Endobronchial management of benign, malignant, and lung transplantation airway stenoses

doi:10.1016/0003-4975(95)00216-8

The Annals of Thoracic Surgery

Volume 59, Issue 6, June 1995, Pages 1417-1422

https://doi.org/10.1016/0003-4975(95)00216-8 Get rights and content

Since 1991, we have managed 57 patients with benign (10), malignant (23), or lung transplantation (24) airway obstructions using silicone stenting and debridement (manual/neodymium:yttrium-aluminum garnet laser). Ten patients with benign lesions (4 intubation, 4 inflammatory, 1 malacia, 1 bronchial fistula) had 4 T tubes, 3 Y stents, 3 bronchial stents, and 1 straight tracheal stent placed. Eight of 10 patients (80%) received symptomatic relief with the stents in place for up to 43 months. Twenty-three patients with malignant strictures (18 lung, 5 metastatic) had 26 stents inserted (13 Y stents, 12 bronchial, 1 T tube) of which 16 required combined debridement and stenting. Four stents required repositioning. Three hospital deaths were due to unrelated causes. Of 20 discharged patients, 6 remain alive at 2 to 10 months, whereas 14 patients who died of progressive disease obtained effective palliation for 10.5 ± 5.6 months. Significant bronchial anastomotic complications developed in 24 of 212 lung transplants (11.3%). Thirty-one stents were placed in 19 of the patients; 5 patients were managed with laser debridement alone. Of the 19 patients receiving stents, 3 required only temporary stents (6 to 15 days), 11 patients needed long-term stents (40 to 507 days), and 5 patients died with their stents in place functioning well. All patients received symptomatic relief with stenting. There were no procedure-related deaths and one bronchial laceration during attempted stent placement. Early, aggressive treatment of benign and malignant tracheobronchial strictures with endoscopic debridement and stenting is safe and well tolerated, and effectively palliates airway obstruction. Repositioning of stents frequently may be required in the transplant population. Techniques of stent insertion require no specialized equipment and may be performed expeditiously with minimal morbidity.

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Cited by (108)

Airway Complications After Lung Transplantation
2017, Clinics in Chest Medicine
Citation Excerpt :
Argon plasma coagulation, electrocautery, and laser ablation also have been described as successful management approaches to excessive granulation tissue.1,89,93,94 Granulation tissue recurs following intervention in 10% to 50% of cases.95 Endobronchial application of antifibrotics like mitomycin or injection of anti-inflammatory agents has been used to reduce the recurrence rate.
Airway Complications Following Lung Transplantation
2011, Clinics in Chest Medicine
Citation Excerpt :
Airway stents may be placed to maintain patency of the airway; however, stents inherently cause granulation tissue. Granulation tissue recurs following interventions in 10% to 50% of cases.36 Endobronchial injection of antifibrotic and inflammatory agents has been used to reduce the recurrence rate.
Treatment outcomes of patients with adenoid cystic carcinoma of the airway
2011, Lung Cancer
Adenoid cystic carcinoma (ACC) of the airway is a slowly growing tumor and airway narrowing is one of the main causes of death. The purposes of this study were to investigate treatment outcomes, prognostic factors, and the indications and outcomes of bronchoscopic interventions in patients with ACC of the airway.
We retrospectively analyzed the clinical characteristics, treatment modalities, and clinical outcomes of patients with histologically-proven ACC of the airway treated between January 1995 and June 2009 at Samsung Medical Center.
A total of 30 patients were included in the study. Sixteen patients were male and the median age was 45 years. Multiple treatment modalities were required for the patients; 17 for surgery, 13 for definitive radiation therapy, 10 for adjuvant radiation therapy, and 1 for adjuvant chemotherapy. Bronchoscopic interventions were required to improve airway narrowing in 20 patients. After bronchoscopic intervention, 19 patients (95%) showed immediate improvement of airway narrowing and suffered no serious complications. The 5- and 10-year overall survival (OS) rates in these patients were 84% and 70%, respectively. The prognostic factors associated with OS were tumor size, tumor location, clinical T stage, surgery as an initial treatment, and bronchoscopic intervention.
ACC of the airway had a good long-term prognosis but bronchoscopic interventions were frequently required during the course of the disease due to the development of airway narrowing. Bronchoscopic interventions may be considered as a bridge therapy before surgery or radiation therapy and as a palliative therapy for airway narrowing.
A retrospective study of silicone stent placement for management of anastomotic airway complications in lung transplant recipients: Short- and long-term outcomes
2010, Journal of Heart and Lung Transplantation
Airway anastomotic complications remain a major cause of morbidity and mortality after lung transplantation (LT). Few data are available with regard to the use of silicone stents for these airway disorders. The aim of this retrospective study was to evaluate the clinical efficacy and safety of silicone stents for such an indication.
Data of adult lung transplant recipients who had procedures performed between January 1997 and December 2007 at our institution were reviewed retrospectively. We included patients with post-transplant airway complications who required bronchoscopic intervention with a silicone stent.
In 17 of 117 (14.5%) LT recipients, silicone stents were inserted at a mean time of 165 (range 5 to 360) days after surgery in order to palliate 23 anastomotic airway stenoses. Symptomatic improvement was noted in all patients, and mean forced expiratory volume in 1 second (FEV₁) increased by 672 ± 496 ml (p < 0.001) after stent insertion. The stent-related complication rate was 0.13/patient per month. The latter consisted of obstructive granulomas (n = 10), mucus plugging (n = 7) and migration (n = 7), which were of mild to moderate severity and were successfully managed endoscopically. Mean stent duration was 266 days (range 24 to 1,407 days). Successful stent removal was achieved in 16 of 23 cases (69.5%) without recurrence of stenosis. Overall survival was similar in patients with and without airway complications (p = 0.36).
Silicone stents allow clinical and lung function improvement in patients with LT-related airway complications. Stent-related complications were of mild to moderate severity, and were appropriately managed endoscopically. Permanent resolution of airway stenosis was obtained in most patients, allowing definitive stent removal without recurrence.
Clinical Experience With a New Removable Tracheobronchial Stent in the Management of Airway Complications After Lung Transplantation
2009, Journal of Heart and Lung Transplantation
Airway complications are among the most challenging problems after lung transplantation. This article describes the use of a new tracheobronchial stent that can be placed and removed easily by flexible bronchoscopy.
A retrospective review was done of 24 consecutive patients requiring tracheobronchial stent placement after lung transplantation. A new self-expanding hybrid nitinol stent was used, and changes in airway diameter and spirometry were assessed. Stent related complications were recorded.
Between February 2007 and April 2008, 24 patients underwent stent placement, and 49 stents were placed for 36 anastomoses at risk. Indications included bronchial stenosis in 12, bronchomalacia in 12, bronchial stenosis plus bronchomalacia in 20, and partial bronchial dehiscence in 5. Adjunctive procedures included electrocautery in 1, balloon dilatation in 7, and electrocautery plus balloon dilatation in 4. The average degree of stenosis decreased from 80% to 20%. After stent placement, the average increase was 0.28 liters in forced vital capacity and 0.44 liters in forced expiratory volume in 1 second. Complications included granulation tissue formation in 10 stents, migration in 9, thick mucus formation in 2, and fracture in 3.
Airway complications in lung transplant patients were effectively palliated. Our complication rate with this new stent is comparable with other airway stents. This stent has the advantage of easy removability during flexible bronchoscopy if complications from the stent outweigh the benefits of palliation.
Current readings: The role of stenting in tracheobronchial disease
2014, Seminars in Thoracic and Cardiovascular Surgery
Citation Excerpt :
The earliest reports by Saad et al15 and Chhajed et al,16 and more recently by Abdel-Rahman et al,17 using metal stents indicate successful use of self-expanding metal stents in post–lung transplant patients. Sonett et al18 and Thistlethwaite et al19 also established the safety and efficacy of silicone stents in the management of post–lung transplant tracheobronchial complications. Successful stent removal was obtained in both studies without subsequent airway compromise.
Airway stents have gained acceptance for palliation or treatment of tracheobronchial pathologies or both since the second half of the 20th century. However, minimal advances have been made in the last 3 decades with regard to innovations in stent technology. Following a health alert issued by the Food and Drug Administration in 2005, silicone stents are now mainly used for benign pathologies whereas self-expanding metal stents are reserved for use with malignant airway obstruction. In this article, we review 5 articles published between 2010 and 2013 addressing the roles of stents in the management of malignant, benign, and post–lung-transplantation-related tracheobronchial narrowing. We identified what were the largest or most clinically relevant series in each case, but with the understanding that all are retrospective reviews with patient selection bias.

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: Presented at the Forty-first Annual Meeting of the Southern Thoracic Surgical Association, Marco Island, FL, Nov 10–12, 1994.

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Endobronchial management of benign, malignant, and lung transplantation airway stenoses

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Chest

Ann Thorac Surg

Ann Thorac Surg

Chest

Ann Thorac Surg