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Correspondence

Reply

^a Department of Respiratory Medicine, Maidstone Hospital, Hermittage Lane, Maidstone, Kent ME16 9QQ, United Kingdom
^b Department of Thoracic Surgery, Bristol Royal Infirmary, Bristol, B52 8HW United Kingdom
^c Department of Respiratory Medicine, Severn Postgraduate School of Medicine, Bristol Royal Infirmary, Bristol, B52 8HW United Kingdom

(Email: dr_arshad_husain{at}yahoo.co.uk; anthony.morgan{at}ubht.nhs.uk; martin.hetzel{at}trantraweb.co.uk).

To the Editor:

We thank Dr Foroulis and colleagues [1] for their interest in our article [2]. However, we believe that the issues raised in their letter are somewhat out of context with the messages in it.

In our series, we have only used Ultraflex endobronchial stents (Boston Scientific, Watertown, MA) in carefully selected patients with benign airway obstruction in whom conventional surgery was not an option. There was never any question of them being suitable for any other therapeutic procedure in the future, and they had severe symptoms; so the only choice for treatment was between expanding wire or silicone stents.

We have certainly not recommended Ultraflex stents (Boston Scientific) in benign upper airways obstruction as a first-line treatment with a view to some other subsequent intervention. Because there was no intention to remove these stents at a later date in our patients, the fact that they are difficult to remove after the first few weeks is not, in our opinion, a major consideration in using them. Whereas Foroulis and colleagues' [1] letter reports problems with granuloma obstruction, as stated in our article, this was not a problem in our experience. The article by Saad and colleagues [3] reports similarly favorable results for expanding wire stents in benign airway obstruction, but it also stresses the importance of careful patient selection.

We note that the complications in the 2 patients described by Foroulis and colleagues [1] involved use of covered Ultraflex stents; whereas we have exclusively used uncovered Ultraflex metallic stents in our benign cases. We do not see the logic of using covered stents in benign airway obstruction, because there is no risk of tumor infiltration through the stent and no fistula is present. It is common knowledge that it is potentially hazardous to use medical lasers anywhere near combustible materials within the patient's airway and the airway fire that may result can prove fatal. We would therefore question the wisdom of trying to remove granulation tissue around a covered stent with a laser, no matter how skillful the endoscopist might be. If these patients had been treated with uncovered stents, there would have been no risk of using laser resection to clear any granulation obstruction. Moreover repeated laser resection would be possible if granulations recurred at a later date.

Madden and colleagues [4] report using the neodymium yttrium–aluminum–garnet laser to clear granulation tissue from Ultraflex stents in 10 cases in their series, and they did not have any complications, but it is not clear from their article how many of these involved covered stents. Nevertheless, we would suggest that this technique is absolutely contraindicated in the presence of covered stents, because there are other methods available by which granulations can be more safely removed.

In conclusion, we maintain our view that Ultraflex stents are a safe and effective treatment in carefully selected patients with symptomatic benign upper airways obstruction in which attempts at curative surgical treatment are not possible. We would advise that uncovered stents are the most appropriate type for this group of patients. Future randomized studies comparing long-term results for Ultraflex metallic expandable wire stents versus silicone stents would be immensely valuable.

	References

Top References

 

1. Foroulis NC, Charokopos N, Papakonstantinou C. Should Ultraflex metallic stents be used in benign airway obstruction (letter)? Ann Thorac Surg 2008;85:1842-1843.[Free Full Text]
2. Husain SA, Finch D, Ahmed M, Morgan A, Hetzel MR. Long-term follow-up of Ultraflex metallic stents in benign and malignant central airway ostruction Ann Thorac Surg 2007;83:1251-1256.[Abstract/Free Full Text]
3. Saad CP, Murthy S, Krizmanich G, Mehta AC. Self-expandable metallic airway stents and flexible bronchoscopy: long-term outcomes analysis Chest 2003;124:1993-1999.[Medline]
4. Madden BP, Loke TK, Sheth AC. Do expandable metallic airway stents have a role in the management of patients with benign tracheobronchial disease? Ann Thorac Surg 2006;82:247-248.

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Anthony Morgan Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Husain, S. A. Articles by Hetzel, M. Search for Related Content PubMed Articles by Husain, S. A. Articles by Hetzel, M. Related Collections Related Article