Ann Thorac Surg 2000;70:1807
© 2000 The Society of Thoracic Surgeons
Invited commentary
Mark K. Ferguson, MDa
a Department of Surgery, The University of Chicago Medical Center, 5841 South Maryland Ave, MC 5035, Chicago, IL 60637, USA
e-mail: mferguso{at}surgery.bsd.uchicago.edu
The introduction of self-expanding wire mesh stents has greatly simplified management of uncomplicated malignant esophageal and airway stenoses. However, when malignant obstructions become extensive enough to involve both the tracheobronchial tree and the esophagus, or when a malignant esophageal-airway fistula develops, palliation of stridor, dysphagia, and aspiration is challenging. With their multiple case reports, Nomori and coauthors illustrated the types of complications and potential benefits that result from combined airway and esophageal stenting. Most patients experienced improvement of both airway and esophageal symptoms after double stenting, albeit for a relatively short time, given that the average life expectancy after the second stent placement was just over 2 months. Of concern is the high likelihood that sandwiching the membranous trachea and the esophagus between two stents will result in tissue necrosis and the development or worsening of esophageal-airway fistulas, which occurred in five of the eight patients in this series. In less skilled hands, these complications might have been catastrophic.
Although it appears to have been of benefit in most patients treated by Nomori and colleagues, the suggestion that placement of additional stents is appropriate for managing iatrogenic fistulas associated with double stenting is counterintuitive. Those involved in the management of these challenging patients may wish to consider other alternatives. Initial placement of stents that have smaller diameters may provide sufficient palliation of symptoms without causing excess pressure on surrounding tissues. When tumors are extremely bulky and combined airway and esophageal compromise is likely to develop in the future, a longer length of esophageal stent than would normally be chosen may prevent any fistula that may develop from becoming symptomatic. Use of the more dynamic self-expanding metal stents rather than silicone or plastic stents in the airway may reduce the propensity for fistula formation. Avoiding double-stent placement except as a last resort, particularly in people with preexisting airway stents, will also limit the likelihood of fistula formation. Ultimately, however, the development of new devices will be necessary to palliate these difficult and rapidly fatal problems.
Related Article
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Double stenting for esophageal and tracheobronchial stenoses
- Hiroaki Nomori, Hirotoshi Horio, Yoshihiro Imazu, and Keiichi Suemasu
Ann. Thorac. Surg. 2000 70: 1803-1807.
[Abstract]
[Full Text]
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