HLC 1500 No. of Pages 3
HOW-TO-DO-IT
Heart, Lung and Circulation (2014) xx, 1–3 1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2013.12.010
Successful Management of Metallic Expandable Stent-associated Tracheal Restenosis by Montgomery T-tube Insertion Xiaogang Zhao, Hao Wang, Xuefei Hu, Ji Liu, Gening Jiang, MD* Department of Thoracic Surgery, Shanghai Pulmonary Hospital, TongJi University, Shanghai, China Received 25 September 2013; received in revised form 4 December 2013; accepted 30 December 2013; online published-ahead-of-print xxx
Objective
Tracheal stenosis can be life-threatening and has been seen with an increasing frequency.
Methods
Metallic stent-associated stenosis remains a therapeutic challenge because of difficulty in tracheostomy.
Results
Here, we report a case with repeated episodes of restenosis after insertion of metallic stents for benign tracheal stenosis which was successfully managed by Montgomery silicone T-tube placement.
Conclusion
We further reviewed the literature of reported cases of inappropriate use of metallic stent for benign diseases.
Keywords
Montgomery T-tube insertion Tracheal Restenosis Lung Case report
Introduction
Case report
Tracheal stenosis can be life-threatening and has been seen with an increasing frequency [1]. Stents have become popular for vascular and tracheal stenosis but are also associated with various complications. With advances in thoracic medicine and development of stent design, especially expandable metallic stents, tracheal stents are being increasingly used in patients with benign tracheal stenosis secondary to prolonged intubation and/or tracheostomy. This, however, has also brought about an increasing number of complications [2,3] associated with the use of tracheal stents including restenosis and blockage of tracheal stents. Since metallic stents are made of stainless steel or titanium mesh, they cannot be cut easily and tracheostomy in restenosis due to metallic stents remains a daunting challenge. We report here the successful management by Montgomery silicone T-tube placement of one patient with repeated episodes of restenosis after insertion of metallic stents for benign tracheal stenosis. We further reviewed the literature of reported cases of inappropriate use of metallic stent for benign diseases.
A 45 year-old man presented himself at the Emergency Department of our hospital with acute dyspnoea and stridor. The patient received care at a local hospital after a car accident four years ago, which led to multiple traumas necessitating mechanical ventilation by tracheostomy for several weeks. However, it was complicated by tracheal stenosis. The physicians at the local hospital were not able to carry out end to end anastomosis and a metallic expandable tracheal stent was inserted instead. However, this stent ruptured two years ago and a second stent insertion was then performed. Unfortunately, stenosis recurred (Fig. 1A to 1D) and bronchoscopy revealed the presence of granulation tissue in the distal end with more than 90% of the mid-trachea obstructed. We decided to place a Montgomery T-tube insertion. The upper airway of the patient was anesthetised by 10% lidocaine viscus gargles and nebulisation of 6 mL 4% lidocaine using a tight fitting mask and standard nebuliser. Glycopyrrolate 0.2 mg was administered intramuscular as an antisialagogue. Median sternotomy incision was made so that
* Corresponding author. 507 Zhengmin Road, Yangpu Distrcit, Shanghai, China 200433. Tel.: +8618616587602; Facsimile: +86-021-65115006., Email: [email protected] © 2014 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved.
Please cite this article in press as: Zhao X, et al. Successful Management of Metallic Expandable Stent-associated Tracheal Restenosis by Montgomery T-tube Insertion. Heart, Lung and Circulation (2014), http://dx.doi.org/10.1016/j.hlc.2013.12.010
HLC 1500 No. of Pages 3
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X. Zhao et al.
Figure 1 (A) Anteroposterior x-ray shows tracheal stenosis (arrow) in a 45 year old man who received metallic stent for benign respiratory disease. (B) Chest CT reconstruction image showing breakage of the metallic stent (arrow). (C) and (D) Chest CT scan showing re-stenosis of the trachea (arrow).
the stenotic lesion was opened and extended. An endotracheal tube was inserted into the distal end of the stenosed site for ventilation (Fig. 2A). We used metallic probes of increasing sizes to gradually dilate the stenosed site. A smaller caliber endotracheal tube was passed across the stenosis, which was then gradually dilated. An endotracheal tube (Fig. 2B) had been previously placed into the lumen of the T-tube (Fig. 2B). Then, an endotracheal tube of appropriate size was inserted from the oral cavity to the stenosed site and through the T-tube lumen (Fig. 2C). When the endotracheal tube backed off, one side of T-tube was placed into the proximal end of the stenosed site. Meanwhile, the other side of the T-tube was placed into the distal end of the stenosed site to complete T-tube insertion (Fig. 2D). The T tube was removed five months later at the same time the granulation tissue was excised. No hyperpnoea was noticed following extubation. The patient made an uneventful recovery and there was no recurrence of tracheal stenosis at six months of follow up.
Discussion Large airway stenting was largely used as palliative treatment for malignant disorders in the past, and now with advances in thoracic medicine and development of novel stent design, especially expandable metallic stents, the
indications for stent placement have been expanded to include certain benign conditions as well [4]. Currently, stenting is recommended for patients with post-intubation tracheal stenosis for whom surgery is not indicated either due to poor general condition or a long involvement of the trachea. Metallic tracheal stents are associated with frequent complications including restenosis and blockage of tracheal stents and in unresectable malignant lesions, the benefit of metallic stenting remains unquestionable. Noppen et al. reported inappropriate use of self-expandable metallic stents in two patients, which led to severe early or late complications [5], and cautioned that a stent should be carefully selected with anticipation of late side effects especially in benign stenosis. The patient in the current report received metallic tracheal stents for benign tracheal stenosis and restenosis occurred two years after stent placement. It is questionable whether the use of metallic tracheal stent, especially in the proximal trachea was justified when the patient presented in the emergency with a compromised airway. In post-intubation stenosis of the trachea, tracheal sleeve resection followed by endto-end anastomosis is considered the gold standard [6]. In our patient, after the occurrence of restenosis, a second metallic stent was inappropriately used. Such repeated attempts and failed intubation could lead to various surgical
Please cite this article in press as: Zhao X, et al. Successful Management of Metallic Expandable Stent-associated Tracheal Restenosis by Montgomery T-tube Insertion. Heart, Lung and Circulation (2014), http://dx.doi.org/10.1016/j.hlc.2013.12.010
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Expandable stent-associated tracheal restenosis
Figure 2 Montgomery T-tube insertion. (A) An endotracheal tube was inserted into the distal end of the stenosed site for ventilation. The stenosed site was gradually dilated with the trachea tube. (B) The T-tube was matched with the endotracheal tube. (C) The endotracheal tube was inserted from the oral cavity to the stenosed site and through the T-tube lumen. When the endotracheal tube backed off, one side of T-tube was placed into the proximal end of the stenosed site. Meanwhile, the other side of the T-tube was placed into the distal end of the stenosed site to complete T-tube insertion (D).
complications and tracheostomy in restenosis due to metallic stents is difficult to perform as metallic stents are made of stainless steel or titanium mesh and cannot be cut easily. When resection is not feasible, non-resection measures may be considered [7]. The Montgomery silicone T-tube used for post-procedural tracheal stenosis can act both as a stent and a tracheostomy tube. The intratracheal limb of the T-tube is vertical while the extraluminal end is horizontal and protrudes through the tracheostomy orifice. The Montgomery Ttube could provide a useful adjunct to the management difficult airway problems. Nakayama et al. reported the successful use of the T-tube in managing a patient with tracheal stenosis due to relapsing polychondritis [8]. Though T-tubes are simple to insert and rarely cause serious complications, physicians should be aware of the indications, contraindications, and complications of the Montgomery T-tubes. The use of Montgomery silicone T-tube in our case allowed us to secure a patent airway, ensuring prompt airway management and adequate ventilation of the patient. In conclusion, physicians should be cautious in using metallic tracheal stents after an initial failed attempt and Montgomery silicone T-tube may be considered for such cases with repeated failed attempts and difficulty in tracheostomy.
Conflicts of interest The authors declared no conflict of interest.
References [1] Pereszlenyi A, Igaz M, Majer I, Harustiak S. Role of endotracheal stenting in tracheal reconstruction surgery-retrospective analysis. Eur J Cardiothorac Surg 2004;25:1059–64. [2] Lim SY, Kim H, Jeon K, Um SW, Koh WJ, Suh GY, et al. Prognostic factors for endotracheal silicone stenting in the management of inoperable post-intubation tracheal stenosis. Yonsei Med J 2012;53:565–70. [3] Li C, Yang Z, Cao K. Retrieval of dislodged coronary stent from left renal artery by gooseneck snare. J Biomed Res 2010;24:479–82. [4] Serrano C, Laborda A, Lozano JM, Caballero H, Sebastia´n A, Lopera J, et al. Metallic Stents for Tracheobronchial Pathology Treatment. Cardiovasc Intervent Radiol 2013; Apr 11. [Epub ahead of print]. [5] Noppen M, Van Renterghem D, Vanderstraeten P. The wrong stent at the wrong time: a cautionary tale. Respiration 2003;70:313–6. [6] Grillo HC, Mathisen DJ, Waen JC. Laryngotracheal resection and reconstruction for subglottic stenosis. Ann Thorac Surg 1992;53:54–63. [7] Phillips PS, Kubba H, Hartley BE, Albert DM. Postintubation multisegmental tracheal stenosis: treatment and results. Int J Pediatr Otorhinolaryngol 2006;70:39–44. [8] Nakayama T, Horinouchi H, Asakura K, Ohtsuka T, Izumi Y, Kohno M, et al. Tracheal stenosis due to relapsing polychondritis managed for 16 years with a silicon T-tube covering the entire trachea. Ann Thorac Surg 2011;92:1126–8.
Please cite this article in press as: Zhao X, et al. Successful Management of Metallic Expandable Stent-associated Tracheal Restenosis by Montgomery T-tube Insertion. Heart, Lung and Circulation (2014), http://dx.doi.org/10.1016/j.hlc.2013.12.010
HOW-TO-DO-IT
Heart, Lung and Circulation (2014) xx, 1–3 1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2013.12.010
Successful Management of Metallic Expandable Stent-associated Tracheal Restenosis by Montgomery T-tube Insertion Xiaogang Zhao, Hao Wang, Xuefei Hu, Ji Liu, Gening Jiang, MD* Department of Thoracic Surgery, Shanghai Pulmonary Hospital, TongJi University, Shanghai, China Received 25 September 2013; received in revised form 4 December 2013; accepted 30 December 2013; online published-ahead-of-print xxx
Objective
Tracheal stenosis can be life-threatening and has been seen with an increasing frequency.
Methods
Metallic stent-associated stenosis remains a therapeutic challenge because of difficulty in tracheostomy.
Results
Here, we report a case with repeated episodes of restenosis after insertion of metallic stents for benign tracheal stenosis which was successfully managed by Montgomery silicone T-tube placement.
Conclusion
We further reviewed the literature of reported cases of inappropriate use of metallic stent for benign diseases.
Keywords
Montgomery T-tube insertion Tracheal Restenosis Lung Case report
Introduction
Case report
Tracheal stenosis can be life-threatening and has been seen with an increasing frequency [1]. Stents have become popular for vascular and tracheal stenosis but are also associated with various complications. With advances in thoracic medicine and development of stent design, especially expandable metallic stents, tracheal stents are being increasingly used in patients with benign tracheal stenosis secondary to prolonged intubation and/or tracheostomy. This, however, has also brought about an increasing number of complications [2,3] associated with the use of tracheal stents including restenosis and blockage of tracheal stents. Since metallic stents are made of stainless steel or titanium mesh, they cannot be cut easily and tracheostomy in restenosis due to metallic stents remains a daunting challenge. We report here the successful management by Montgomery silicone T-tube placement of one patient with repeated episodes of restenosis after insertion of metallic stents for benign tracheal stenosis. We further reviewed the literature of reported cases of inappropriate use of metallic stent for benign diseases.
A 45 year-old man presented himself at the Emergency Department of our hospital with acute dyspnoea and stridor. The patient received care at a local hospital after a car accident four years ago, which led to multiple traumas necessitating mechanical ventilation by tracheostomy for several weeks. However, it was complicated by tracheal stenosis. The physicians at the local hospital were not able to carry out end to end anastomosis and a metallic expandable tracheal stent was inserted instead. However, this stent ruptured two years ago and a second stent insertion was then performed. Unfortunately, stenosis recurred (Fig. 1A to 1D) and bronchoscopy revealed the presence of granulation tissue in the distal end with more than 90% of the mid-trachea obstructed. We decided to place a Montgomery T-tube insertion. The upper airway of the patient was anesthetised by 10% lidocaine viscus gargles and nebulisation of 6 mL 4% lidocaine using a tight fitting mask and standard nebuliser. Glycopyrrolate 0.2 mg was administered intramuscular as an antisialagogue. Median sternotomy incision was made so that
* Corresponding author. 507 Zhengmin Road, Yangpu Distrcit, Shanghai, China 200433. Tel.: +8618616587602; Facsimile: +86-021-65115006., Email: [email protected] © 2014 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved.
Please cite this article in press as: Zhao X, et al. Successful Management of Metallic Expandable Stent-associated Tracheal Restenosis by Montgomery T-tube Insertion. Heart, Lung and Circulation (2014), http://dx.doi.org/10.1016/j.hlc.2013.12.010
HLC 1500 No. of Pages 3
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X. Zhao et al.
Figure 1 (A) Anteroposterior x-ray shows tracheal stenosis (arrow) in a 45 year old man who received metallic stent for benign respiratory disease. (B) Chest CT reconstruction image showing breakage of the metallic stent (arrow). (C) and (D) Chest CT scan showing re-stenosis of the trachea (arrow).
the stenotic lesion was opened and extended. An endotracheal tube was inserted into the distal end of the stenosed site for ventilation (Fig. 2A). We used metallic probes of increasing sizes to gradually dilate the stenosed site. A smaller caliber endotracheal tube was passed across the stenosis, which was then gradually dilated. An endotracheal tube (Fig. 2B) had been previously placed into the lumen of the T-tube (Fig. 2B). Then, an endotracheal tube of appropriate size was inserted from the oral cavity to the stenosed site and through the T-tube lumen (Fig. 2C). When the endotracheal tube backed off, one side of T-tube was placed into the proximal end of the stenosed site. Meanwhile, the other side of the T-tube was placed into the distal end of the stenosed site to complete T-tube insertion (Fig. 2D). The T tube was removed five months later at the same time the granulation tissue was excised. No hyperpnoea was noticed following extubation. The patient made an uneventful recovery and there was no recurrence of tracheal stenosis at six months of follow up.
Discussion Large airway stenting was largely used as palliative treatment for malignant disorders in the past, and now with advances in thoracic medicine and development of novel stent design, especially expandable metallic stents, the
indications for stent placement have been expanded to include certain benign conditions as well [4]. Currently, stenting is recommended for patients with post-intubation tracheal stenosis for whom surgery is not indicated either due to poor general condition or a long involvement of the trachea. Metallic tracheal stents are associated with frequent complications including restenosis and blockage of tracheal stents and in unresectable malignant lesions, the benefit of metallic stenting remains unquestionable. Noppen et al. reported inappropriate use of self-expandable metallic stents in two patients, which led to severe early or late complications [5], and cautioned that a stent should be carefully selected with anticipation of late side effects especially in benign stenosis. The patient in the current report received metallic tracheal stents for benign tracheal stenosis and restenosis occurred two years after stent placement. It is questionable whether the use of metallic tracheal stent, especially in the proximal trachea was justified when the patient presented in the emergency with a compromised airway. In post-intubation stenosis of the trachea, tracheal sleeve resection followed by endto-end anastomosis is considered the gold standard [6]. In our patient, after the occurrence of restenosis, a second metallic stent was inappropriately used. Such repeated attempts and failed intubation could lead to various surgical
Please cite this article in press as: Zhao X, et al. Successful Management of Metallic Expandable Stent-associated Tracheal Restenosis by Montgomery T-tube Insertion. Heart, Lung and Circulation (2014), http://dx.doi.org/10.1016/j.hlc.2013.12.010
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Expandable stent-associated tracheal restenosis
Figure 2 Montgomery T-tube insertion. (A) An endotracheal tube was inserted into the distal end of the stenosed site for ventilation. The stenosed site was gradually dilated with the trachea tube. (B) The T-tube was matched with the endotracheal tube. (C) The endotracheal tube was inserted from the oral cavity to the stenosed site and through the T-tube lumen. When the endotracheal tube backed off, one side of T-tube was placed into the proximal end of the stenosed site. Meanwhile, the other side of the T-tube was placed into the distal end of the stenosed site to complete T-tube insertion (D).
complications and tracheostomy in restenosis due to metallic stents is difficult to perform as metallic stents are made of stainless steel or titanium mesh and cannot be cut easily. When resection is not feasible, non-resection measures may be considered [7]. The Montgomery silicone T-tube used for post-procedural tracheal stenosis can act both as a stent and a tracheostomy tube. The intratracheal limb of the T-tube is vertical while the extraluminal end is horizontal and protrudes through the tracheostomy orifice. The Montgomery Ttube could provide a useful adjunct to the management difficult airway problems. Nakayama et al. reported the successful use of the T-tube in managing a patient with tracheal stenosis due to relapsing polychondritis [8]. Though T-tubes are simple to insert and rarely cause serious complications, physicians should be aware of the indications, contraindications, and complications of the Montgomery T-tubes. The use of Montgomery silicone T-tube in our case allowed us to secure a patent airway, ensuring prompt airway management and adequate ventilation of the patient. In conclusion, physicians should be cautious in using metallic tracheal stents after an initial failed attempt and Montgomery silicone T-tube may be considered for such cases with repeated failed attempts and difficulty in tracheostomy.
Conflicts of interest The authors declared no conflict of interest.
References [1] Pereszlenyi A, Igaz M, Majer I, Harustiak S. Role of endotracheal stenting in tracheal reconstruction surgery-retrospective analysis. Eur J Cardiothorac Surg 2004;25:1059–64. [2] Lim SY, Kim H, Jeon K, Um SW, Koh WJ, Suh GY, et al. Prognostic factors for endotracheal silicone stenting in the management of inoperable post-intubation tracheal stenosis. Yonsei Med J 2012;53:565–70. [3] Li C, Yang Z, Cao K. Retrieval of dislodged coronary stent from left renal artery by gooseneck snare. J Biomed Res 2010;24:479–82. [4] Serrano C, Laborda A, Lozano JM, Caballero H, Sebastia´n A, Lopera J, et al. Metallic Stents for Tracheobronchial Pathology Treatment. Cardiovasc Intervent Radiol 2013; Apr 11. [Epub ahead of print]. [5] Noppen M, Van Renterghem D, Vanderstraeten P. The wrong stent at the wrong time: a cautionary tale. Respiration 2003;70:313–6. [6] Grillo HC, Mathisen DJ, Waen JC. Laryngotracheal resection and reconstruction for subglottic stenosis. Ann Thorac Surg 1992;53:54–63. [7] Phillips PS, Kubba H, Hartley BE, Albert DM. Postintubation multisegmental tracheal stenosis: treatment and results. Int J Pediatr Otorhinolaryngol 2006;70:39–44. [8] Nakayama T, Horinouchi H, Asakura K, Ohtsuka T, Izumi Y, Kohno M, et al. Tracheal stenosis due to relapsing polychondritis managed for 16 years with a silicon T-tube covering the entire trachea. Ann Thorac Surg 2011;92:1126–8.
Please cite this article in press as: Zhao X, et al. Successful Management of Metallic Expandable Stent-associated Tracheal Restenosis by Montgomery T-tube Insertion. Heart, Lung and Circulation (2014), http://dx.doi.org/10.1016/j.hlc.2013.12.010
