A Simplified Insertion Technique for Tracheobronchial Silicone Stents

A Simplified Insertion Technique for Tracheobronchial Silicone Stents* Marc Noppen, MD ., F.e.c.p.; Erwin Dhondt , MD .; Marc Meysman, MD .; Ingr id Mon sieur, MD .; Elisabeth Gept s, MD .; and Walter G. Vincken , M.D ., PhD. , F.C.C.P. In many patients with central airway obstruction due to e xtrinsic compression or malacia, insertion of tracheobronch ial stents can provide effective and permanent relief. Of the various types of prostheses described, the silicone Dumon-Artemis st ents (Medicore, Brussels, Belguim) are probably the most efficient. The u se of an el egant and sa fe sp e ci a lly designed stent introducer sy stem combined with a special bronchoscope is proposed for insertion by Dumon. This combined st en t insertion

obstruction due to benign , eg, Tracheobronchial postsurgical stenosis, postintubation stri ctures or

malignant , eg, tracheal tumors, neoplastic inva sion from adjacent tumors, disorders can ofte n be successfully managed by various endoscopic techniques, thus avoiding the potential morbidity of open surgery.! In case of coexisting extrinsic compression or malacia, however , th ese techniques can offer-if feasible at all- only temporary relief . In the se patients , insertion of tracheobronchial stents can provide safe, effective, and permanent distention of the compromised airw ay, thus improving the quality of life. 2.3 Of the various types and mod els of prosthesis described , by far the greatest experience has been obtain ed with silicone Dumon-Artemi s stents (Medicore, Brussels, Belguim).2,4 Classically, stent insertion is achi eved by pushing the sten t (which is mounted over the tip of the bronchoscop e) off with a pro sthesis pusher .'' to avoid the risk of vocal cord damage during passage of th e stent-mounted bronchoscope, a special ste nt introducer system combined with a special bronchoscope featuring a series of int erchangeable tubes of var ious size (Efer-Dumon, la Ciotat , France) has been designed and is proposed by Dumon .2,4,5 Though elegant and safe , this introducing system is rather cumbersom e and expensive for most centers where relatively limited numbers of patients are treated . We describe our experience with tracheobronchial Dumon-Artemis prosthesis intubation , using a simplified insertion technique. *From the Departments of Pneumology (Drs. Noppen, Dhondt, Meysman, Monsieur , and Vincken) and Anesthesiology (Dr. Cepts), University Hospital AZ-VUB, Fr ee University of Brussels, Brussels, Belgium . Manuscr ipt received July 6, 1993; revision accepted November 1. Reprint requests: Dr. Noppen, Respiratory DiVision , Acade mic Hospita l AZ-V UB, B-1090 Brussels, Belgium

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system, however, is relatively expensive and cumbersome, especially for centers where relatively limited numbers of patients are treated. We propose an alternative, simplified insertion technique of silicone Dumen-Artemis stents, which was proven safe and efficient in our series of patients. (Chest 1994; 106:520-23) Key words: bronchoscopy ; prosthesis; stenosis, bronchial; ste nosis, trach eal M ETHODS

Eight pati ents with obstruc ting tracheal (five) or bronchial (three) disorders (six men , two women, mean age 72 ± 10 years, range 59 to 90 years) were treated . Five pati ents had neoplastic involvement by lung cancer (one ade nocarcinoma , four squamous cell carcinoma), thr ee pati ent s had benign tracheal stenosis (one postintub ation stricture, two inoperable intrathor acic goiter) (Table 1). A simplified insertion technique was designed and tried out on a dumm y (Nakhosteen Bronchoscopy Model Scopin, CL A, Coburg , Germany ). Prior to intubation , the lumen of the rigid bronchoscope (Storz, Tuttingen , Germany) was lubricated with a silicone spray (Silkospray , Rusch AG, Weiblin gen, German y) for about 10 s. Dumon-Artem is silicone stents of variou s sizes (Medicor, Brussels, Belgium ) were longitudinally folded and introdu ced into the externa l orifice of the bronchoscope, and pushed down the shaft using a foreign body forceps. All stent sizes up to 14-mm diameter could be passed throu gh the shaft. During expulsion of the stent, the bronchoscope was simult aneously retract ed over a distance eq ual to the lengt h of the stent. Th e entire procedure was repeated num erou s times, so as to obta in maxim al expertise and thus perform the inserti on as quickly as possible, since ventil ation of the patient is impossible during the passage of the stent . Rigid bronchoscopy was perfo rmed under general anesthesia (intravenous propofol, Dipri van , ICI Pharma ) using an 8.5 rigid bronchoscope (Storz) amended with a multiport head (Storz, Tuttingen , Germany). Vent ilation was ensured with high-frequency jet ventil ation (Acutronic) through a plastic 14F-di ameter catheter previously introduced and fixed in the proximal part of the tra chea (six pati ent s) or via a side port of the bronchoscope (two pati ents). Prior to intubation , the lumen of the bronchoscope was generously lubr icat ed with the silicone spray. After Nd:YAG laser photor esection of the endoluminal compon ent of the stenosis in five pat ients with malignant obstruction and in one pati ent with postintubation stricture, the bronchoscope was positioned with the tip d istally to the stenotic lesion. A Dumon-Artemis silicone stent of appropriate dim ension was then longitudinally folded and int roduc ed into the externa l orifice of the bronchoscope, and inserted using the techniq ue described above. Dur ing the expulsion of the stent, the bronchoscope was simultaneously retr acted over a distance eq ual to the length of the stent (Fig 1). Final adjustme nts were made using the same forceps. Trac heobronchial toilet and verification of stent placement was perfo rm ed with the flexible fiberoptic bronchoscope befor e extubation. Simplified Insertion for Tracheobronchial Silicone Stents (Nappen et all

T able I-Patient Cha rac te ristics, Obstru ctive Lesions , and Complications" Patient / Sex/ Age, yr

Obstructin g Disorder

1/M / 66 2/M /6 8 3 / M/75 4/M /72 5/ M/62 6/M /59 7/F/ 90 8/ F /89

Adenocarcinoma LMB Postintub alion stricture Squamou s cell carc T Squamous cell carc T Squam ous cell carc LMB Squam ous cell care RMB Intrathoracic goiter Intra thoracic goiter

Laser Tr eatm ent

Minor Complications

+

+ + +

+ +

Superinfeclion S aureus Stent obstruction < 24 h: removal of debris + stent read justment

Stent Type and Size BD; 30 X12 mm TD; 30 X I 4 mm TD; 40X14 mm TD; 40X 14 mm BD; 30X lO mm BD; 30 XlO mm TD; 50XI4 mm TD ; 40X 14 mm

*LMB=l eft main bronchus; T =trachea; RMB=right main bronchus; TD = tracheal type; BD=stand ard bronchial type; carc =ca rcinoma . Reg ular follow-up with th e fibe roptic bronc hoscope was perfor me d a t a monthly basis. R ESULTS

Results are sum marized in Table 1. Eight stents we re successfully inserted in eig ht pati ents. Ther e were no com plications during the procedure. Prelubri cati ng of th e bronch oscope sha ft allowe d quick and uncom plicated int roduction of stents up to 14 mm in di ameter and in two pati ents not included in thi s series, 16-mm-diam eter stents were uneventfully introduced using th e "classical" externa l pro sthesis pusher method .' In one pati ent in our series, reintubat ion had to be perform ed 48 hours afte r insertion , d ue to airway obstruc tion with necr otic tumor materi al and imperfec t stent place me nt. After mechanical debridem ent and stent placem ent readjustm ent , th e postoperati ve evolution was uneventful. In the pa tien ts treated for ma lignant tracheobronchial involvement, airwa y paten cy was ensured until death , except for one patient in who m th e stent was rem oved after 6 months du e to bulk y tu mor growth distal to th e pr osth esis. In one pati ent with benign

A

a=t1.-t-+----71€

airway stenosis, th e stent is still in place 1 yea r afte r insertion ; in th e oth er pat ient th e stent has been successful for 4 months (with the patien t' s death due to acute myocardial inf arction). We did not observe migr ati on of sten ts; th e sten ts were well tolerated , and irrita tive cough did not occur. Ther e we re no cases of stent obstr uction due to dri ed secretions. Follow-up included regul ar fiber optic br onchoscopy at mon th ly int er vals. We observe d one case of superinfect ion with Staphy lococcus aureu s that respond ed well to antibiotic th erapy (oral floxacillin , 500 mg th ree tim es a da y during 3 weeks). D ISCUSSION

We pr opose an insertion technique of silicone tr acheo bro nchial stents th at is cheap , simple, safe, and efficie nt. Airwa y obstruction with d yspn ea , hypoxemia , and ultimat ely suffocation represent s a major com plica tion of various upper airway disorders. Malignant airway disease is th e most freq uent ca use of airway obstruct ion: an estimated 20 to 30 per cent of patients will have retro-obstructi ve com plica tions, and pa-

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FIGURE 1. A, Un der visual control, an d aft er eve ntual Nd :YAG laser tr eat m ent , th e previously lub ricat ed bronchoscop e is positioned with its tip distal to th e stenosis. B, T he telescope is rem oved a nd the longitu d inally folded stent is inserted in the fixed-positioned broncho scop e. The sten t is grasped with a foreign-bod y force ps and pu shed distally. C, Dur ing expulsion of the stent into the stenosis, the bronchoscop e is sim ultaneously retra cted .

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Table 2-Various Types and Models of Tracheobronchial Stents Reported in the Literature Stent Type and Materi al Silicone/plastic Silicone rubber T tube (Montgome ry)

Modified (lengthe ned and /or bifurcated ) T tub e Modified (removed tracheostomy side limb ) T tub e Dacron-sili cone stent Molded silicone (Dumon-Artemis)

Fenestrated silicone dra in Tailor-made modified tracheostom y cannulas Endotracheal tub e via tra cheostomy Metal Metal alloy tube Stainless steel wire coil Modified soutta r tube Stainless steel expanda ble wire Z stent (Gianturco)

Mixed Stainless steel wirc springs covered with silicone Nylon and PVC- covered expandable metal stent s Self-expanding stai nless stcel wire mesh Scheider prosthesis

Cha rac teristic/ Rem arks Tr ache ostomy orifice necessary ; used in subglott ic stenosis, tra cheal injury , tra cheal stenosis, and com plicated tra cheal resection s Saddles the carina; trach eostomy orifice necessary Tracheostomy orifice no longer needed Intubation of trachea and both mainstem bron chi Various sizes and typ es comm erci ally available. 1'\0 fenestration. Easily remov ed or changed. Larg est experience reported. Case report Case report Case report

Are inserted rath er easily. Do not prevent recurrence by intraluminal tum or growth throu gh the zig-zag wires. Cannot be removed or displac ed.

13-19 20,28,39 21-23 24 4-11

25 26

27

12 29 30 31-34,37

35 Offers protection again st encroachm ent by intraluminal tumor growth Originally designed for use in blood vessels

tients with lung cancer in whom all therapeutic options are exhausted are often at risk for severe airway compromise.P Benign causes of airway obstruction include postintubation or postoperative tracheal or bronchial stenosis and/or malacia .e-" Endoluminal obstruction can be managed with a variety of endoscopic techniques such as Nd :YAG laser photodestruction," mechanical tumor removal with forceps or with th e tip of the rigid bronchoscope.f diatherrny.l' cryotherapy, 10 or photodynamic therapy. 11 If extrinsic compression or malacia are involved , however , these techniques offer, when feasible at all, only temporary relief. Stent insertion can maintain airway patency in these cases. A wid e variety of types and models of tracheobronchial stents have been used in the past few decades (Table 2).4-39 Recently, a dedicated stent made of molded silicone on which th e outer surface bears regularly placed pitted studs to ensur e adherence to the airway wall was introduced by Dumon;4,5 by far , the largest experience has been built up with th is type of stent. The use of a specially designed rigid Dumon-Harrell Universal Bronchoscope (Efer-Dumon, la Ciotat, France) with a specifically designed stent introducer system (Efer-Dumon , la Ciotat , France) for the insertion of these increasingly used silicone stents is propagated,2,4,5 although insertion with a fiberoptic bronchoscope is possible. t" We agree with Dumon that, although fiberoptic bronchoscopy is often useful simultaneously with 522

Refer ence 1'\0.

36

38

rigid bronchoscopy, eg, for laser photodestruction (personal experience) , the rigid system is easi er and safer for interventional endoscopic procedures such as hemostasis, aspiration, removal, or repositioning of stent.'! In most centers, however, therapeutic bronchoscopy with stent insertions is not routinely performed, and relatively limited numbers of patients ar e treated and in our hospital, it is about ten to fifteen patients a year. Acquisition of the relatively expensive (± $25 ,000) bronchoscope-stent introducer system is, therefore, not easily justifiable. Moreover, the proposed introducer system seems rather cumbersome: the stent is folded and aspirated into a prosthesis introducer tube through a hockey-puck-shaped funnel loader using a vacuum aspiration; the introducer tube is passed down the open bronchoscope, and a prosthesis pusher is th en used to expel the stent out into the stenotic segment. The system features a system of interchangeable tubes of various sizes that are used to calibrate and dilate the stenosis .v" Although the results of this introducer system appear excellent in experienced hands in specialized referral centers,2,4,5 we developed a cheaper and less cumbersome stent introducer system requiring only a "simple" rigid bronchoscope size 8.5 and a for eign body forceps . As shown , the results are excellent in stents with a maximal diameter of 14 mm . For larger tracheal stents, the "classical" system can still be used " (pe rsonal data) . Simplified Insertionfor Tracheobronchial SiliconeStents (Noppen et al)

In conclusion, obstruction of central airways by extrinsic compression or malacia can often be managed by tracheobronchial stents. The silicone Dumen-Artemis stent offers several advantages over other types of prosthesis: th ey are well tolerated, easily removable or interchangeable, inpenetrable for tumor growth, and resistant to obstruction by dry secretions.e-" The stent insertion system and bronchoscope proposed by Dumon, however, is relatively expensive and cumbersome. Since numbers of patients actually candidates for this type of treatment are usually limited in most hospitals, an alternative simple, safe, efficient, and cheap Dumon-Artemis stent insertion technique is proposed. ACKNOWLEDGMENTS: The authors thank Hilde De Smedt for secretarial work and are grateful for the invaluable aid offered by the nursing staff: Bea Van Elewijck, May Dierickx , Carine Michiels, Anne Ringoir , and Daniel Schuermans. REFERENCES

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