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Ann Thorac Surg 2000;70:1142
© 2000 The Society of Thoracic Surgeons
a Department of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
Address reprint requests to Dr Grillo, Department of Thoracic Surgery, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02144
In this issue of The Annals, covered expandable stents are offered for management of "tracheal granulation tissue" where tracheal resection is not possible [1]. We have recently been referred a number of patients with postintubation tracheal stenosis—characterized in earlier postulcerative stages by profuse granulation tissue—who were treated with expandable, uncovered stents. The inevitable followed. Granulations grow through the interstices of the stent incorporating the stent into the tracheal wall. The consequent obstruction becomes difficult to manage, even palliatively, with laser. It is often impossible to remove the offending stent bronchoscopically, and sometimes difficult even by open total linear tracheotomy. What is almost incomprehensible is that this outcome was not evident in advance to the surgeon.
The problem arises from the uncritical employment of technology without understanding the pathology being treated. It was shown long ago that postintubation tracheal stenosis arises from pressure ulceration and subsequent healing, beginning with granulations followed by cicatrization and ultimately, contraction of the scar [2, 3]. Thus, attempts to treat these lesions by dilation, steroids, mechanical debridement, cryosurgery and most recently, by laser, generally fail. The T tube was originally developed for definitive treatment of such stenoses, but it soon became apparent that the scar contracted again as soon as the tube was removed [4]. T tubes remain useful as a safe method of stenting lesions which are too lengthy for safe reconstruction [5, 6]. The inlying silicone stent of the type developed by Dumon evolved from this. At least it can always be removed. However, it is not uncommon to see granulations form at one end or another of a silicone stent or T tube, especially proximally when near the conus elasticus of the subglottic larynx. This occurs despite the tube’s inert composition in response to mechanical irritation. Granulation tissue was also observed in the present report at the edge of a covered stent. We have also encountered rings of granulation tissue at either end of covered expandable stents.
When stenting an inflammatory cicatricial tracheal lesion, or even a neoplastic one, a solid or covered stent alone is acceptable. It seems surprising that this need be said, but basic pathology of lesions being treated must be understood by the surgeon before he plugs in the latest gadget [7]. Indeed, I must point out that in the paper discussed, the authors were not treating simply tracheal granulations, but rather an incipient stenosis.
Further comment needs to be made on the unfortunate current tendency of pulmonologists and even some surgeons, otolaryngological and thoracic, to treat surgically resectable stenoses with stents. Stenting is not a benign procedure. Expandable stents regularly and irreversibly convert wholly resectable lesions to lesions of irresectable length. The full range of complications is yet to be seen, as with any recent technique. Some early and obvious failures are noted in this commentary. Resection and reconstruction, on the other hand, is of proven value and has low morbidity and mortality especially when applied as initial treatment [8, 9]. During a period when over five hundred such operations were performed, very few patients were refused repair for systemic reasons, given the low physiological impact of a well-conducted reconstruction. Excessive length of lesion, almost always the result of inappropriate prior surgery rather than of the original injury, was a more common contraindication to resection. Such patients were largely managed and quite well with T tubes [6]. A very real advantage of the T tube is its complete and easy removal in the event of complications such as progressive airway obstruction.
Airway stents are a useful concept. Their incarnations will vary in the years ahead in materials and in mechanism. They must be employed intelligently if major problems are to be avoided.
References
This article has been cited by other articles:
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  C.S. Pramesh and R. C. Mistry Management of pediatric airway obstruction J. Thorac. Cardiovasc. Surg., January 1, 2006; 131(1): 253 - 254. [Full Text] [PDF]
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 C.S. Pramesh and R. C. Mistry Self-Expandable Metal Stents for Endobronchial Pathology Ann. Thorac. Surg., December 1, 2005; 80(6): 2419 - 2419. [Full Text] [PDF]
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M. Altmayer, C. Biancosino, J. Strauss, and P. Macchiarini Multiple tracheal stenting or perseverare diabolicum est J. Thorac. Cardiovasc. Surg., July 1, 2005; 130(1): 223 - 224. [Full Text] [PDF]
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 C.S. Pramesh, R. C. Mistry, and V. V. Upasani Stents and sensibility--use of the Montgomery T-tube in tracheal stenosis Eur. J. Cardiothorac. Surg., November 1, 2004; 26(5): 1060 - 1060. [Full Text] [PDF]
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 Y.-H. Liu, P.-J. Ko, Y.-C. Wu, and H.-P. Liu Incorporated airway stent: a useful option for treating tracheal stenosis after metallic stenting Interactive CardioVascular and Thoracic Surgery, June 1, 2004; 3(2): 254 - 256. [Abstract] [Full Text] [PDF]
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