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Ann Thorac Surg 1997;63:1515-1516
© 1997 The Society of Thoracic Surgeons
Cattedra di Chirurgia Toracica, Policlinico Umberto I, Univ. of Rome "La Sapienza", V.le del Policlinico 00100 Rome Italy
To the Editor:
We read with interest the article "Expandable Metallic Stents for Tracheobronchial Stenoses in Esophageal Cancer" by Takamori and associates [1]. Takamori and associates report 12 cases of compression/infiltration of the airway by esophageal carcinoma; in all cases relief of respiratory failure was accomplished by placing one or more uncovered Gianturco stents in the trachea or main bronchi.
In the last 3 years we performed more than 200 neodymium:yttrium-aluminium garnet laser resections of lesions obstructing the airway; in 7 cases the obstruction was related to direct infiltration of the trachea (4), left main bronchus (2), and right main bronchus (1) by esophageal carcinoma. The airway involvement occurred at first presentation of the esophageal tumor in 6 patients and at mediastinal recurrence after operation in 1. Dyspnea and dysphagia were the primary symptoms and the main indication for operation. The clinical status was critical in all patients due to severe weight loss, respiratory failure, and aspiration. All patients had lesions growing inside the airway, and 4 presented a fistula between the esophagus and the trachea. Laser resection was always required as the first step of treatment to obtain a viable airway before insertion of the stent. In all patients we used a covered expandable metallic stent in the esophagus and one or more silicone stents in the airway (Endoxane; Novatech, Aubagne, France).
It is important to stress that these patients present locally advanced esophageal carcinoma (T4) and cure is obviously impossible. Thus, the aim of the endoscopic treatment is to provide temporary palliation and relief of symptoms and improve the quality of life. Life expectancy could also be improved because effective palliation allows feeding and thus enhancement of the nutritional status; also aspiration and infectious complication are prevented when a tracheoesophageal fistula is correctly sealed.
Reports in the literature are scanty, and the operative strategy is still controversial. In fact, single or double stenting of the esophagus and the proximal airway has been reported, and both techniques seem to be relatively successful in small series of patients. Also, the type of stent employed is different in each report. In our opinion, effective and long-lasting palliation is better accomplished by placing a stent in both the esophagus and the airway (Fig 1
) [2, 3]. In fact, if only a single stent is placed either in the trachea or the esophagus, the other viscus could be compressed and closed by the bulge of the tumor. We believe that uncovered metallic stents should not be used in these patients because the tumor could grow within the mesh of the stent, causing early recurrence of symptoms and bleeding, and favoring the development of a fistula, if it is not yet present. Also, closure of the fistula is obviously impossible with uncovered stents. In addition, life expectancy is not that short in this subset of patients (from 3 to 23 months in our experience) [4] if they are properly treated after stent placement (nutritional support and chemotherapy), and erosion of the tumor by the uncovered wires is always possible. In particular, the Gianturco stents have large mesh and virtually no predetermined limit to their expansion. For this reason we prefer covered expandable stents in the esophagus and one or more silicone stents in the airway. Furthermore, neodymium:yttrium-aluminium garnet laser resection both in the esophagus and the airway can be performed safely if the surface is completely covered and sealed by the stent. We always obtained complete and immediate relief of symptoms without further aspiration in patients with tracheoesophageal fistula; no fistula developed after the endoscopic treatment. No migration of the stent occurred.
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References
First Department of Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume 830, Japan
To the Editor:
I appreciate the opportunity to respond to correspondence by Venuta and colleagues regarding our report of metallic stents for tracheobronchial stenoses in esophageal cancer [1].
I concur with their concept of the use of double stenting for esophageal cancer patients with a fistula between the esophagus and the trachea. They employed a covered expandable metallic stent in the esophagus and one or more silicone stents in the airway, which may be ideal for palliative treatment in their cases. In our series, healing or closing of the fistula failed in 1 patient with tracheoesophageal fistula. We have had little experience of stenting for a tracheoesophageal fistula, the management of which remains a difficult problem.
On the choice of stent, we advocate Gianturco stent when the patient is severely compromised because the procedure of stent insertion is noninvasive compared with that for a silicone stent. Our choice is consistent with that of Carrasco and associates [2], who reported that in patients with no other options, the presence of severe symptoms warrants consideration of palliation with an intraluminal stent. Basically, the Gianturco stent should be applied to alleviate extrinsic compression having no infiltration of tracheobronchial stenosis.
References
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