Ann Thorac Surg 2009;87:971-974. doi:10.1016/j.athoracsur.2008.06.049
© 2009 The Society of Thoracic Surgeons
How To Do It
Silicone Y-Stent Placement on the Carina Between Bronchus to the Right Upper Lobe and Bronchus Intermedius
Masahide Oki, MD, PhD*,
Hideo Saka, MD,
Chiyoe Kitagawa, MD, PhD,
Yoshihito Kogure, MD
Department of Respiratory Medicine, Nagoya Medical Center, Nagoya, Japan
Accepted for publication June 16, 2008.
* Address correspondence to Dr Oki, Department of Respiratory Medicine, Nagoya Medical Center, 4-1-1 Sannomaru, Naka-ku, Nagoya, 460-0001, Japan (Email: masahideo{at}aol.com).
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Abstract
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Airway stenting using a silicone stent has become widespread for the palliation of airway stenosis. We often encounter patients with tumors involving the carina between the bronchus to the right upper lobe and bronchus intermedius. However, there has not been ideal stenting for such cases, especially to maintain the patency of the right upper lobe bronchus. We report three cases of malignant disease inserted with a Y-stent so that the bronchial limbs of the stent saddle the involved carina between the bronchus to the right upper lobe and bronchus intermedius. The respiratory symptoms improved immediately after the procedure.
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Introduction
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Airway stenting using silicone stents is a well-established procedure to maintain the airway patency in patients with airway stenosis [1]. We often encounter patients with malignant involvement around the carina between the bronchus to the right upper lobe and bronchus intermedius that require stent placement. In such cases, we insert a silicone straight stent with a side hole for right upper lobe ventilation or plural straight stents into the right main stem bronchus and bronchus intermedius. However, these are less effective because the patency of the right upper lobe bronchus cannot be maintained by such methods. Tumor ingrowth through the side hole or the junction of the stents tends to occur.
The bifurcated silicone stent, which is called the "Y-stent," provides effective palliative treatment for patients with main carinal stenosis [2, 3]. Such a bifurcated stent may also be useful for patients with airway stenosis around the carina between the bronchus to the right upper lobe and bronchus intermedius. We report 3 patients with malignant disease inserted with a Y-stent so that the bronchial limbs of the stent saddle the involved carina between the bronchus to the right upper lobe and bronchus intermedius, and thus provided successful palliation.
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Technique
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Silicone stent placement is performed using a rigid and flexible bronchoscope under general anesthesia. Before stent insertion, re-establishment of the airway lumen should be performed by argon plasma coagulation, electrocautery, balloon dilatation, or bronchoscopic mechanical dilatation, or a combination of these. Then the stent size and length are decided. The bronchi diameters are measured using a balloon method with endobronchial ultrasonography (ie, a balloon covering an endobronchial ultrasound probe is inflated with sterile water up to the whole airway wall, and the diameter of the bronchus is measured on ultrasound imaging) [4]]. The length of stenotic bronchi is measured using a flexible bronchoscope that is advanced to the distal margin of the stenotic bronchus under bronchoscopic visualization. The point on the flexible bronchoscope just emerging from the proximal end of a rigid bronchoscope is marked. Then it is pulled back to the proximal margin of the stenotic bronchus, and the length of the flexible bronchoscope protruding from the rigid bronchoscope is measured. The stent is cut to the length measured using this method. The main carinal angle is different from the angle of the carina between the bronchus to the right upper lobe and bronchus intermedius, so the orifice of the Y-stent should be cut at an angle to assure good flow, not toward the bronchial wall. The Y-stent insertion technique is similar to that for the main carina. The Y-stent can be inserted with a "pushing method" or a "pulling back method" as follows [3]. With the pushing method, the Y-stent is inserted into the right main stem bronchus just above the carina between the bronchus to the right upper lobe and bronchus intermedius. Then the stent is grasped with a rigid forceps and pushed so as to saddle the bifurcation. With the pulling back method, before the stent insertion, the limb of the Y-stent for the right upper lobe bronchus is cut shorter than the other limb for the bronchus intermedius. First, both limbs of the Y-stent are inserted into the bronchus intermedius. Then, the stent is grasped with the rigid forceps and slowly pulled back until a limb slips into the right upper lobe bronchus. Finally, the stent is pushed to fit on the bifurcation.
Patient 1
A 52-year-old man with lung cancer (squamous cell carcinoma: stage IV) had dyspnea develop while undergoing palliative radiation therapy. A chest roentgenogram revealed atelectasis of the right lung. Therapeutic bronchoscopy using a rigid and flexible bronchoscope under general anesthesia was performed, which showed a tumor obstructing the right main stem bronchus (Fig 1A). Tumor resection with argon plasma coagulation and electrocautery was performed for re-establishing airway lumen. As the right main stem bronchus, bronchus intermedius, and right upper lobe bronchus were invaded, a Dumon Y-stent (outer diameter; 14 x 10 x 10 mm, Tracheobronxane Y [Novatech, Grasse, France]) was placed on the carina between the bronchus to the right upper lobe and bronchus intermedius to maintain the airway lumen (Figs 1B–1D). After the procedures, the chest roentgenogram showed expansion of the right lung, and his dyspnea immediately improved. The patient underwent radiation therapy again. Although there were no stent-related adverse effects, the patient died due to the progression of lung cancer 69 days later.
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Fig 1. Bronchoscopic views (A) before and (B–D) after Y-stent placement. (A) Squamous cell carcinoma involving right main stem bronchus. (B) Proximal end of Y-stent in right main stem bronchus. (C) Y-stent covering carina between right upper lobe bronchus (RUL) and bronchus intermedius (BI). (D) Distal end of Y-stent in right upper lobe bronchus.
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Patient 2
A 67-year-old man suffering from right main stem bronchial obstruction due to endobronchial metastasis of renal cell carcinoma (Fig 2A) was referred to our department for bronchoscopic treatment. He complained of dyspnea and bloody phlegm. Therapeutic bronchoscopy with argon plasma coagulation and electrocautery was performed followed by a Dumon Y-stent (outer diameter; 16 x 13 x 13 mm) placement on the carina between the bronchus to the right upper lobe and bronchus intermedius to prevent recurrence (Figs 2B–2D; Fig 3). Respiratory symptoms improved immediately after the procedure, and the patient was returned to his referring physician. Although there were no stent-related adverse effects, the patient died due to the progression of the renal cell carcinoma 64 days later.
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Fig 2. Bronchoscopic views (A) before and (B–D) after radiopaque Y-stent placement. (A) Endobronchial metastases from renal cell carcinoma obstructing right main stem bronchus. (B) Proximal end of Y-stent in right main stem bronchus. (C) Y-stent covering carina between right upper lobe bronchus (RUL) and bronchus intermedius (BI). (D) Distal end of Y-stent in right upper lobe bronchus.
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Patient 3
A 64-year-old man with lung cancer (adenocarcinoma, stage IIIB) was referred to our department for treatment of dyspnea caused by a tumor involving the right main stem bronchus. Chest roentgenogram showed atelectasis of the right middle and lower lobe. Bronchoscopy showed a severe narrowing of the right main stem bronchus due to extrinsic compression from the membranous portion (Fig 4A). To re-establish the airway lumen, tumor resection and airway dilation were performed with argon plasma coagulation and balloon. Because the tumor involved the right upper lobe bronchus and bronchus intermedius, a Dumon Y-stent (outer diameter; 15 x 12 x 12 mm) was placed on the carina between the bronchus to the right upper lobe and bronchus intermedius (Figs 4B–4D). Chest roentgenogram after the procedures showed improvement of atelectasis and immediate improvement of dyspnea. Although the patient followed a satisfactory recovery course, the patient died due to the progression of lung cancer 105 days after the procedure.
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Fig 4. Bronchoscopic views (A) before and (B–D) after Y-stent placement. (A) Extrinsic compression from the membranous portion of right main stem bronchus. (B) Proximal end of Y-stent in right main stem bronchus. (C) Y-stent placed on carina between right upper lobe bronchus (RUL) and bronchus intermedius (BI). (D) Distal end of Y-stent in re-established right upper lobe bronchus.
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Comment
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Airway stenting has become widespread for the palliation of airway stenosis. Among the available prostheses, silicone stents are the most widely used for patients with malignant or benign stenosis [5], and various-shaped silicone stents are commercially available. However, silicone stents that require rigid bronchoscopy for insertion have generally been placed into the airway where a rigid bronchoscope can be easily reached, including the trachea, right main stem bronchus, bronchus intermedius, and left main stem bronchus. The right upper lobe bronchus usually branches off at sharp angles from the right main stem bronchus, and it is hardly accessible using a rigid bronchoscope. Therefore, there has not been ideal stenting to maintain the patency of the right upper lobe bronchus. Our method should be an effective way for stenting to the right upper lobe bronchus.
For the airway stenosis around the main carina, two or three straight stents had been used until the Y-stent was developed [6]. But the method had some problems including the tumor or granulation tissue overgrowth from the site between the edges of the stents and migration. The Y-stent dedicated to the palliation of the stenosis around the main carina significantly solved such problems [2, 3]. Theoretically, similar efficacy can be expected for the palliation of the stenosis around the carina between the bronchus to the right upper lobe and bronchus intermedius. Obstruction by secretion is another well-known complication associated with silicone stent placement. In the largest study of 1,574 placements with Dumon silicone stents (Novatech, Grasse, France) [1], the complication occurred in 3.6% of all procedures. To prevent or treat accumulation of secretions, the utility of saline solution or acetylcysteine nebulization, or both [3, 7], has been suggested. In our cases, no special airway management, such as bronchoscopy to clear secretions or stent replacement, was required except acetylcysteine nebulization 3 times daily after the procedure.
Commercially available Y-stents are designed for placement in the trachea, so they may be too large to place in the right main stem bronchus in some patients. A greater range in sizes of commercially available Y-stents would be needed for ensuring this procedure. Furthermore, we are hopeful that dedicated bifurcated stents with exclusive limb angles or sizes will be developed for more ideal stenting.
In conclusion, bronchoscopic placement of the Y-stent on the involved carina between the bronchus to the right upper lobe and bronchus intermedius is technically feasible, safe, and effective. Further studies with larger patient groups are needed to elucidate in more detail the use of this procedure.
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References
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- Dumon JF, Cavariere S, Diaz-Jimenez JP, et al. Seven-year experience with the Dumon prosthesis J Bronchol 1996;3:6-10.
- Dumon JF, Dumon MC. Dumon-Novatech Y-stents: a four-year experience with 50 tracheobronchial tumors involving the carina J Bronchol 2000;7:26-32.
- Dutau H, Toutblanc B, Lamb C, Seijo L. Use of the Dumon Y-stent in the management of malignant disease involving the carina: a retrospective review of 86 patients Chest 2004;126:951-958.[Abstract/Free Full Text]
- Shirakawa T, Imamura F, Hamamoto J, Shirkakusa T. A case of successful airway stent placement guided by endobronchial ultrasonography J Bronchol 2004;11:45-48.
- Ernst A, Feller-Kopman D, Becker HD, Mehta C. Central airway obstruction Am J Respir Crit Care Med 2004;69:1278-1297.
- Cavaliere S, Venuta F, Foccoli P, Toninelli C, La Face B. Endoscopic treatment of malignant airway obstructions in 2,008 patients Chest 1996;110:1536-1542.[Abstract/Free Full Text]
- Wood DE, Liu YH, Vallières E, Karmy-Jones R, Mulligan MS. Airway stenting for malignant and benign tracheobronchial stenosis Ann Thorac Surg 2003;76:167-174.[Abstract/Free Full Text]
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Role of Palliative Tracheobronchial Stenting in Hospice Patients: Boon or Bane?
American Journal of Hospice and Palliative Medicine,
September 1, 2011;
28(6):
445 - 448.
[Abstract]
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Abstract
Introduction
