25%)). Conclusion: Our findings indicate that SEMS should be avoided until positive results are consistently reported by high-quality studies in patients with benign TBS.

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 ).

Insertion of a Dumon Y-stent via a permanent tracheostoma without using a rigid bronchoscope

A 63-year-old man who had received a permanent tracheostoma after oesophageal cancer surgery developed fistulas in the left and right main bronchi and suffered repeated aspiration pneumonia. Placing an indwelling Dumon Y-stent using a rigid bronchoscope is an option to treat fistula and stenosis at the tracheal bifurcation, but in some cases, it may be difficult to use a rigid bronchoscope in patients with a permanent tracheostoma. In this study, we report placing a Dumon Y-stent in a patient with a permanent tracheostoma using a specially modified stent and forceps instead of a rigid bronchoscope.

Airway stent complications: the role of follow-up bronchoscopy as a surveillance method

Background

Airway stenting has become an integral part of the therapeutic endoscopic management of obstructive benign and malignant central airway diseases. Despite increased use of airway stents and frequent stent-associated complications, no clear guidelines for surveillance and maintenance exist. This study aim is to elucidate predictive factors associated with development of stent complications, as well as an optimal surveillance period for follow-up bronchoscopy for early detection and possible prevention of stent-associated complications.

Methods

Retrospective cohort study of all patients who underwent airway stent placements at our institution from April 2010 to December 2013 for benign and malignant airway diseases. Metallic, silicone (straight, Y stent, T-tube) and hybrid stents were included in the study. Stent complications were analyzed at the time of follow-up bronchoscopy performed four to six weeks after initial stent placement or earlier if patients became symptomatic.

Results

The study included 134 patients of which 147 stents were placed. Follow-up bronchoscopy was performed in 94 patients. Symptomatic status at the time of follow-up bronchoscopy was not associated with stent complications [odds ratio (OR) =1.88; 95% CI: 0.79-4.45; P=0.15]. Patient age, sex, indication for stent placement, and stent location, were not associated with development of complications (all P>0.05). Compared to all other stents, hybrid stents were more likely to migrate (OR =6.60; 95% CI: 2.16-20.2; P=0.001) or obstruct by secretions (OR =2.53; 95% CI: 1.10-5.84; P=0.03). There were no complications associated with surveillance bronchoscopy.

Conclusions

Surveillance bronchoscopy within 4 to 6 weeks of stent placement may be useful for early detection of complications and their subsequent management, regardless of symptomatic status and indication for stent placement. Prospective multicenter studies are needed to compare optimal surveillance methods and the impact on patient mortality, morbidity and healthcare costs.

Double stenting with silicone and metallic stents for malignant airway stenosis

For severe malignant airway stenosis, there are several types of commercially available airway stents, and each has its own advantages and disadvantages. We herein describe the safety and efficacy of combination stenting with silicone and metallic stents for patients with extended malignant airway stenosis. Seven patients with malignant airway stenosis were treated via combination stenting with a silicone stent and a metallic stent for extended airway stenosis from the central to peripheral airways. Five patients were diagnosed with advanced esophageal cancer, two of whom had tracheoesophageal fistulas. One patient had adenoid cystic carcinoma, and another had mediastinal tumor. There were no specific complications related to the double stenting. Combination stenting with silicone and metallic stents proved to be a safe option for patients with severe, extended, and complicated malignant airway stenosis.

Covered airway stent placement for malignant tracheobronchial strictures in patients with an endotracheal tube

AIM

To evaluate the technical feasibility and safety of covered airway stent placement for malignant tracheobronchial strictures in patients with an endotracheal tube.

MATERIALS AND METHODS

Data regarding retrievable, expandable, metal stent placement under fluoroscopic guidance in 20 patients with an endotracheal tube inserted for malignant tracheobronchial strictures were retrospectively analysed. The clinical effectiveness was assessed using the following variables: technical and clinical success; procedure and stent-related complications; and duration of intubation following stent placement.

RESULTS

Stent placement was technically successful in all 20 patients (100%), and with 19 of the 20 patients (95%) showing symptomatic improvement within 5 days. The endotracheal tube could be removed during (n=7) or after (n=12) stent placement, and the mean duration of intubation following stent placement was 1.4 days (range 0-3 days). One patient could not have his endotracheal tube removed and he died 9 days following stent placement in an intubated state. There were no procedure-related complications. Stent-related complications in three patients included partial (n=2) and complete (n=1) stent migration, all of which were managed with placement of a second stent (n=2) or stent removal and placement of a second stent (n=1).

CONCLUSION

Covered airway stent placement under fluoroscopic guidance in patients with an endotracheal tube inserted for malignant tracheobronchial strictures, is both technically feasible and safe.