Eur J Cardiothorac Surg 2006;30:680-681
© 2006 Elsevier Science NL
Right upper lobe ‘window’ in right main bronchus stenting
Nir Peleda,b,
David Shitrita,b,
Daniele Bendayana,b,
Mordechai R. Kramera,b,*
a Pulmonary Institute, Rabin Medical Center, Beilinson Campus, Petah Tiqwa 49100, Israel
b Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
Received 3 June 2006;
received in revised form 11 July 2006;
accepted 14 July 2006.
* Corresponding author. Address: Tel.: +972 3 9377221; fax: +972 3 9377142. (Email: peledbn{at}zahav.net.il).
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Abstract
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Stent insertion for bronchial stenosis has become common practice in lung transplantation and advanced lung malignancy, and for external compression of the airways for other reasons. Right main bronchus stenting may require blocking the right upper lobe by the stent, placing the patient at risk of recurrent pneumonia and atelectasis. In this study, three patients after insertion of a metal stent to the right main bronchus are described. In all cases, the right upper lobe was covered by the stent, and a laser (Nd:YAG) procedure was used to open a ‘window’ in the stent toward the right upper lobe with a follow-up of 1 year. We conclude that stent insertion to the right main bronchus may be followed by a laser therapy to open a ‘window’ toward the right upper lobe.
Abbreviations: FEV1 = forced vital capacity in the 1st second • Nd:YAG = neodymium yttrium aluminum garnet laser • RMB = right main bronchus • RUL = right upper lobe
Key Words: Bronchial • Stent • Transplantation
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1. Introduction
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Right main bronchus (RMB) stenosis may occur as a consequence of external compression, luminal processes such as an endobronchial tumor/polyp, or local postoperative granulation tissue with or without bronchomalacia [1]. In lung transplantation, extensive necrosis and anastomotic dehiscence are now rarely encountered; problems of granulation tissue accumulation, stenosis, and bronchomalacia may persist [2]. Most cases can be managed by debridement, but sometimes, bronchial stenting is mandatory. The stents in use today are composed of silastic rubber or metal alloys [3]. Stenting the right main bronchus may cover the entrance of the right upper lobe (RUL), placing the patient at risk of recurrent infections and atelectasis. There are currently no clinically appropriate solutions to this problem.
We describe three patients after stent insertion to the RMB in whom we opened a ‘window’ in the stent.
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2. Case 1
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A 60-year-old man underwent right lung transplantation due to idiopathic pulmonary fibrosis. Bronchoscopic evaluations revealed patent anastomoses at 3 days after surgery, followed by the development of necrosis and Aspergillus infection by day 14. On week 8, necrotic cartilage and granulation tissue were noted over 80% of the lumen in the anastomosis area. Laser cauterization improved the FEV1 from 43% to 61%. However, within 2 weeks moderate stenosis occurred (FEV1 45%), which decreased further to 35% within 2 weeks. Mechanical balloon dilatation (12 mm) performed in weeks 12 and 14 proved ineffective, so a Wallstent (40/12 mm) was inserted at the RMB with an increase in FEV1 to 70%. Two weeks later, we opened a ‘window’ (diameter 6–7 mm) toward the RUL using neodymium yttrium aluminum garnet (Nd:YAG) laser (2000 J; Fig. 1
). At the 8-month visit, the stent was easily observed in the RMB, with a patent orifice toward the RUL. The FEV1 findings are shown in Fig. 2
.
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3. Case 2
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A 54-year-old man underwent right lung transplantation due to idiopathic pulmonary fibrosis. Bronchoscopic evaluation 3 days after transplantation showed an open elliptic anastomosis. Evaluation after 6 weeks showed necrotic tissue around the anastomosis with local Pseudomonas and Aspergillus infection (FEV1 62%). On weeks 8 and 10, a laser procedure was performed to improve the patency of the anastomosis. FEV1 increased from 45% to 57%, but then dropped to 35%. Because of the severe persistent stenosis, a Wallstent (20/10 mm) was inserted to the RMB on week 14, and FEV1 rose to 66%. Three weeks later, a ‘window’ toward the RUL was introduced in the stent using Nd:YAG laser (diameter 6 mm; 2380 J). Immediately thereafter preventive 1000 cGy brachytherapy was done. On month 6, there was good anastomosal patency with mild local granulation tissue which was removed (FEV1 59%).
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4. Case 3
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A 64-year-old woman had right lower lobe collapse due to benign external compression by enlarged and hard lymph nodes. She had diffuse anthracosis over the lung and pericard, and enlarged lymph nodes around the right intermedius bronchus diagnosed as silicosis by open lung biopsy. Owing to the presence of right-side nonresolving pneumonia, Wallstent (20/10 mm) was inserted to the right intermedius bronchus with a significant improvement and an increase in FEV1 from 66% to 82%. One month later, laser therapy was performed to open a hole in the stent toward the RUL (diameter 6 mm; 1800 J). The clinical course was excellent, and FEV1 improved to 94% within 1 year.
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5. Discussion
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Metal stents have been used with increasing frequency in the last decade for the treatment of narrowed airways due to malignant and other strictures, complications of lung transplantation, and injuries to the bronchi [1,4–6]. We describe our experience wherein a ‘window’ is created in a metal stent inserted to the RMB to prevent RUL coverage. In the three patients in this series with anastomotic stenosis or external compression of the airways, immediate improvement was noted after stent insertion. However, it was necessary to cover the RUL with the stent in order to keep the right intermedius and RMB open. Thereafter, a window was formed by Nd:YAG laser at the first follow-up examination. The window was not introduced at stent insertion owing to the risk of stent migration within the first 2 weeks [1,7]. The procedure was not followed by stent collapse or other side effects and none of the patients had RUL pneumonia or atelectasis prior to the procedure, but we expected some degree of secretions after stent deployment, placing the poorly ventilated lung segment at risk of pneumonia. Although the clinical impact of opening a window is difficult to assess, our assumption was based on a study in pigs, wherein seven of nine stents placed over the RUL became obstructed by granulation tissue or plugs of mucous and inflammatory cells. RUL inflammation and atelectasis were seen in eight of the animals, with histopathologic findings of acute and chronic pneumonia [4].
In our series, Wallstents were used in all cases. We preferred the metal Wallstents because they are expandable, easy to place with a flexible bronchoscope, have a high internal/external diameter ratio, and preserve mucociliary function [5]. Furthermore, the mesh configuration of metal stents prevents complete obstruction, and it is easier to cut a window with a laser or balloon technique in metal than in silicon stents. The window was created by cutting one wire after the other in a circuit order without any stent malformation or local burns. The site for creating the hole has been identified by direct visualization through the bronchoscope. New version of silicon stents with a protrusion branch might be also a feasible option.
In conclusion, stenting the RMB can be safely followed by laser-assisted opening a ‘window’ in the stent toward the right upper lobe.
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References
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F. Venuta
Editorial comment Lateral window in self-expanding metal stents.
Eur. J. Cardiothorac. Surg.,
October 1, 2006;
30(4):
682 - 682.
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Abstract
1. Introduction
