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Ann Thorac Surg 2005;80:2419-2420
© 2005 The Society of Thoracic Surgeons
Department of Cardiothoracic Surgery, St. Georges Hospital, Tooting, London, SW17 0QT UK
(Email: brendan.madden{at}stgeorges.nhs.uk).
We believe that Drs Pramesh and Mistry [1] are missing the point of our publications regarding endobronchial stenting [2–4]. As we stated in our first publication and have consistently repeated, tracheal resection and reconstruction operations are the gold standard for tracheal stenosis caused by benign granulation tissue [2]. We make the point however that some patients may be medically unfit for these procedures and alternative approaches such as neodymium yttrium–aluminium–garnet (Nd YAG) laser fulguration or tracheal stenting are used. Throughout our publications we have consistently made it clear that we are considering patients for endobronchial intervention who are not deemed suitable candidates for formal tracheal surgery. Our multidisciplinary approach comprises input from cardiothoracic surgeons, physicians, and anesthetists, intensive care specialists, pulmonologists, and pathologists. We are very aware of the different pathologies that can give rise to endobronchial compromise. We have weekly theatre lists in a multidisciplinary setting to address patients with diverse endobronchial pathologies leading to large airway compromise.
As we and others have shown, we believe that expandable metallic stents do indeed have a role to play in the management of carefully selected patients with diverse endobronchial pathologies including non-malignant conditions. We strongly disagree with Drs Pramesh and Mistry's dogmatic statement that expandable metallic stents should be reserved for patients with malignant disease. As with many other centers, we believe that patients need to be considered for the best and most appropriate treatment on an individual basis.
We agree that certain lesions in the airways can be effectively stented using fiberoptic as opposed to rigid bronchoscopy, and indeed many centers have encouraging experience using the fibreoptic bronchoscope. Our preference is to deploy the stents through a rigid bronchoscope in a controlled environment with multidisciplinary input. We perform an average of 20 endobronchial interventions (ie, stent deployment, Nd YAG laser fulguration, dilatation techniques, foreign body retrieval, and pediatric bronchoscopies) per month. During the past 5 years we have had no mortality; 2 patients developed a pneumothorax and each was successfully treated by intercostal chest drain insertion. One patient had significant bleeding and was successfully treated by endobronchial maneuvers. To date we have deployed 130 expandable metallic stents, and our median time for rigid bronchoscopy and stent deployment is 10 minutes.
With more and more centres worldwide using expandable metallic stents to manage patients with diverse airway pathology we believed it most important to report complications which may develop in the medium term and to describe our approach to problems which we have encountered.
We look forward to reading publications from Drs Pramesh and Mistry relating to their practice and would warmly invite them to visit our unit.
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