Ann Thorac Surg 1995;59:1422
© 1995 The Society of Thoracic Surgeons
DISCUSSION
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Introduction
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See also page 1417.
DR FREDERICK L. GROVER (Denver, CO): I congratulate Dr Sonett on a very nice presentation on a difficult group of patients. One problem we have had when we have had to use stents is that the silicone stents tend to be fairly thick, so that the internal to external diameter ratio is not as great as one would like. We have used stents more often for malignant disease, because only one of our 38 patients with lung transplants has had a bronchial complication. We have used expandable Palmaz wire stents; however, a major problem with these stents is in-growth and stimulation of granulation tissue from the wire, I presume. According to Dr Joel Cooper, there is a stent that is being developed that takes advantage of the expandable wire support and has a very thin silicone coating on the outside. Have you had any experience with this type of stent?
DR SONETT: We have limited experience with the wire stents, although I agree with you that silicone stents are not ideal, especially in regard to migration and in the ratio of the internal to the external diameter of the stent. I think wire stents at present have had limited use in North America, and the use they have had in Europe has shown significant complications. We too are looking forward to the stent that Dr Cooper has talked about with a silicone coating. It is sort of a combination between the expandable wire stent and the silicone stent that may allow an expandable stent to have a good purchase in a short stricture as well as being able to be removed.
DR LEWIS WETSTEIN (Freehold, NJ): This is a rather new and exciting modality. Unfortunately I do not have any significant experience with these techniques, but I do have substantial experience with the endoesophageal prosthesis.
In an attempt to extrapolate from that experience, an extremely difficult problem occurs when the gastroenterologists attempt to pass or dilate an unresectable malignant esophageal obstruction and they perforate the esophagus. In those instances I have occluded the perforation and bypassed the obstruction with an exophageal prosthesis [1].
My question to you, therefore, is could you generate similar results with bronchial perforations by inserting a stent? I am sure you would agree that an esophageal perforation is a more devastating complication than a bronchial one. We have obviated a major operative procedure with our stents; don't you think you could do likewise?
DR SONETT: I suppose you may be able to, but I think the safest thing, as we knew we tore it right away, was to go in and fix it appropriately, as the patient was a good risk for standard repair. We have used endobronchial stents in the past for persistent fistulas in patients with septic lung transplants that were unrelated to iatrogenic fistulas. But I think in this situation the safest thing to do was to repair it primarily and not to try to see if a stent could work.
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Reference
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- Wetstein L, Kirby DF. Esophageal perforation [Letter]. Arch Surg 1989;124:876.[Abstract/Free Full Text]
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