Ann Thorac Surg 2004;78:e22-e23
© 2004 The Society of Thoracic Surgeons
Case report
Airway obstruction complicating esophageal stent placement in two post-pneumonectomy patients
Alexander S. Farivar, MDa*,
Eric Vallières, MDa,
Kris V. Kowdley, MDb,
Douglas E. Wood, MDa,
Michael S. Mulligan, MDa
a Department of Thoracic Surgery, Washington Medical Center, Seattle, Washington, USA
b Department of Gastroenterology, Washington Medical Center, Seattle, Washington, USA
Accepted for publication September 11, 2003.
* Address reprint requests to Dr Farivar, University of Washington Medical Center, Box 356310, 1959 NE Pacific St, Seattle, WA 98195, USA
e-mail: afarivar{at}u.washington.edu
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Abstract
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Expandable metallic stents have been used effectively to treat multiple nonsurgical esophageal conditions. Here we describe two cases in postpneumonectomy patients in which expandable esophageal stent placement resulted in respiratory compromise requiring reintervention due to airway compression.
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Introduction
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Expandable metallic stents have gained favor as therapy for individuals suffering from multiple nonsurgical esophageal conditions, including esophago-respiratory fistulas and malignant esophageal strictures. We describe two patients who had each previously undergone a pneumonectomy in which the placement of an esophageal stent resulted in airway compression and respiratory failure. Airway compromise after esophageal stent placement is a rare complication [1], and we report a possible association with a prior pneumonectomy.
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Case reports
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Patient 1
Patient 1 is a 40-year-old woman with right-sided malignant mesothelioma, which had been treated with three cycles of platinum, methotrexate, and vinblastine induction therapy followed by an extrapleural pneumonectomy. The patient's course was complicated by a postpneumonectomy empyema requiring a Clagett window, and she subsequently received adjuvant radiation therapy. Approximately 1 year later she noted food material draining from her Clagett window, and had an esophagogram that demonstrated a leak in the upper portion of the esophagus. An esophagogastroduodenoscopy (EGD) was performed, which revealed a fistula 23-cm from the incisors and no evidence of stricture. After an uncomplicated positioning of a covered esophageal expandable stent (Ultraflex, Boston Scientific Corp, Natic, MA), the patient immediately had respiratory difficulties develop that required urgent reintubation. Endoscopy showed severe extrinsic compression of the distal trachea and left main bronchus. After discussion with the patient's family members it was decided to attempt insertion of a tracheobronchial stent in an effort to overcome the extrinsic compression from the endoesophageal stent. A modified Hood Y 12-mm stent (Hood Laboratories, Pembroke, MA) was inserted after shortening the right-sided limb to accommodate the patient's pneumonectomy stump. The stent was successful in creating a patent airway, and she was discharged home 3 days later, tolerating a liquid diet without any evidence of fistula drainage.
Patient 2
Patient 2 was a 52-year-old woman with a central right main bronchial nonsmall cell lung cancer who was initially judged to have nonresectable disease. She was referred after receiving definitive chemoradiation therapy and underwent complete resection of the residual IIB (T3N0) malignancy by way of a right pneumonectomy. She later had progressive dysphagia develop, which led to an esophagoscopy and esophageal stent placement for a benign stricture, presumably related to her radiation therapy for lung cancer treatment. Minor respiratory symptoms after stent placement became progressive with dyspnea and stridor. Bronchoscopy performed at an outside facility reported a left mainstem bronchial obstruction believed to be extrinsic compression from the esophageal stent. The patient required intubation to maintain a stable airway. She was transferred for urgent bronchoscopy and esophagoscopy. Bronchoscopy revealed a virtually completely occluded proximal left mainstem bronchus from posterior compression and no evidence of recurrent tumor. Rigid esophagoscopy was done and the stent was retrieved. Follow-up bronchoscopy revealed a widely patent left mainstem bronchus. The patient was awakened and extubated in the operating room. She was discharged the next day.
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Comment
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These two cases describe the rare complication of severe airway obstruction requiring reintubation secondary to placement of expandable metal esophageal stents. In addition, both of these patients had also undergone chemoradiation therapy and had a right pneumonectomy performed.
The plastic esophageal stents introduced in the 1970s have now been replaced by expandable metal stents. Plastic stents had high rates of complications secondary to their insertion (procedure related mortality, 2% to 16%), and the small internal diameter (10 to 12 mm) resulted in patients oftentimes having difficulty with swallowing and resuming a normal diet [2]. Newer self-expanding metallic stents are primarily used to palliate symptoms of dysphagia in patients with inoperable esophageal cancer, and other indications include anastomotic recurrence after esophageal surgery and secondary tumors within the mediastinum that compress the esophagus extrinsically [3]. There have also been large series reported that have used covered stents to treat tracheoesophageal fistulas and esophageal perforation with success rates of 80% to 100% [4].
The complication rates with metallic stents are significantly lower than those seen with plastic stents. Reported complications with expandable metal stents include chest pain, foreign body sensation, stent migration, bleeding, esophageal tears and perforation, aspiration, and tumor ingrowth or overgrowth [5]. Airway compression is rare with few reports in the literature to date [1, 6]. Airway obstruction is unlikely for the majority of esophageal stents placed in the distal third of the esophagus. However, more proximal stents can abut the posterior wall of the trachea, carina, or a mainstem bronchus and result in extrinsic compression and obstruction. Therefore the complication and degree of airway obstruction is due to the location of the stent, the diameter of the stent, and the relational anatomy of the esophagus and airway in the individual patient.
This is the first report of a possible association of this complication in patients who had previously undergone a pneumonectomy. We speculate that a shift of mediastinal structures after pneumonectomy resulted in the potential for more severe airway obstruction secondary to esophageal stent placement, and less opportunity for compensation by another, less affected, lung. The majority of these patients have a grave and life-limiting prognosis, but their immediate survival and quality of life is threatened by the acute onset of iatrogenic airway obstruction.
There are several potential options for palliating or correcting airway obstruction in these types of situations. We described removal of the esophageal stent in one scenario, and insertion of a tracheal stent in another. When attempting to remove an esophageal stent under conditions similar to that described in this report, it is best to use a rigid esophagoscope. The proximal stent can be grasped with alligator forceps, and the tip of the rigid esophagoscope can be used to disengage the proximal stent from the underlying mucosa. Then it may be possible to extract the stent intact. It is helpful to rotate the esophageal stent when trying to intussuscept it into the rigid scope to avoid stent impaction in the scope, which make further attempts at extraction more difficult. In most cases respiratory symptoms will occur shortly after esophageal stent placement, at a time when prompt stent removal can realistically be performed before tissue ingrowth occurs. Esophageal stent removal may not be possible, or it may result in prohibitive esophageal trauma in cases in which the stent has had time to become incorporated into the esophageal wall.
We would recommend that the placement of expandable esophageal stents proximal to the carina in postpneumonectomy patients occur in a setting where experienced interventional bronchoscopy is immediately available and where rigid esophagoscopy and early stent removal can be entertained.
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References
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- Dasgupta A., Jain P., Sandur S., Dolmatch B.L., Geisinger M.A., Mehta A.C. Airway complications of an esophageal self-expandable metallic stent. Gastrointest Endosc 1998;47:532-535.[Medline]
- Tan D.S., Mason R.C., Adam A. Minimally invasive therapy for advanced esophageal disease. Clin Radiol 1996;51:828-836.[Medline]
- Knyrim K., Wagner H.J., Bethge N., Keynling M., Vakil N. A controlled trial of an expansile metal stent for palliation of esophageal obstruction due to inoperable cancer. New Engl J Med 1993;329:1302-1307.[Abstract/Free Full Text]
- Kozarek R., Raltz S., Brugge W.R., et al. Prospective multi-center trial of esophageal stent placement for malignant dysphagia and tracheoesophageal fistula. Gastrointest Endosc 1996;44:562-567.[Medline]
- Lee S. The role of esophageal stenting in the non-surgical management of esophageal strictures. Brit J Rad 2001;74:891-899.
- Libby E.D., Fawaz R., Leano A.M., Hassoun P.M. An airway complication of an expandable stent. Gastrointest Endosc 1999;49:136-137.[Medline]
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Abstract
Introduction
