- Email: [email protected]
Double stents for carcinoma of the esophagus invading the airway
Ann Thorac Surg 1997;63;1511-6
CORRESPONDENCE
1515
his and our findings, which were confirmed over the past 3 years in our laboratory.
Sophie M. Carpentier, PhD Alain F. Carpentier, MD, PhD Lin Chen, MD Ming Shen, MD Lillian J. Quintero, MS Thomas H. Witzel, MS Laboratoire d'Etude des Greffes et Protheses Cardiagues H6pital Broussais 96 rue Didot Paris 75674 France
Double Stents for Carcinoma of the Esophagus Invading the A i r w a y
A
To the Editor: We read with interest the article "Expandable Metallic Stents for Tracheobronchial Stenoses in Esophageal Cancer" by Takamori and associates [1]. Takamori and associates report 12 cases of compression/infiltration of the airway by esophageal carcinoma; in all cases relief of respiratory failure was accomplished by placing one or more uncovered Gianturco stents in the trachea or main bronchi. In the last 3 years we performed more than 200 neodymium: yttrium-aluminium garnet laser resections of lesions obstructing the airway; in 7 cases the obstruction was related to direct infiltration of the trachea (4), left main bronchus (2), and right main bronchus (1) by esophageal carcinoma. The airway involvement occurred at first presentation of the esophageal tumor in 6 patients and at mediastinal recurrence after operation in 1. Dyspnea and dysphagia were the primary symptoms and the main indication for operation. The clinical status was critical in all patients due to severe weight loss, respiratory failure, and aspiration. All patients had lesions growing inside the airway, and 4 presented a fistula between the esophagus and the trachea. Laser resection was always required as the first step of treatment to obtain a viable airway before insertion of the stent. In all patients we used a covered expandable metallic stent in the esophagus and one or more silicone stents in the airway (Endoxane; Novatech, Aubagne, France). It is important to stress that these patients present locally advanced esophageal carcinoma (T4) and cure is obviously impossible. Thus, the aim of the endoscopic treatment is to provide temporary palliation and relief of symptoms and improve the quality of life. Life expectancy could also be improved because effective palliation allows feeding and thus enhancement of the nutritional status; also aspiration and infectious complication are prevented when a tracheoesophageal fistula is correctly sealed. Reports in the literature are scanty, and the operative strategy is still controversial. In fact, single or double stenting of the esophagus and the proximal airway has been reported, and both techniques seem to be relatively successful in small series of patients. Also, the type of stent employed is different in each report. In our opinion, effective and long-lasting palliation is better accomplished by placing a stent in both the esophagus and the airway (Fig 1) [2, 3]. In fact, if only a single stent is placed either in the trachea or the esophagus, the other viscus could be compressed and closed by the bulge of the tumor. We believe that uncovered metallic stents should not be used in these patients because the tumor could grow within the mesh of the stent, causing early recurrence of symptoms and bleeding, and © 1997 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
B
Fig 1. (A) Preoperative computed tomographic scan of esophageal carcinoma invading the aimvay: a fistula between the esophagus and the trachea is shown. (B) Computed tomographic scan after double stenh'ng: the fistula is compressed and plugged by the two stents, and the caliber of the trachea and the esophagus is restored.
favoring the development of a fistula, if it is not yet present. Also, closure of the fistula is obviously impossible with uncovered stents. In addition, life expectancy is not that short in this subset of patients (from 3 to 23 m o n t h s in our experience) [4] if they are properly treated after stent placement (nutritional support and chemotherapy), and erosion of the tumor by the uncovered wires is always possible. In particular, the Gianturco stents have large mesh and virtually no predetermined limit to their expansion. For this reason we prefer covered expandable stents in the esophagus and one or more silicone stents in the airway. Furthermore, neodymium:yttrium-aluminium garnet laser resection both in the esophagus and the airway can be performed safely if the surface is completely covered and sealed by the stent. We always obtained complete and immediate relief of symptoms without further aspiration in patients with tracheoesophageal fistula; no fistula developed after the endoscopic treatment. No migration of the stent occurred. On the basis of our limited experience we advocate double esophageal and tracheal stenting for palliation of this difficult situation. We prefer to insert covered expandable metallic stents within the esophagus and silicone stents in the airway. Uncovered metallic stents should be used only in case of malacia or
0003-49751971517.00
1516
CORRESPONDENCE
Ann Thorac Surg 1997;63;1511-6
compression without infiltration, but this condition was not present in our series of patients.
be applied to alleviate extrinsic compression having no infiltration of tracheobronchial stenosis.
Federico Venuta, MD Tiziano De Giacomo, MD Erino A. Rending MD Paolo Trentino, MD Giorgio Della RoccG MD Costante Ricci, MD
First Department of Surgery Kurume University School of Medicine 67 Asahi-machi Kurume 830, Japan
Cattedra di Chirurgia Toracica Policlinico Umberto I Univ. of Rome "La Sapienza" V.le del Policlinico 00100 Rome, Italy References 1. Takamori S, Fujita H, Hayashi A, et al. Expandable metallic stents for tracheobronchial stenoses in esophageal cancer. Ann Thorac Surg 1996;62:844-7. 2. Ell G, May A, H e h n EG. Gianturco-Z stents in the palliation treatment of malignant esophageal obstruction and esophagotracheal fistulas. Endoscopy 1995;27:495-500. 3. Colt HG, Meric B, D u m o n JF. Double stents for carcinoma of the esophagus invading the tracheobronchial tree. Gastrointest Endosc 1992;38:485-9. 4. Rebeiz EE, Beamis JF Jr, Vergas K, Shapshay SM. Tracheobronchial obstruction from esophageal carcinoma: bronchoscopic treatment with neodymium:yttrium-aluminium-garnet laser. Ann Otol Rhinol Laryngol 1992;101:556-9.
Reply To the Editor: I appreciate the opportunity to respond to correspondence by Venuta and colleagues regarding our report of metallic stents for tracheobronchial stenoses in esophageal cancer [1]. I concur with their concept of the use of double stenting for esophageal cancer patients with a fistula between the esophagus and the trachea. They employed a covered expandable metallic stent in the esophagus and one or more silicone stents in the airway, which may be ideal for palliative treatment in their cases. In our series, healing or closing of the fistula failed in 1 patient with tracheoesophageal fistula. We have had little experience of stenting for a tracheoesophageal fistula, the management of which remains a difficult problem. On the choice of stent, we advocate Gianturco stent w h e n the patient is severely compromised because the procedure of stent insertion is noninvasive compared with that for a silicone stent. Our choice is consistent with that of Carrasco and associates [2], who reported that in patients with no other options, the presence of severe symptoms warrants consideration of palliation with an intraluminal stent. Basically, the Gianturco stent should
© 1997 by The Society of Thoracic Surgeons Published by Elsevier Science lnc
Shinzo Takamori, MD
References 1. Takamori S, Fujita H, Hayashi A, et al. Expandable metallic stents for tracheobronchial stenoses in esophageal cancer. Ann Thorac Surg 1996;62:844-7. 2. Carrasco CH, Nesbitt JC, Charnsangavej C, et al. Management of tracheal and bronchial stenoses with the Gianturco stent. Ann Thorac Surg 1994;58:1012-7. H e n r y S w a n II, M D
To the Editor: I read with interest the obituary of Dr Henry Swan II by Dr Rainer [1]. I too admired Dr Swan's pioneering work on open heart surgical repair of atrial septal defect u n d e r hypothermia, although his name was often overshadowed by the sameinitialled Dr H. J. C. Swan of the Swan-Ganz catheter. Doctor Rainer wrote that Swan established the Halstead Laboratory for surgical research in the University of Colorado School of Medicine. Lest your readers be confused that there might be another pioneer in surgical research by the n a m e of Halstead, I would like to point out that Halstead was a misspelling of Hatsted, one of the four giants from Johns Hopkins University: Halsted the surgeon, Osler the physician, Kelly the gynecologist, and Welch the pathologist [2].
Tsung O. Cheng, MD Division of Cardiology George Washington University Medical Center 2150 Pennsylvania Ave, N W Washington, DC 20037 References 1. Rainer WG. Henry Swan II, MD. A n n Thorac Surg 1996;62: 1565. 2. Cheng TO. William Osler. Clin Cardiol 1988;11(9):A19.
Editor's Note The alert Dr Cheng has picked up a typographic error that was not corrected during copy editing. The Editor apologizes for the mistake. The correct reading should be "the Halsted Laboratory for surgical research."
0003-49751971517.00
CORRESPONDENCE
1515
his and our findings, which were confirmed over the past 3 years in our laboratory.
Sophie M. Carpentier, PhD Alain F. Carpentier, MD, PhD Lin Chen, MD Ming Shen, MD Lillian J. Quintero, MS Thomas H. Witzel, MS Laboratoire d'Etude des Greffes et Protheses Cardiagues H6pital Broussais 96 rue Didot Paris 75674 France
Double Stents for Carcinoma of the Esophagus Invading the A i r w a y
A
To the Editor: We read with interest the article "Expandable Metallic Stents for Tracheobronchial Stenoses in Esophageal Cancer" by Takamori and associates [1]. Takamori and associates report 12 cases of compression/infiltration of the airway by esophageal carcinoma; in all cases relief of respiratory failure was accomplished by placing one or more uncovered Gianturco stents in the trachea or main bronchi. In the last 3 years we performed more than 200 neodymium: yttrium-aluminium garnet laser resections of lesions obstructing the airway; in 7 cases the obstruction was related to direct infiltration of the trachea (4), left main bronchus (2), and right main bronchus (1) by esophageal carcinoma. The airway involvement occurred at first presentation of the esophageal tumor in 6 patients and at mediastinal recurrence after operation in 1. Dyspnea and dysphagia were the primary symptoms and the main indication for operation. The clinical status was critical in all patients due to severe weight loss, respiratory failure, and aspiration. All patients had lesions growing inside the airway, and 4 presented a fistula between the esophagus and the trachea. Laser resection was always required as the first step of treatment to obtain a viable airway before insertion of the stent. In all patients we used a covered expandable metallic stent in the esophagus and one or more silicone stents in the airway (Endoxane; Novatech, Aubagne, France). It is important to stress that these patients present locally advanced esophageal carcinoma (T4) and cure is obviously impossible. Thus, the aim of the endoscopic treatment is to provide temporary palliation and relief of symptoms and improve the quality of life. Life expectancy could also be improved because effective palliation allows feeding and thus enhancement of the nutritional status; also aspiration and infectious complication are prevented when a tracheoesophageal fistula is correctly sealed. Reports in the literature are scanty, and the operative strategy is still controversial. In fact, single or double stenting of the esophagus and the proximal airway has been reported, and both techniques seem to be relatively successful in small series of patients. Also, the type of stent employed is different in each report. In our opinion, effective and long-lasting palliation is better accomplished by placing a stent in both the esophagus and the airway (Fig 1) [2, 3]. In fact, if only a single stent is placed either in the trachea or the esophagus, the other viscus could be compressed and closed by the bulge of the tumor. We believe that uncovered metallic stents should not be used in these patients because the tumor could grow within the mesh of the stent, causing early recurrence of symptoms and bleeding, and © 1997 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
B
Fig 1. (A) Preoperative computed tomographic scan of esophageal carcinoma invading the aimvay: a fistula between the esophagus and the trachea is shown. (B) Computed tomographic scan after double stenh'ng: the fistula is compressed and plugged by the two stents, and the caliber of the trachea and the esophagus is restored.
favoring the development of a fistula, if it is not yet present. Also, closure of the fistula is obviously impossible with uncovered stents. In addition, life expectancy is not that short in this subset of patients (from 3 to 23 m o n t h s in our experience) [4] if they are properly treated after stent placement (nutritional support and chemotherapy), and erosion of the tumor by the uncovered wires is always possible. In particular, the Gianturco stents have large mesh and virtually no predetermined limit to their expansion. For this reason we prefer covered expandable stents in the esophagus and one or more silicone stents in the airway. Furthermore, neodymium:yttrium-aluminium garnet laser resection both in the esophagus and the airway can be performed safely if the surface is completely covered and sealed by the stent. We always obtained complete and immediate relief of symptoms without further aspiration in patients with tracheoesophageal fistula; no fistula developed after the endoscopic treatment. No migration of the stent occurred. On the basis of our limited experience we advocate double esophageal and tracheal stenting for palliation of this difficult situation. We prefer to insert covered expandable metallic stents within the esophagus and silicone stents in the airway. Uncovered metallic stents should be used only in case of malacia or
0003-49751971517.00
1516
CORRESPONDENCE
Ann Thorac Surg 1997;63;1511-6
compression without infiltration, but this condition was not present in our series of patients.
be applied to alleviate extrinsic compression having no infiltration of tracheobronchial stenosis.
Federico Venuta, MD Tiziano De Giacomo, MD Erino A. Rending MD Paolo Trentino, MD Giorgio Della RoccG MD Costante Ricci, MD
First Department of Surgery Kurume University School of Medicine 67 Asahi-machi Kurume 830, Japan
Cattedra di Chirurgia Toracica Policlinico Umberto I Univ. of Rome "La Sapienza" V.le del Policlinico 00100 Rome, Italy References 1. Takamori S, Fujita H, Hayashi A, et al. Expandable metallic stents for tracheobronchial stenoses in esophageal cancer. Ann Thorac Surg 1996;62:844-7. 2. Ell G, May A, H e h n EG. Gianturco-Z stents in the palliation treatment of malignant esophageal obstruction and esophagotracheal fistulas. Endoscopy 1995;27:495-500. 3. Colt HG, Meric B, D u m o n JF. Double stents for carcinoma of the esophagus invading the tracheobronchial tree. Gastrointest Endosc 1992;38:485-9. 4. Rebeiz EE, Beamis JF Jr, Vergas K, Shapshay SM. Tracheobronchial obstruction from esophageal carcinoma: bronchoscopic treatment with neodymium:yttrium-aluminium-garnet laser. Ann Otol Rhinol Laryngol 1992;101:556-9.
Reply To the Editor: I appreciate the opportunity to respond to correspondence by Venuta and colleagues regarding our report of metallic stents for tracheobronchial stenoses in esophageal cancer [1]. I concur with their concept of the use of double stenting for esophageal cancer patients with a fistula between the esophagus and the trachea. They employed a covered expandable metallic stent in the esophagus and one or more silicone stents in the airway, which may be ideal for palliative treatment in their cases. In our series, healing or closing of the fistula failed in 1 patient with tracheoesophageal fistula. We have had little experience of stenting for a tracheoesophageal fistula, the management of which remains a difficult problem. On the choice of stent, we advocate Gianturco stent w h e n the patient is severely compromised because the procedure of stent insertion is noninvasive compared with that for a silicone stent. Our choice is consistent with that of Carrasco and associates [2], who reported that in patients with no other options, the presence of severe symptoms warrants consideration of palliation with an intraluminal stent. Basically, the Gianturco stent should
© 1997 by The Society of Thoracic Surgeons Published by Elsevier Science lnc
Shinzo Takamori, MD
References 1. Takamori S, Fujita H, Hayashi A, et al. Expandable metallic stents for tracheobronchial stenoses in esophageal cancer. Ann Thorac Surg 1996;62:844-7. 2. Carrasco CH, Nesbitt JC, Charnsangavej C, et al. Management of tracheal and bronchial stenoses with the Gianturco stent. Ann Thorac Surg 1994;58:1012-7. H e n r y S w a n II, M D
To the Editor: I read with interest the obituary of Dr Henry Swan II by Dr Rainer [1]. I too admired Dr Swan's pioneering work on open heart surgical repair of atrial septal defect u n d e r hypothermia, although his name was often overshadowed by the sameinitialled Dr H. J. C. Swan of the Swan-Ganz catheter. Doctor Rainer wrote that Swan established the Halstead Laboratory for surgical research in the University of Colorado School of Medicine. Lest your readers be confused that there might be another pioneer in surgical research by the n a m e of Halstead, I would like to point out that Halstead was a misspelling of Hatsted, one of the four giants from Johns Hopkins University: Halsted the surgeon, Osler the physician, Kelly the gynecologist, and Welch the pathologist [2].
Tsung O. Cheng, MD Division of Cardiology George Washington University Medical Center 2150 Pennsylvania Ave, N W Washington, DC 20037 References 1. Rainer WG. Henry Swan II, MD. A n n Thorac Surg 1996;62: 1565. 2. Cheng TO. William Osler. Clin Cardiol 1988;11(9):A19.
Editor's Note The alert Dr Cheng has picked up a typographic error that was not corrected during copy editing. The Editor apologizes for the mistake. The correct reading should be "the Halsted Laboratory for surgical research."
0003-49751971517.00