Ann Thorac Surg 1996;62:844-847
© 1996 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Expandable Metallic Stents for Tracheobronchial Stenoses in Esophageal Cancer
Shinzo Takamori, MD,
Hiromasa Fujita, MD,
Akihiro Hayashi, MD,
Kohsuke Tayama, MD,
Masahiro Mitsuoka, MD,
Shoji Ohtsuka, MD,
Kazuo Shirouzu, MD
First Department of Surgery, Kurume University School of Medicine, Kurume, Japan
Accepted for publication April 24, 1996.
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Abstract
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Background. Tracheobronchial stenosis in patients with esophageal cancer can be life threatening. Few reports have discussed use of expandable metallic stents for central airway stenoses in patients with esophageal cancer.
Methods. Twelve patients with esophageal cancer underwent placement of expandable metallic stents for respiratory distress caused by tracheobronchial stricture. Single or double metallic stents were placed in the stenotic airways under fluoroscopic guidance. Improvement in respiratory symptoms and clinical outcome were assessed.
Results. Most stenoses were located in the trachea or the left main bronchus. From one to four expandable metallic stents were placed in each stricture site, with immediate relief of respiratory symptoms in 8 patients. One patient with tracheomalacia in alive 3 years after stent placement and another is alive 6 months after stent insertion. The other 10 patients lived from 10 to 70 days (mean; survival, 35 days) after stent placement. Death was due to progression of disease.
Conclusions. Although metallic stents are useful for relieving respiratory distress in patients with advanced esophageal cancer, additional therapies should be considered.
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Introduction
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The Gianturco expandable metallic stent was initially designed for intravascular stenosis [1–3]. However, these stents have also been used for various obstructions in the tracheobronchial tree [4–6]. Patients with advanced esophageal cancer often have respiratory distress as a result of tracheobronchial invasion. We report the use of expandable metallic stents in the treatment of tracheobronchial stenosis in patients with esophageal cancer.
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Patients and Methods
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The expandable metallic stent is constructed of stainless steel wire 0.45 mm in diameter for the trachea and 0.40 mm in diameter for the main bronchus. The wires are shaped into zigzag cylinders with six or eight bends. The stent is concentrically compressed in a sterile cartridge 20 mm in length and 30 mm in diameter for the trachea and 25 mm in diameter for the main bronchus. Often, two stents are connected together, and lateral barbs are attached to this double stent to minimize migration in the tracheobronchial tree (Fig 1
). Single and double stents are used for tracheobronchial obstructions.
Typically, local anesthesia of the vocal cords is induced, and the tracheobronchial obstruction is assessed by fiberoptic bronchoscopy. The chest wall is marked at the site of maximal airway obstruction as determined by the fluoroscopic evaluation. The delivery catheter (Medikit, Co, Ltd, Tokyo, Japan) (Fig 2) is introduced under fluoroscopic guidance, and the stent is released from the catheter when aligned with the skin marker. Two or more single or double stents may be necessary in some patients.
Over a 3-year period, expandable metallic stents were inserted in 12 patients with tracheobronchial stenosis caused by esophageal cancer. Mean age of the patients was 60 years (range, 49 to 76 years), and there were 11 men and 1 woman. All patients had histologically confirmed squamous cell carcinoma of the esophagus. The primary sites of the esophageal cancer were located mainly in the upper thoracic esophagus. Curative surgical intervention had been performed in 4 patients, a palliative operation in 1 patient, an exploratory procedure in 1, and no surgical procedures in the remaining 6 patients (Table 1).
Pathologic or clinical T states was T1 in 2 patients, T3 in 5, and T4 in 5. Eleven of the 12 patients had metastasis to the lymph nodes. Six patients were classified as M1, which is M1-Lym according to the TNM classification [7]. One patient had stage I disease and the other 11 patients, stage IV disease. One patient had tracheomalacia as a result of prolonged postoperative tracheal intubation, and another patient was seen with severe dilatation of the gastric tube caused by a gastric tube–tracheal fistula. The stage I patient, who had undergone a left pneumonectomy 6 years earlier, had a tracheoesophageal fistula resulting from intraluminal irradiation for esophageal carcinoma. Neodymium:yttrium-aluminum garnet laser therapy was used in 6 patients for severe stenosis of the lumen.
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Results
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The sites of stenoses included the trachea in 5 patients, the trachea and the left main bronchus in 4, the right and left main bronchi in 1 patient, and the left main bronchus in 2. The causes of the tracheobronchial stenoses involved primary tumor invasion in 5 patients, mediastinal lymph node recurrence in 2, mediastinal recurrence in 2, tracheomalacia in 1 patient, inflammatory granulation in 1, and compression by a dilated gastric tube in 1 (Table 2). From one to four expandable metallic stents in the single or double configuration were placed for tracheobronchial stenoses (Fig 3), and immediate relief of respiratory symptoms was obtained in 8 of the 12 patients (Table 3). Laser vaporization was useful for intraluminal mucosal stenosis before insertion of the stent.
Two patients are alive after stent placement. The patient with tracheomalacia has survived for 3 years and another patient, for 6 months. The other 10 patients lived for 10 to 70 days (mean time, 35 days) after stent insertion. Causes of death were obstructive pneumonia in 5 patients, airway bleeding in 2, and cancer progression in 3.
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Comment
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Malignant stenoses of the tracheobronchial tree are most frequently due to the primary pulmonary carcinoma and its metastases or mediastinal metastases from other pulmonary tumors. Tracheobronchial stenosis caused by esophageal carcinoma is often recognized in patients with advanced disease and can be life threatening. In such patients, the expandable metallic stent is not often applied because of the advanced status of the disease. De Souza and co-workers [6] reported successful use of expandable wire stents for malignant airway obstruction in a series of 21 patients, 1 of whom had esophageal carcinoma. In a series of 36 cancer patients who received Gianturco stents for tracheobronchial stenoses, Carrasco and associates [8] had 2 patients with esophageal carcinoma and tracheobronchial stenoses. In the current series, 12 patients with tracheobronchial stenoses caused by esophageal cancer underwent stenting with relief of respiratory symptoms in 8.
Although conventional stenting with T tubes requires a tracheostomy [9], metallic stents can be inserted endoscopically [4–6]. The technique is quick, safe, and relatively noninvasive. Silicone stents, which are flexible and compatible with living tissue, can be used for various tracheobronchial stenoses [10, 11]. Recently, advances in materials and technique have established stenting as a widely recognized procedure for the management of tracheobronchial stenoses. General anesthesia is commonly required for silicone stent insertion, whereas local anesthesia is used for placement of the expandable metallic stent. We have little experience with silicone stent insertion. Choice of the stent is somewhat controversial. Covered metallic stents have been reported to be useful for retarding the growth of tumor of granulation tissue between the wires of the stent [12]. However, our group has not yet used a covered expanding metallic stent in patients with tracheobronchial stenosis because of the possibility of bacterial infection in the mesh-covered stent.
Albes and colleagues [13] developed a foam-cuffed stent for occlusion of a tracheoesophageal fistula from the tracheal side. One patient in our series had a tracheobronchial fistula resulting from intraluminal irradiation for esophageal carcinoma, and the expandable metallic stent was not effective in healing or closing the fistula. The management of a tracheobronchial fistula remains a difficult problem.
The contraindication to stent placement was complete obstruction of the lumen. Minor contraindications consisted of severe bleeding, respiratory failure including severe hypoxia, and inability to maintain the patient in a supine position. The characteristic of patients who fared well was extrinsic compression of the tracheobronchial stenosis. Exophytic tumor invasion is ideally treated by bronchoscopic neodynium:yttrium-aluminum garnet laser vaporization [14]. In our experience, laser vaporization is necessary to open the lumen in patients with mucosal proliferation of the tumor or granuloma. The combined treatment of expandable metallic stent placement and laser therapy is reliable for tracheobronchial stenoses. In conclusion, we suggest the use of expandable metallic stents and laser therapy for tracheobronchial stenoses in patients with esophageal cancer even if the patients are in very poor clinical condition.
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Footnotes
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Address reprint requests to Dr Takamori, First Department of Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume 830, Japan.
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References
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Top
Abstract
Introduction
