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Endobronchial Stenting for Anastomotic Stenosis After Sleeve Resection
Endobronchial Stenting for Anastomotic Stenosis After Sleeve Resection Victor Tsang, FRCS, and Peter Goldstraw, FRCS Brompton Hospital, London, England
Bronchial anastomotic stenosis is a potentially serious complication of sleeve resection. A Silastic endobronchial stent that prevents progressive narrowing at the anastornotic site is described. Insertion of the stent offers a simple and effective treatment that allows improved pulmonary performance, clearing of infection, and good quality of life. The long-term prognosis, however, remains questionable. (Ann Thorac Surg 1989;48:568-71)
S
urvival after sleeve resection for lung tumors in select patients compares favorably with that after pneumonectomy. Morbidity and mortality are reduced while preserving lung tissue and without compromising on tumor clearance. A potentially serious complication of sleeve resection is bronchial anastomotic stenosis, which is due to interrupted bronchial blood supply to the distal bronchial segment and partial anastomotic dehiscence, with granulation tissue formation. There are few therapeutic options available for the treatment of this complication. They include repeated dilations of the stenotic area, immediate resection and reanastomosis, or completion pneumonectomy. This report describes our clinical experience with 2 patients in whom an endobronchial stent was used to manage bronchial anastomotic stenosis. We discuss the advantages and potential disadvantages of this method.
Material and Methods Technique
Fig 1 . Silastic endobronchial stent.
A fine English bougie (Fig 2) is positioned across the stricture (Fig 3a). The stent of desired size is selected and placed over the bougie (Fig 3b), and is then manipulated through the larynx and into the trachea with a laryngoscope and McGill's forceps. The rigid bronchoscope is used to push the stent to the stricture site (Fig 3c, d). The tip of the bronchoscope is used to keep the stent in a stable position while the fine bougie is withdrawn (Fig 3e). Any fine adjustment can then be done with a grasping forceps through the rigid bronchoscope (Fig 3).
Case Reports PATIENT I. A 65-year-old male smoker was given four courses of chemotherapy (cyclophosphamide, vincristine
The stent is fashioned using an appropriate length of the vertical limb of a 10- to 14-mm Silastic (Dow Corning) Montgomery T tube, and the rims are made from short segments of a slightly larger Montgomery T tube. The parts are fitted together with silicone glue (Fig 1). The stent is inserted at bronchoscopy under general anesthesia. Ventilation is maintained by a Venturi jet system. The site and length of the stricture are assessed. With bronchoscopic guidance, the stenotic area is dilated with graduated English bougies. Secretion and pus are evacuated from the distal bronchial tree. The bronchoscopic telescope can then be negotiated through the stricture, and the anatomy beyond can be assessed and biopsy done. Accepted for publication July 7, 1989. Address reprint requests to Mr Goldstraw, Brompton Hospital, Fulham Rd. London SW3 6HP, England. 0 1989 by The Society of Thoracic Surgeons
Fig 2 . Fine English bougie with a highly malleable stem and a hard plastic tip. 0003-4975/89/$3.50
..--
TSANG AND GOLDSTRAW ENDOBRONCHIAL STENTING FOR STRICTURE
Ann Thorac Surg 1989;48:568-71
569
equate, and a 12-mm stent was inserted, which was later replaced by a 14-mm stent. The stent has been well tolerated, and the patient has managed well with good exercise tolerance over the last 15 months (FEV,/FVC = 2.7:4.9). 2. A 55-year-old male nonsmoker with a 4-year history of asthma was seen with hemoptysis. The asthma did not lessen with bronchodilators, and the patient had always maintained it was unilateral. Bronchoscopy revealed a 1-cm polypoid tumor in the left main bronchus (Fig 6). The biopsy specimen demonstrated it to be a squamous papilloma. Computed tomography revealed an endobronchial lesion and no mediastinal abnormality.
PATIENT a
C
b
d
e
Fig 3 . Technique of bronchoscopic endobronchial stenting. See text for details.
sulfate, methotrexate) for small cell carcinoma of the right upper lobe bronchus diagnosed on brush cytology in January 1987. He was well until 8 months later when he was seen with recurrent hemoptysis. Bronchoscopy and repeat biopsy showed squamous carcinoma in the right upper lobe bronchus, and the original cell type was thought to be erroneous. Computed tomography predicted a normal mediastinum. The lung function was good with a forced expiratory volume in 1 second to forced vital capacity ratio (FEVJFVC) of 2.74.0. A right upper lobectomy was undertaken. However, the bronchial margin appeared erythematous, and frozen section of this area revealed carcinoma in situ. Sleeve resection of the right main bronchus was carried out, and an end-to-end anastomosis was performed using a continuous suture of 3-0 Prolene. Postoperative evaluation showed resection margins to be clear, and confirmed squamous cell type and NO status. Six weeks later, the residual right lung collapsed, and the patient became profoundly hypoxic (Fig 4A). Emergency bronchoscopy demonstrated complete closure at the bronchial anastomotic site with granulation tissue, which was excised with diathermy to establish an adequate lumen. Three weeks later, the patient returned with further collapse of the residual right lung, and a tight fibrous stricture was noted at the site of the sleeve anastomosis (FEV,/FVC = 1.6:2.8). The biopsy specimen showed no malignancy. In an attempt to avoid a completion pneumonectomy, we elected to insert a Silastic endobronchial stent 10 mm in diameter. After this procedure, the chest radiograph showed good aeration of the right lung (Fig 4B), and there was associated symptomatic improvement. was changed to a bigger size Four weeks later’ the (12mm) and was left in position for weeks (Fig5 ) . At the end of 10 weeks from the time of initial stent Placement) the stent was removed, and 4 weeks later, the anastomotic site was assessed. The lumen was considered inad-
B Fig 4 . (Patient 1.) Chest roentgenograms of anastornotic stenosis occurring after sleeve resection and treated by endobronchial stenting. (A) Complete collapse of the residual right lung. (B) Stent (arrow) was placed across the bronchial anastomosis and resulted in reaeration of the remaining lobes on the right.
570
TSANG AND GOLDSTRAW ENDOBRONCHIAL STENTING FOR STRICTURE
Fig 5 . Bronchoscopic v i m of the bronchial stent in situ.
Through a left thoracotomy, sleeve resection of 1.5 cm of the left main bronchus was undertaken with a clear margin. The residual left main bronchus was anastomosed to the carina using a continuous suture of 3-0 Prolene with interrupted 2-0 Prolene sutures at the 6o’clock and 12-o’clock positions. At the end of the procedure, the anastomosis was checked by bronchoscopy and found to be satisfactory. Four weeks after sleeve resection, a persistent cough developed, but the patient clinically had normal aeration
Ann Thorac Surg 1989;48:56%71
Fig 7. Bronchial stent (arrow), the proximal margin flush with the carinu. There was full aeration of the left lung.
of the left lung (FEV,/FVC = 2.6:2.8). Bronchoscopy revealed edematous mucosa narrowing the anastomosis. The stenotic site was dilated. Two months later, there was absent air entry over the left lung (FEV,IFVC = 2.0:2.6). Bronchoscopy disclosed a very tight fibrous stricture at the sleeve resection site, which was opened with a bougie. A biopsy specimen taken at the time was reported to show no tumor. A 12-mm bronchial stent was inserted with the proximal margin flush with the carina (Fig 7). The patient became asymptomatic and has led an active life for the last 12 months (FEV,/FVC = 3.1:3.4).
Comment
Fig 6 . Bronchoscopic view of the polypoid tumor occluding the left main bronchus.
In select patients, bronchoplastic resection has become an established treatment of bronchogenic carcinoma [1, 21 and benign pulmonary lesions [3] with the advantage of preservation of lung parenchyma. The operative mortality, which ranges from 2% to 7% in most series [ l , 21, compares favorably with that of pneumonectomy. Bronchial healing at the site of the anastomosis is a potential problem. At our institution, the incidence of early and late stricture formation after sleeve resection by one of us (P.G.) is 13% (3/23). We believe such formation is mainly related to interrupted bronchial blood supply to the distal bronchial segment, especially when there is extensive mediastinal dissection. In terms of suture material, it has been suggested that the use of absorbable suture may avoid bronchial irritation, which may be related to protruding nonabsorbable suture material [4]. Continuous Prolene suture was used for the bronchial anastomosis in both of our patients, but no protrusion of suture into the bronchial lumen was found. Few surgical options are available. Bronchoscopic dilation of the anastomotic stenosis and removal of granulation tissue can reestablish an adequate lumen in some
Ann Thorac Surg 1989;48.568-71
patients. For tight fibrous stricture, repeated dilations at short intervals become unpleasant. Traumatic shearing force as a result of multiple bougienages causes further damage to the bronchial mucosa at the anastomotic site. Early resection and reanastomosis is hazardous because of the marked inflammation around the hilar region. Completion pneumonectomy carries a high risk [5], and the patient may not tolerate the loss of the remaining ipsilatera1 lung tissue. To avoid repeat dilations and early repeat thoracotomy, it seems appropriate to investigate the use of endobronchial stents for tight anastomotic bronchial strictures. The purpose of the Silastic endobronchial stent is to prevent progressive narrowing of the lumen, thus allowing maximal expansion and recovery of the residual lung and avoiding early reoperation. The design of the stent is simple, and the stent can be made to whatever size and length required using a silicone Montgomery T tube [6]. Once in place, it is stable and flexible, and has no focal pressure effect. In addition, it can be changed to a bigger size. We have noted no complications resulting from our technique. The Silastic stents have been well tolerated and maintain an adequate bronchial lumen, as demonstrated in our 2 patients. Tube displacement has not occurred. Despite the apparent lack of ingrowth of respiratory epithelium over the stent surface, distal accumulation of secretion has not presented any problem to our patients. They have better pulmonary performance, coughing, and deep breathing. Frequent changing of the stent has not been necessary. Use of the endobronchial stent appears to be a desirable stopgap in the treatment of bronchial anastomotic stricture. There is a potential problem with shrinking of tissue once the stent is removed, as shown in our first patient. The alternative, use of an endobronchial stent as a longterm measure, should be considered if the stricture re-
TSANG AND GOLDSTRAW ENDOBRONCHIAL STENTING FOR STRICTURE
571
curs, provided the stent is well tolerated and gives the patient better pulmonary performance and improved quality of life. While the stent maintains the patency of the bronchial lumen, the anastomotic scar tissue undergoes maturation and becomes stiffened. This makes a possible future reoperation less hazardous and reanastomosis feasible. We are also exploring the possibility of long-term stenting using expandable steel stents as an alternative to reoperation [7]. Our experience with the medium-term follow-up of 2 patients encourages us to recommend the use of the Silastic endobronchial stent as a simple and safe treatment for early anastomotic bronchial stricture after sleeve resection.
References 1. Weisel RD, Cooper JD, Delarue NC, et al. Sleeve lobectomy for carcinoma of the lung. J Thorac Cardiovasc Surg 1979; 78:839-49. 2. Faber LP, Jensik RJ, Kittle CF. Results of sleeve lobectomy for bronchogenic carcinoma in 101 patients. Ann Thorac Surg 1984;37279-85. 3. Lowe JE, Bridgman AH, Sabiston DC. The role of bronchoplastic procedures in the management of benign and malignant pulmonary lesions. J Thorac Cardiovasc Surg 1982; 83:22734. 4. Hsieh CM, Tomita M, Ayabe H, et al. Influence of suture on bronchial anastomosis in growing puppies. J Thorac Cardiovasc Surg 1988;95:998-1002. 5. McGovern EM, Trastek VF, Pairolero PC, Payne WS. Completion pneumonectomy:indications, complications, and results. Ann Thorac Surg 1988;46:141-6. 6. Montgomery WW. T-tube tracheal stent. Arch Otolaryngol 1965;82:320-1. 7. Wallace MJ, Charnsangavej C, Ogawa K, et al. Tracheobronchial tree: expandable metallic stents used in experimentaland clinical applications. Radiology 1986;158:309-12.
Bronchial anastomotic stenosis is a potentially serious complication of sleeve resection. A Silastic endobronchial stent that prevents progressive narrowing at the anastornotic site is described. Insertion of the stent offers a simple and effective treatment that allows improved pulmonary performance, clearing of infection, and good quality of life. The long-term prognosis, however, remains questionable. (Ann Thorac Surg 1989;48:568-71)
S
urvival after sleeve resection for lung tumors in select patients compares favorably with that after pneumonectomy. Morbidity and mortality are reduced while preserving lung tissue and without compromising on tumor clearance. A potentially serious complication of sleeve resection is bronchial anastomotic stenosis, which is due to interrupted bronchial blood supply to the distal bronchial segment and partial anastomotic dehiscence, with granulation tissue formation. There are few therapeutic options available for the treatment of this complication. They include repeated dilations of the stenotic area, immediate resection and reanastomosis, or completion pneumonectomy. This report describes our clinical experience with 2 patients in whom an endobronchial stent was used to manage bronchial anastomotic stenosis. We discuss the advantages and potential disadvantages of this method.
Material and Methods Technique
Fig 1 . Silastic endobronchial stent.
A fine English bougie (Fig 2) is positioned across the stricture (Fig 3a). The stent of desired size is selected and placed over the bougie (Fig 3b), and is then manipulated through the larynx and into the trachea with a laryngoscope and McGill's forceps. The rigid bronchoscope is used to push the stent to the stricture site (Fig 3c, d). The tip of the bronchoscope is used to keep the stent in a stable position while the fine bougie is withdrawn (Fig 3e). Any fine adjustment can then be done with a grasping forceps through the rigid bronchoscope (Fig 3).
Case Reports PATIENT I. A 65-year-old male smoker was given four courses of chemotherapy (cyclophosphamide, vincristine
The stent is fashioned using an appropriate length of the vertical limb of a 10- to 14-mm Silastic (Dow Corning) Montgomery T tube, and the rims are made from short segments of a slightly larger Montgomery T tube. The parts are fitted together with silicone glue (Fig 1). The stent is inserted at bronchoscopy under general anesthesia. Ventilation is maintained by a Venturi jet system. The site and length of the stricture are assessed. With bronchoscopic guidance, the stenotic area is dilated with graduated English bougies. Secretion and pus are evacuated from the distal bronchial tree. The bronchoscopic telescope can then be negotiated through the stricture, and the anatomy beyond can be assessed and biopsy done. Accepted for publication July 7, 1989. Address reprint requests to Mr Goldstraw, Brompton Hospital, Fulham Rd. London SW3 6HP, England. 0 1989 by The Society of Thoracic Surgeons
Fig 2 . Fine English bougie with a highly malleable stem and a hard plastic tip. 0003-4975/89/$3.50
..--
TSANG AND GOLDSTRAW ENDOBRONCHIAL STENTING FOR STRICTURE
Ann Thorac Surg 1989;48:568-71
569
equate, and a 12-mm stent was inserted, which was later replaced by a 14-mm stent. The stent has been well tolerated, and the patient has managed well with good exercise tolerance over the last 15 months (FEV,/FVC = 2.7:4.9). 2. A 55-year-old male nonsmoker with a 4-year history of asthma was seen with hemoptysis. The asthma did not lessen with bronchodilators, and the patient had always maintained it was unilateral. Bronchoscopy revealed a 1-cm polypoid tumor in the left main bronchus (Fig 6). The biopsy specimen demonstrated it to be a squamous papilloma. Computed tomography revealed an endobronchial lesion and no mediastinal abnormality.
PATIENT a
C
b
d
e
Fig 3 . Technique of bronchoscopic endobronchial stenting. See text for details.
sulfate, methotrexate) for small cell carcinoma of the right upper lobe bronchus diagnosed on brush cytology in January 1987. He was well until 8 months later when he was seen with recurrent hemoptysis. Bronchoscopy and repeat biopsy showed squamous carcinoma in the right upper lobe bronchus, and the original cell type was thought to be erroneous. Computed tomography predicted a normal mediastinum. The lung function was good with a forced expiratory volume in 1 second to forced vital capacity ratio (FEVJFVC) of 2.74.0. A right upper lobectomy was undertaken. However, the bronchial margin appeared erythematous, and frozen section of this area revealed carcinoma in situ. Sleeve resection of the right main bronchus was carried out, and an end-to-end anastomosis was performed using a continuous suture of 3-0 Prolene. Postoperative evaluation showed resection margins to be clear, and confirmed squamous cell type and NO status. Six weeks later, the residual right lung collapsed, and the patient became profoundly hypoxic (Fig 4A). Emergency bronchoscopy demonstrated complete closure at the bronchial anastomotic site with granulation tissue, which was excised with diathermy to establish an adequate lumen. Three weeks later, the patient returned with further collapse of the residual right lung, and a tight fibrous stricture was noted at the site of the sleeve anastomosis (FEV,/FVC = 1.6:2.8). The biopsy specimen showed no malignancy. In an attempt to avoid a completion pneumonectomy, we elected to insert a Silastic endobronchial stent 10 mm in diameter. After this procedure, the chest radiograph showed good aeration of the right lung (Fig 4B), and there was associated symptomatic improvement. was changed to a bigger size Four weeks later’ the (12mm) and was left in position for weeks (Fig5 ) . At the end of 10 weeks from the time of initial stent Placement) the stent was removed, and 4 weeks later, the anastomotic site was assessed. The lumen was considered inad-
B Fig 4 . (Patient 1.) Chest roentgenograms of anastornotic stenosis occurring after sleeve resection and treated by endobronchial stenting. (A) Complete collapse of the residual right lung. (B) Stent (arrow) was placed across the bronchial anastomosis and resulted in reaeration of the remaining lobes on the right.
570
TSANG AND GOLDSTRAW ENDOBRONCHIAL STENTING FOR STRICTURE
Fig 5 . Bronchoscopic v i m of the bronchial stent in situ.
Through a left thoracotomy, sleeve resection of 1.5 cm of the left main bronchus was undertaken with a clear margin. The residual left main bronchus was anastomosed to the carina using a continuous suture of 3-0 Prolene with interrupted 2-0 Prolene sutures at the 6o’clock and 12-o’clock positions. At the end of the procedure, the anastomosis was checked by bronchoscopy and found to be satisfactory. Four weeks after sleeve resection, a persistent cough developed, but the patient clinically had normal aeration
Ann Thorac Surg 1989;48:56%71
Fig 7. Bronchial stent (arrow), the proximal margin flush with the carinu. There was full aeration of the left lung.
of the left lung (FEV,/FVC = 2.6:2.8). Bronchoscopy revealed edematous mucosa narrowing the anastomosis. The stenotic site was dilated. Two months later, there was absent air entry over the left lung (FEV,IFVC = 2.0:2.6). Bronchoscopy disclosed a very tight fibrous stricture at the sleeve resection site, which was opened with a bougie. A biopsy specimen taken at the time was reported to show no tumor. A 12-mm bronchial stent was inserted with the proximal margin flush with the carina (Fig 7). The patient became asymptomatic and has led an active life for the last 12 months (FEV,/FVC = 3.1:3.4).
Comment
Fig 6 . Bronchoscopic view of the polypoid tumor occluding the left main bronchus.
In select patients, bronchoplastic resection has become an established treatment of bronchogenic carcinoma [1, 21 and benign pulmonary lesions [3] with the advantage of preservation of lung parenchyma. The operative mortality, which ranges from 2% to 7% in most series [ l , 21, compares favorably with that of pneumonectomy. Bronchial healing at the site of the anastomosis is a potential problem. At our institution, the incidence of early and late stricture formation after sleeve resection by one of us (P.G.) is 13% (3/23). We believe such formation is mainly related to interrupted bronchial blood supply to the distal bronchial segment, especially when there is extensive mediastinal dissection. In terms of suture material, it has been suggested that the use of absorbable suture may avoid bronchial irritation, which may be related to protruding nonabsorbable suture material [4]. Continuous Prolene suture was used for the bronchial anastomosis in both of our patients, but no protrusion of suture into the bronchial lumen was found. Few surgical options are available. Bronchoscopic dilation of the anastomotic stenosis and removal of granulation tissue can reestablish an adequate lumen in some
Ann Thorac Surg 1989;48.568-71
patients. For tight fibrous stricture, repeated dilations at short intervals become unpleasant. Traumatic shearing force as a result of multiple bougienages causes further damage to the bronchial mucosa at the anastomotic site. Early resection and reanastomosis is hazardous because of the marked inflammation around the hilar region. Completion pneumonectomy carries a high risk [5], and the patient may not tolerate the loss of the remaining ipsilatera1 lung tissue. To avoid repeat dilations and early repeat thoracotomy, it seems appropriate to investigate the use of endobronchial stents for tight anastomotic bronchial strictures. The purpose of the Silastic endobronchial stent is to prevent progressive narrowing of the lumen, thus allowing maximal expansion and recovery of the residual lung and avoiding early reoperation. The design of the stent is simple, and the stent can be made to whatever size and length required using a silicone Montgomery T tube [6]. Once in place, it is stable and flexible, and has no focal pressure effect. In addition, it can be changed to a bigger size. We have noted no complications resulting from our technique. The Silastic stents have been well tolerated and maintain an adequate bronchial lumen, as demonstrated in our 2 patients. Tube displacement has not occurred. Despite the apparent lack of ingrowth of respiratory epithelium over the stent surface, distal accumulation of secretion has not presented any problem to our patients. They have better pulmonary performance, coughing, and deep breathing. Frequent changing of the stent has not been necessary. Use of the endobronchial stent appears to be a desirable stopgap in the treatment of bronchial anastomotic stricture. There is a potential problem with shrinking of tissue once the stent is removed, as shown in our first patient. The alternative, use of an endobronchial stent as a longterm measure, should be considered if the stricture re-
TSANG AND GOLDSTRAW ENDOBRONCHIAL STENTING FOR STRICTURE
571
curs, provided the stent is well tolerated and gives the patient better pulmonary performance and improved quality of life. While the stent maintains the patency of the bronchial lumen, the anastomotic scar tissue undergoes maturation and becomes stiffened. This makes a possible future reoperation less hazardous and reanastomosis feasible. We are also exploring the possibility of long-term stenting using expandable steel stents as an alternative to reoperation [7]. Our experience with the medium-term follow-up of 2 patients encourages us to recommend the use of the Silastic endobronchial stent as a simple and safe treatment for early anastomotic bronchial stricture after sleeve resection.
References 1. Weisel RD, Cooper JD, Delarue NC, et al. Sleeve lobectomy for carcinoma of the lung. J Thorac Cardiovasc Surg 1979; 78:839-49. 2. Faber LP, Jensik RJ, Kittle CF. Results of sleeve lobectomy for bronchogenic carcinoma in 101 patients. Ann Thorac Surg 1984;37279-85. 3. Lowe JE, Bridgman AH, Sabiston DC. The role of bronchoplastic procedures in the management of benign and malignant pulmonary lesions. J Thorac Cardiovasc Surg 1982; 83:22734. 4. Hsieh CM, Tomita M, Ayabe H, et al. Influence of suture on bronchial anastomosis in growing puppies. J Thorac Cardiovasc Surg 1988;95:998-1002. 5. McGovern EM, Trastek VF, Pairolero PC, Payne WS. Completion pneumonectomy:indications, complications, and results. Ann Thorac Surg 1988;46:141-6. 6. Montgomery WW. T-tube tracheal stent. Arch Otolaryngol 1965;82:320-1. 7. Wallace MJ, Charnsangavej C, Ogawa K, et al. Tracheobronchial tree: expandable metallic stents used in experimentaland clinical applications. Radiology 1986;158:309-12.