Eur J Cardiothorac Surg 1999;14:329-331
© 1999 Elsevier Science NL
Open surgery for removal of a failing Gianturco stent with reversed sleeve resection of the right middle and lower lobes
Jhingook Kim,
Hojoong Kim,
Kwhanmien Kim,
Young Mog Shim
Department of Thoracic Surgery, Division of Pulmonary Medicine, Samsung Medical Center, 50 IL Won-Dong, Kangnam-Ku, Seoul, 135-230, South Korea
Received 2 February 1998;
received in revised form 7 May 1998;
accepted 3 June 1998.
Corresponding author. Tel.: +82 2 34103489; fax: +82 2 34100089; e-mail: jkim@smc.samsung.co.kr
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Abstract
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Although the use of a metallic stent in the treatment of benign tracheobronchial stenosis has been reported as a useful and safe technique, the incorporation of wire stents into the airway may be irreversible and is associated with problems. The authors' experience in a patient with incorrectly positioned metallic stent in the right main bronchus, which was successfully treated with bronchial sleeve resection, is presented.
Key Words: Gianturco expandable metal stent • Incorrect position • Bronchial sleeve resection
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Introduction
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Although some reported that the metallic stent for the treatment of benign tracheobronchial stenosis is useful and safe
[1]
[2]
[3]
[4], the indication of its insertion should be evaluated cautiously. We, here, report a case with an incorrectly positioned Gianturco expandable metal stent (GEMS), which was successfully treated with bronchial sleeve resection.
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Cases
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A 27-year-old woman with frequent cough and blood-tinged sputum was referred to our institute. Five years ago, she was diagnosed with endobronchial tuberculosis at the local community hospital, and had completed 9 months of anti-tuberculosis medication. Two years ago, she was diagnosed as having bronchial stenosis in the bronchus intermedius of the right lung, and had GEMS insertion. Since then, she suffered from current symptoms. In her physical examination, there was no remarkable abnormality except some rhonchi in the right chest. Her radiological examination showed a metal stent in the right main bronchus and complete atelectasis of the right middle and lower lobes (
Fig. 1
A). The spikes of the metal stent crossed the midline of the carina and penetrated the bronchial wall, but did not encroach upon the nearby vascular structures (
Fig. 1B). On bronchoscopic examination, two end-spikes of GEMS were visible around the right main bronchial opening (
Fig. 2
A), but the body of the stent itself could not be seen because bronchial mucosa covered it. Right upper lobar bronchus, up to the openings of segmental bronchi, revealed redness and inflammatory changes, and the bronchus intermedius was completely obstructed. As the stent, which was supposedly incorrectly positioned in the right main bronchus at the time of insertion, caused intractable symptoms and could not be removed by non-surgical methods, operation was inevitable.
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Fig. 1. (a) Chest X-ray film shows a Gianturco's expandable metallic stent (GEMS, arrow) in the right main bronchus and the atelectatic right middle and lower lobes due to complete obstruction of bronchus intermedius. (b) Chest CT film shows a metallic stent (arrow) in the right main bronchus. The spikes of the metal stent penetrated the bronchial wall, but did not encroach upon the nearby vascular structures.
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Fig. 2. (a) Pre-operative bronchoscopic view of carina shows the spikes of the stent as well as redness and inflammatory changes in the carina and right main bronchus (RM, Right main bronchus; LM, Left main bronchus). (b) Post-operative (5 months after the operation) bronchoscopic view of distal trachea. Right upper lobar bronchus opens directly from the distal trachea and forms a new carina with left main bronchus (RU, Right upper lobar bronchus; LM, Left main bronchus).
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Under the general anesthesia, right posterolateral thoracotomy was performed and the thoracic cavity was entered through the right fifth intercostal space. The right middle and lower lobes were completely collapsed and densely adhering to the surrounding parietal pleura. Careful and limited dissection of the tissues around the right main bronchus and carina revealed the spikes of the stent, which penetrated the bronchial wall. Firstly, we did right middle and lower lobectomy, and resected the right main bronchus. To remove the GEMS completely, carina as well as the proximal portion of right upper lobar bronchus should have been included in the resection. Then, the saved right upper lobe was attached to the proximal airway opening, which was made up by distal trachea and a portion of left main bronchial opening (
Fig. 2B). The anastomosis was performed with interrupted sutures of 4–0 vicryl, with care being taken to maintain even stitch intervals on each side. An air leak test at 40 cmH2O on inspiratory pressure did not show any air leak through the anastomosis.
The patient's post-operative course was uneventful. In 16 months following the operation, she has been well with full functional activity and free from the pre-operative symptoms.
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Discussion
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In recent years, there have been several reports of the successful treatment of bronchial stenosis with a metal stent in benign disease
[1]
[2]
[3]
[4]. The authors insist that it provides an alternative to surgery, because (1) the metal stent can be inserted through an endotracheal tube under local anesthesia, (2) it does not impair the drainage of sputum because ciliary movement is not interrupted, and (3) if it covers another non-stenosed bronchus, ventilation will not be blocked because of the spaces between the wires.
However, as seen in this particular case, the stents which are currently used, may not be suitable for the benign disease because of serious complications such as fatal hemorrhage, fistula formation, obstruction of the stent and migration of the stent
[3]
[5]. Moreover, once expanded, a GEMS has spikes that embed in the bronchial walls, making it extremely difficult to remove, and it is thus often considered as permanent. If there had been encroachment upon any nearby blood vessels, the pulmonary artery for example, any reckless attempt to remove or relocate the stent may have resulted in a fatal outcome.
There has been no reported experience of bronchoplastic procedure to manage the complication of GEMS in benign bronchial stricture. Most of the cases were managed by cryo- or laser-ablation pallitively
[3] or by pneumonectomy
[5]
[6]. Experience with this case re-emphasizes that the principle management of patients with large-airway stenosis should be surgical resection with end-to-end anastomosis and, in benign bronchial stenosis, the insertion of metal stent should be restricted to patients who cannot tolerate the operation.
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References
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- Nashaf S.A.M., Dromer C., Velly J., et al. Expanding wire stents in benign tracheobronchial disease: indications and complication. Ann Thorac Surg 1992;54:937-940.[Abstract]
- Sawada S., Fujiwara Y., Furui S., et al. Treatment of tuberculosis bronchial stenosis with expandable metallic stents. Acta Radiol 1993;34:263-265.[Medline]
- George P.J.M., Irving J.D., Khanghani A., et al. Role of the Gianturco expandable metal stent in the management of tracheobronchial obstruction. Cardiovasc Intervent Radiol 1992;15:375-381.[Medline]
- Han J.K., Im J.G., Park J.H., et al. Bronchial stenosis due to endobronchial stenosis: successful treatment with self-expanding metallic stent. AJR 1992;159:971-972.[Abstract/Free Full Text]
- Kim W., Lee Y.C., Rhee Y.K. Obstruction after self-expanding metallic stents in tuberculous bronchial stenosis. Kor J Intern Med 1995;10:64-67.
- Fox R.A., Stanbridge R.D.L., Brown J., et al. Expandable metal stents for non-malignant bronchial obstruction. Thorax 1996;51:1963-1964.
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Abstract
Introduction
